10  FAIR ALLOCATION OF ICU AND CRITICAL CARE DEVICES: PRIORITIZATION OF PATIENTS
Resource allocation guidelines pertaining to in‐hospital COVID‐19 emergencies have the objective of fairly apportioning access to scarce critical care resources. In this specific context, what criteria ought to be applied? How can the interests of the worst off be protected? A survey undertaken before the current pandemic identified various criteria that have been offered for the allocation of critical care resources, including: “‘sickest first’, ‘waiting list’, ‘prognosis’, ‘behaviour’ (i.e., those who engage in risky behaviour should not be prioritized), ‘instrumental value’ (e.g., health care workers should be favoured during epidemics), ‘combination of criteria’ (i.e., a sequence of the ‘youngest first’, ‘prognosis’, and ‘lottery’ principles), ‘reciprocity’ (i.e., those who provided services to the society in the past should be rewarded), ‘youngest first’, ‘lottery’, and ‘monetary contribution’.”147 Krütli, P., et al. (2016) How to Fairly Allocate Scarce Medical Resources: Ethical Argumentation under Scrutiny by Health Professionals and Lay People. PLoS ONE. 11(7): e0159086. Retrieved March 23, 2020, from https://doi.org/10.1371/journal. pone.0159086
With specific reference to COVD‐19, guidelines coming out of many countries have been offered, including those from the United States,148 Emanuel, E.J., et al. (2020, March 23). Fair Allocation of Scarce Medical Resources in the Time of Covid‐ 19. The New England Journal of Medicine. Retrieved March 23, 2020, from https://www.nejm.org/doi/full/10.1056/NEJMsb2005114?query=featured_coronavirus.
Italy,149 Vergano, M., et al. (2020, March 16). Clinical Ethics Recommendations for the Allocation of Intensive Care Treatments, in Exceptional, Resource‐Limited Circumstances. Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI). Retrieved March 23, 2020, from http://www.siaarti.it/SiteAssets/News/COVID19%20‐%20documenti%20SIAARTI/SIAARTI%20‐%20Covid‐19%20‐%20Clinical%20Ethics%20Reccomendations.pdf. opens in new tab).
France,150 Azoulay, E., et al. (2020). Admission Decisions to Intensive Care Units in the Context of the Major COVID‐19 Outbreak: Local Guidance from the COVID‐19 Paris‐Region Area. Critical Care. 24:1.
and the Philippines.151 Task Force Ethics Guidelines COVID‐19 Philippines. (2020). Ethical Guidelines for Leaders in Health Care Institutions during the COVID‐19 Pandemic. Philippine Journal of Internal Medicine. 58(1). Retrieved April 9, 2020, from https://www.pcp.org.ph/index.php/pjim/pjim/1094‐phil‐journal‐of‐internal‐medicine‐vol‐58‐no‐1.
Considering that issues may arise in variable contexts, it is helpful to be clear about the level of scarcity obtaining in a particular situation. The WHO Working Group on Ethics and COVID‐19 distinguishes three levels of scarcity and their corresponding effects on the fair allocation of resources like ventilators: first, with little scarcity, first come, first served may be best for equality; second, with more scarcity, the prioritization of the worst off may be best; and third, “with even greater scarcity, a principle that aims to maximize benefit from the resource may be most justified.”152 WHO Working Group on Ethics and COVID‐19. (2020). Ethics and COVID‐19: Resource Allocation and Priority Setting. Retrieved June 29, 2020, from https://www.who.int/ethics/publications/ethics‐covid‐19‐resource‐allocation.pdf?ua=1
Of interest in this section is the scarcest level. In extreme situations where there are simply not enough resources to accommodate everyone in need, giving protection to the vulnerable could take a backseat as medical vulnerability, in the sense of having comorbidities, could be seen to indicate futility of critical care that includes ventilatory support. An early study showed that for COVID‐19, the Case Fatality Rate (CFR) was elevated among those with preexisting comorbid conditions such as cardiovascular disease, diabetes, chronic respiratory disease, hypertension, and cancer.153 Wu, Z., & McGoogan, J.M. (2020, February 24). Characteristics of and Important Lessons from the Coronavirus Disease 2019 (COVID‐19) Outbreak in China: Summary of a Report of 72,314 Cases from the Chinese Center for Disease Control and Prevention. JAMA. Retrieved March 26, 2020, from http://dx.doi.org/10.1001/jama.2020.2648
Another study of laboratory‐confirmed cases of COVID‐19 showed that “patients with any comorbidity yielded poorer clinical outcomes than those without” and “a greater number of comorbidities also correlated with poorer clinical outcomes.”154 Guan, W., et al. (2020). Comorbidity and its Impact on 1590 Patients with Covid‐19 in China: a Nationwide Analysis. European Respiratory Journal. Retrieved April 20, 2020, from https://doi.org/10.1183/13993003.00547‐2020
Moreover, “persons with underlying chronic illnesses are more likely to contract the virus and become severely ill, . . . [while those] with history of hypertension, obesity, chronic lung disease, diabetes, and cardiovascular disease have the worst prognosis and most often end up with deteriorating outcomes such as acute respiratory distress syndrome (ARDS) and pneumonia.”155 Sanyaolu, A., et al. (2020, June 25). Comorbidity and its Impact on Patients with COVID‐19. SN Comprehensive Clinical Medicine. 2, 1–8. Retrieved June 27, 2020, from https://doi.org/10.1007/s42399‐020‐00363‐4
A patient rendered vulnerable by comorbidities may be considered ineligible for the application of “intensive care treatments, in exceptional, resource limited circumstances.”156 Vergano, et al., op. cit. note 149, p. 1.
Within Italy, COVID‐19 deaths were mainly observed among older, male patients who were also suffering from multiple comorbidities.157 Onder, G., Rezza, G., & Brusaferro, S. (2020, March 23). Case‐Fatality Rate and Characteristics of Patients Dying in Relation to COVID‐19 in Italy. JAMA. Retrieved April 15, 2020, from http://dx.doi.org/10.1001/jama.2020.4683
According to another study, “the existence of comorbidities increases the probability of dying from COVID‐19 by 2.4 times compared to those who do not have pre‐existing conditions.”158 Espinosa, O.A., et al. (2020, June 22). Prevalence of Comorbidities in Patients and Mortality Cases Affected by SARS‐CoV2: a Systematic Review and Meta‐Analysis. Revista do Instituto de Medicina Tropical de Såo Paulo vol.62 São Paulo. Retrieved May 2, 2020, from https://doi.org/10.1590/s1678‐9946202062043
In the United States, a study showed deaths were 12 times higher among patients with reported underlying conditions compared with those without reported underlying conditions (19.5% versus 1.6%).159 Stokes, E.K., et al. (2020, June 19). Coronavirus Disease 2019 Case Surveillance — United States, January 22–May 30, 2020. Morbidity and Mortality Weekly Report. 69(24), 759–765. Retrieved June 30, 2020, from http://dx.doi.org/10.15585/mmwr.mm6924e2
Research findings such as these resulted in elderly patients being refused ventilatory support in Italy.160 Bosotti, A. (2020). Coronavirus Horror: Over‐70s Left to Die in Italy as Doctors Told Focus on Young Patients. Express. Retrieved April 15, 2020, from https://www.express.co.uk/news/world/1257840/Coronavirus‐news‐Italy‐over‐70s‐dead‐covid‐19‐death‐toll‐Bergamo‐funeral‐latest
The Independent reported that a doctor gave an account of medics being forced to ration care to patients in the wake of the COVID‐19 outbreak such that elderly patients were being denied care based on their age and whether they had other conditions or not: “In Bologna, we are working with 80‐years‐old as our cut off, but between 65 and 80‐years‐old we still consider comorbidities.”161 Lintern, S. (2020, March 13). ‘We are making difficult choices’: Italian doctor tells of struggle against coronavirus. Independent. Retrieved August 16, 2020, from https://www.independent.co.uk/news/health/coronavirus‐italy‐hospitals‐doctor‐lockdown‐quarantine‐intensive‐care‐a9401186.html
There are similar accounts pertaining to Sweden’s Karolinska Institute.162 Habib, H. (2020, April 13). ‘I’ve never written so many death certificates’: Is Sweden having second thoughts on lockdown? Independent. Retrieved August 25, 2020, from https://www.independent.co.uk/news/world/europe/sweden‐coronavirus‐lockdown‐doctor‐death‐certificates‐latest‐a9462796.html
, 163 Svensson, O. (2020, April 9) Dokument visar: De prioriteras bort från intensivvård. Aftonbladet. Retrieved August 25, 2020, from https://www.aftonbladet.se/nyheter/samhalle/a/lAyePy/dokument‐visar‐de‐prioriteras‐bort‐fran‐intensivvard
Yet, the acceptance of advanced age in itself as an indicator of medical futility has to be conclusively established by evidence. Statistical findings of high mortality rates among patients belonging to the highest age groups can merely be reiterative of the high mortality rates among patients with comorbidities ‐‐ elderly patients have a higher likelihood of having more comorbidities. If we overlook this point, the elderly could be exposed to unfair allocation of resources based simply on their age rather than on their having comorbidities that leave them with poor chances of surviving with the use of critical care devices.164 de Castro‐Hamoy, L., & de Castro, L.D. (2020). Age Matters but it Should not Be Used to Discriminate Against the Elderly in Allocating Scarce Resources in the Context of COVID‐19. Asian Bioethics Review. 12, 331–340. Retrieved August 16, 2020, from https://doi.org/10.1007/s41649‐020‐00130‐6
As George Kuchel asserts, “having multiple chronic diseases and frailty is in many ways as or more important than chronological age” and “an 80‐year‐old who is otherwise healthy and not frail might be more resilient in fighting off infection than a 60‐year‐old with many chronic conditions.”165 Begley, S. (2020, March 30). What Explains COVID‐19’s Lethality for the Elderly? Scientists Look to ‘Twilight’ of the Immune System. STAT News. Retrieved April 15, 2020, from https://www.statnews.com/2020/03/30/what‐explains‐coronavirus‐lethality‐for‐elderly/
In addition, recent studies have generated optimism about the success of measures to delay or minimize age‐related immunological defects.166 Nikolich‐Žugich, J. (2017). The Twilight of Immunity: Emerging Concepts in Aging of the Immune System. Nature Immunology. 19(1), 10–19. Retrieved August 16, 2020, from https://doi.org/10.1038/s41590‐017‐0006‐x
Admittedly, age serves as a useful indicator of the presence of comorbidities that the elderly are likely to have. However, the studies about chronological age and immunological developments cited above indicate that statistical correlation should not necessarily be taken to mean causal correlation. For this reason, age by itself should not be regarded as a valid basis for short‐term triage decision‐making. In the absence of validated empirical proof that a particular age level indicates the medical futility of applying scarce critical care resources, the vulnerability of patients that is associated with advanced age should instead signify a need for them to be given protection deserved by those who are worst off – the most vulnerable – among members of society.
Vulnerability can also give rise to injustice when a patient’s level of health literacy results in a failure accurately to communicate one’s medical history or the nature or intensity of symptoms being experienced. This exemplifies a failure in relation to the fair allocation of full and adequate information mentioned in an earlier section. For instance, a poor patient from a far‐flung area with no prior knowledge about her condition may not mention relevant details in her history because she feels that these may not be important for a doctor’s diagnosis. When caregivers overlook this point and do not try hard enough to clarify to the patient what could be relevant, they could be compounding the effects of inequity in education, or dissemination of information. By their neglect, they allow the inequity to be manifested in the allocation of scarce lifesaving resources, especially in a triage situation. Where the dangers to a patient’s life may already be difficult to deal with, missing treatment opportunities just because of miscommunication is going to magnify the adverse impact of vulnerability. These examples of possible discrimination in a triage setting are most likely to affect those who belong to economically and educationally disadvantaged sectors of society because of their limited health literacy. Rather than being blamed on the disadvantaged themselves, a community’s level of health literacy should be presumed to be the result of a failure on the part of health authorities to convey pertinent information and make it understandable to the public.
Disadvantaged sectors are also more likely to be affected by disparities in the location of hospital facilities. In order to address the disproportionate access to critical care services by disadvantaged sectors, it would have been useful to have a monitoring, communication, and transport mechanism to facilitate their conveyance to pertinent facilities in case of need. Moreover, temporary measures established during this period have to make way for a more durable network for the just distribution of various levels of hospital care consistent with the concept of universal healthcare.
In light of the risk of the country’s emergency care infrastructure being overwhelmed by COVID‐19, it may be tempting to invest huge sums of money on acquiring more critical care units and devices. However, a more sustainable response would be mindful of the unfair allocation of access to such resources. It would be more prudent to invest in a healthcare infrastructure that is anchored on equity and gives priority to the preventive aspects of healthcare that would give timely attention to the needs of disadvantaged sectors and eventually ease the burden on more expensive tertiary care.