Story at a glance

  • Hospitals have to stretch their resources during health emergencies like the swine flu pandemic of 2009 and the current COVID-19 pandemic.
  • The CDC has a document that lays out the ethical landscape of deciding who to put on ventilators.
  • “A public health emergency creates a need to transition from individual patient-focused clinical care to a population-oriented public health approach intended to provide the best possible outcomes for a large cohort of critical care patients,” states the document.

Although there are signs that the number of new COVID-19 cases may have peaked in the U.S., the hospitals are still full of COVID patients. More and more doctors are needing to make decisions about who gets a ventilator and who may be left to end-of-life care.

The Centers for Disease Control and Prevention (CDC) has a few ethics guidance documents for public health emergencies. One that was published in July 2011, titled “Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators during a Severe Influenza Pandemic or Other Public Health Emergency,” is about deciding who should get put on ventilators during a disease emergency.

Here’s what it says.

About the document

The document is supplemental to another CDC document from 2007 titled “Ethical Guidelines in Pandemic Influenza.” The goal is to give an overview of the “ethical landscape” regarding decisions about ventilators in the case of an influenza pandemic to leaders at the federal, tribal, territorial, state and local levels. It’s not intended to guide decisions but to help with the planning process in a fair and equitable way.

The assumptions are that in an influenza pandemic, the number of patients with respiratory failure far outnumber the available resources. The authors cite the 2009 H1N1 pandemic, also known as swine flu, as the most recent example of a situation like that. Now in 2020, it’s happening again but at a much larger scale.


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The report says, “A public health emergency creates a need to transition from individual patient-focused clinical care to a population-oriented public health approach intended to provide the best possible outcomes for a large cohort of critical care patients.” The transition happens when there is a “substantial extreme mismatch between patient need and available resources, that is, when the numbers of critically ill patients surpass the capability of traditional critical care capacity.”

What happens in normal times

In normal times, the "sickest first" principle may be used to triage patients in the emergency department. This is when staff time is scarce but resources are still available. Other patients can get cared for, but may need to wait longer.

For intensive care units (ICUs), it’s first come, first served. Once someone is in an ICU, they are generally not transferred out “unless the patient or surrogate agrees to forego life-sustaining interventions.”

What may happen in health emergencies

If "sickest first" is still followed, this could lead to “resources being used by patients who ultimately are too sick to survive.” Similarly with first come, first served, “After a public health emergency is declared, rules that favor the overall benefit to the population and society may have to be considered,” states the report.

In a health emergency, which does not happen often, doctors may need to choose to think about the population at the same time as they are treating individuals. Remember, this is not like normal operations in an emergency department, even though emergency is in the name. This is when the emergency is a much larger, pandemic-sized emergency. In some situations when resources are scarce, they may need to choose to give priority to “those who are most likely to recover after receiving them.”

The authors give the example of treating soldiers with life threatening injuries. Medics may give priority to those who are most likely to survive with relatively small amounts of resources. During cholera epidemics, intravenous fluids may be given to people with moderate dehydration rather than severe dehydration.


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Biomedical ethical principles

Respect: This means the health professionals need to get informed consent from patients and should respect their informed refusal.

Beneficence: “The principle of beneficence requires physicians to act in the best interests of their patients and to subordinate their personal and institutional interests to those of the patient.”

Justice: This one is more complex. It means that the “distribution of benefits and burdens should be equitable; allocation decisions should be applied consistently across people and across time. Responses to a pandemic should not exacerbate existing disparities in health outcomes, as unfortunately has occurred in some past public health emergencies.” Although unfortunately, we are already seeing disparities in health outcomes in the COVID-19 pandemic with black communities disproportionately affected. There is a long section discussing this topic in the report if you are interested in knowing more.

Ethical considerations

This section discusses ways that health professionals and leaders can think about maximizing net benefit. Below are short explanations for a few different ways to approach this. See the report for more detail.

Maximize the number of lives saved: This perspective holds that each life has equal claim on being saved. “Prioritizing individuals according to their chances for short-term survival also avoids ethically irrelevant considerations, such as race or socioeconomic status,” states the report.

Maximizing the number of years saved: This one is self-explanatory. For example, if short-term survival is the same for two patients of the same age, then saving the patient with fewer severe co-occurring health complications (comorbidities) would potentially maximize the number of years of life saved.

Maximizing adjusted years of life saved: This approach maximizes the number of years saved after adjusting for quality of those years. There are two terms in medicine and science called quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs). QALYs are index calculations that try to include both the quantity of life left and the quality of that life in terms of health and disease burden. DALYs are a measure of how much life is lost due to disability. During a health emergency, you would need to know quite a bit of information about the patient to try to do a QALY or DALY assessment, and doing it on the fly in an emergency department may be difficult.

What this means for COVID-19

Many doctors have been making tough decisions for weeks and may have to continue to do so for many more. Earlier in the outbreak, people may have felt reassured that only older adults were severely affected by the disease. But in reality, younger and middle aged people in their 20s, 30s and 40s are being admitted to ICUs and being put on ventilators.

This means that with more younger people needing more serious treatment, that older adults also being admitted to hospitals may not get priority for ventilators. Your parents, grandparents, aunts and uncles who are older may not be prioritized if they need ventilators. It’s important to take the pandemic seriously and protect those people in your life and yourself as well.

In many hospitals, it may be the doctors who are working on the floor who are deciding who is put on a ventilator. Some experts say that a triage committee, rather than the clinicians, should make the decisions to help with the mental health burden. The reality is that many people are forced to think about these ethical decisions and people’s lives are being affected. If you are interested, take a closer look at the ethics document.

For up-to-date information about COVID-19, check the websites of the Centers for Disease Control and Prevention and the World Health Organization. For updated global case counts, check this page maintained by Johns Hopkins University.

You can follow Chia-Yi Hou on Twitter.


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Published on Apr 16, 2020