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How hospitals will decide who lives and who dies in the COVID-19 crisis

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I have never seen doctors as anxious and stressed as now. COVID-19 patients already are overwhelming hospitals, forcing excruciating decisions of who should receive treatment and who should not, and how these decisions should be made. Of course, doctors try to save all patients but, unfortunately, in the coming weeks they may not be able to do so.

In the 18th century, military doctors developed principles of triage to help decide who should be treated on battlefields when not all patients could be aided. In other extreme emergencies since then, including the current COVID-19 pandemic, physicians have similarly had to choose how to allocate limited resources to benefit the largest possible number of patients — those who are most likely to survive. Sadly, the severely sick might not get care if their odds of recovery with treatment are nil.

Hospitals have been struggling with shortages of COVID-19 test kits, masks and ventilators. Of these, ventilators are by far the most expensive and, in coming weeks, will be in the shortest supply. In 2018, the U.S. had about 180,000 ventilators. While most COVID-19 patients recover on their own, approximately 5 percent to 10 percent will need ventilators. The eventual total number of U.S. COVID-19 patients remains unknown, but at least 1 million reportedly may soon require these machines. New York state alone will need 30,000 ventilators but currently has only 7,000. The federal government has promised to send more to the states, including 4,000 to New York. Additional machines clearly are needed. But high costs — and politics — have been bogging down plans to manufacture more. Physicians are thus having to prepare to confront conundrums of which patients should — and should not — get one.

Ethically, hospitals should work to save as many lives as possible — but how, exactly, should that be done? Clearly, medical centers should not decide randomly or through lotteries, or simply on a first-come-first-served basis, or based on income, socioeconomic status, race, ethnicity or insurance.

Rather, physicians need to consider patients’ rights, short- and long-term risks, benefits to individual patients and to society as a whole, and social justice. Still, these principles can conflict and be hard to weigh.

Over the past decade, the New York State Task Force on Life and the Law and the National Academy of Medicine have provided important frameworks, articulating key principles. Importantly, hospitals should prepare in advance before disasters hit, anticipating these challenges, establishing clear criteria and processes, stockpiling and conserving limited supplies, adapting other equipment that might help, and reusing materials that can be appropriately disinfected.

Nonetheless, with COVID-19, doctors ultimately may need to assign patients to categories with different priority levels, based on an assessment of each patient’s risk of death if he or she does or doesn’t get a ventilator. These are controversial topics that require scientific and public awareness and discussion.

According to the published guidelines, doctors should, overall, prioritize patients who are both most likely to die if they do not receive a ventilator and are most likely to recover if they get one. Patients who are most likely to survive without a ventilator would have lower priority. Those who are severely sick and have an intermediate or uncertain chance of recovering if they receive a ventilator may obtain one — if higher-priority patients get them first. Patients who receive ventilators also should be monitored every few days to ensure that they are improving.

Regrettably, if ventilators are limited, certain categories of patients might need to be excluded from consideration, such as those with advanced cancer or severe Alzheimer’s disease. Ideally, doctors should not abandon such patients but, instead, provide other treatment or resources that might be available, such as palliative or so-called “comfort” care. Alas, humans are bad at making predictions, but doctors have developed careful, agreed-upon assessments tools.

Even after making these initial difficult categorizations, however, physicians may confront further quandaries of whether to ever remove a ventilator from one patient to benefit another who has a better chance of surviving. The patient withdrawn from the ventilator would probably die, so that another would live. Ideally, such decisions would never even arise — but the reality now is that they might.

When all else is equal, first responders and health care workers should get relatively high priority, since they can each help save the lives of many other patients and cannot, in a crisis, be replaced.

Yet, given the rapidly surging numbers of patients, even these arrangements may not suffice, and doctors may have to place more than one patient on a single ventilator. Hospitals are now debating whether they should plan to do so and, if so, how. There are risks: While one patient might survive on a ventilator he or she obtains, two or four patients sharing the same machine might give each only half or one-quarter the needed amount of oxygen. Hopefully, more than one of these patients would consequently survive, but no published research has examined this question. Doctors are struggling in uncharted territory and wonder if they should begin to experiment with this strategy now, before they are forced to make such decisions on a more widespread basis.

In making these tough tradeoffs, ethical processes as well as outcomes are crucial, necessitating transparency, consistency and accountability. To avoid conflicts of interest, these decisions should be made by a triage committee of professionals who are not directly involved in the care of any patients whose cases are being considered; the committee should also regularly revisit these assessments. Public awareness, discussion and input about these issues are vital as well.

Good ethics begin with good facts, but many questions remain, regarding how many patients will in fact need ventilators, how much social distancing will “flatten the curve” to reduce this demand, and what percent of patients with various underlying conditions will improve. Legal questions arise as well, and may vary between states. Physicians would need legal protection against lawsuits.

These choices cause medical staff angst and painful moral distress. No one wants or likes to make these life-or-death decisions.

The solution to these quandaries is to have more ventilators. Unfortunately, for weeks, the Trump administration minimized the COVID-19 threat, delaying the manufacture of critical supplies. As a country, we should now work toward building enough ventilators, and accept that they are relatively expensive. The costs, however, are vital to saving American lives. Public pressure can help motivate our political leaders to continue to act as swiftly as possible to have more of these machines and other key supplies produced.

Hopefully, we won’t have to make these trade-offs. But, alas, we may have to.

At the least, we can prepare as best we can.

Dr. Robert Klitzman is a professor of psychiatry, director of the Masters of Bioethics Program and a co-founder and former co-director of the Center for Bioethics in the Vagelos College of Physicians & Surgeons and the Mailman School of Public Health at Columbia University. He is the author of nine books, including “When Doctors Become Patients” (2007), “Am I My Genes? Confronting Fate and Family Secrets in the Age of Genetic Testing” (2012) and “Designing Babies: How Technology is Changing the Ways We Create Children” (2020).

Tags Coronavirus coronavirus pandemic COVID-19 Donald Trump Louisiana Medical ethics Medical ventilator New Orleans New York New York City Palliative care Respiratory therapy Triage ventilators Washington state

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