In a recent paper, the USA-based Hastings Center, which addresses social and ethical issues in health care, science and technology, observes that in public health emergencies a shift needs to take place away from the ethical norms of standard clinical practice, which is patient-centred and responsive to individual patient preferences, towards public health ethics, which is concerned with safeguarding the health of the population by means of the best use of resources. This can entail limiting individual rights and choices.(1) They assert that “public health emergencies may feature tragically limited resources that are insufficient to save lives that under normal conditions could be saved”.(1) This necessitates decisions about how to allocate limited resources: “In a public health emergency featuring severe respiratory illness, triage decisions may have to be made about level of care …; initiation of life-sustaining treatment …; withdrawal of life-sustaining treatment; and referral to palliative … care if life-sustaining treatment will not be initiated or is withdrawn”.(1)
This is equally true in the South African context. However, clinicians here may be more accustomed to working with limited resources and rationing decisions, and the tension between the patient-centred and public health orientations might not be as unfamiliar or stark for them. However, this does not change the fact that triage decisions take their toll on health-care workers, emotionally. The Hastings Center asserts that one important way in which this emotional distress can be alleviated is by ensuring that there are clear rules in place for public health emergencies, for instance, “triage protocols … help first responders to swiftly prioritize patients for different levels of care based on their needs and their ability to respond to treatment given resource constraints”.(1) Unclear rules or rules that cause patient distress can lead to moral distress in caregivers, especially in situations in which protocols require the withholding or withdrawing of treatment against the wishes of patients or their families. Thus, there is a critical need and an ethical obligation for ethics guidelines for decision-making about treatment allocation to be in place before the pandemic reaches the level where tragic choices need to be made.
The question now is, what would an ethically sound policy for rationing in a health emergency look like? In a recently published paper entitled “Fair allocation of scarce medical resources in the time of Covid-19”, Emanuel et al. write that the literature on resource allocation in pandemics emphasizes four main values that should inform policies: “Maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value and giving priority to the worst off”.(2) They go on to make six recommendations derived from these four principles. It is not possible to discuss these in any detail here, and only the four most pertinent recommendations will be briefly discussed in the following.(2)
Their first recommendation is that the most important value when faced with a pandemic is the maximizing of the benefits of scarce resources. They assert, “priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life”.(2) Given the lack of time and information in this pandemic, they go on to claim that it is “justifiable to give priority to maximizing the number of patients that survive treatment with a reasonable life expectancy and to regard maximizing improvements in length of life as a subordinate aim”.(2) Several recent publications broadly agree with this position.(3–6) Emanuel et al. acknowledge that there are many possible ways of seeking a balance between saving more lives and saving more life years, but whatever means of balancing is chosen ought to be applied consistently.(2)
This recommendation applies as much in South Africa as anywhere else. The biggest challenge it presents in our context relates to the existing inequalities in our health-care system, where the private sector is far better resourced than the public sector. Organs of State ought to be considering ways in which the total pool of resources available in the country can best be employed to maximize the benefits for all citizens, not only the privileged. This can only be achieved through intense cooperation between the two health sectors.
The second recommendation responds to the value of “promoting and rewarding instrumental value”.(2) Emanuel et al. submit that health-care workers, other front-line carers and workers who keep infrastructure running should be granted priority for treatment and the allocation of vaccines. The reason for this is not because these individuals are more worthy than others, it is because they are instrumentally important in the response to the pandemic. Also, this assurance could encourage health-care workers to accept the higher risks and continue caring for patients in these circumstances.(2) Prioritizing health-care workers is even more justified in South Africa where we already have such a shortage of qualified practitioners. The authors also warn against possible abuses of the principle of giving regard to instrumental value by “prioritizing wealthy or famous persons of the politically powerful above first responders and medical staff …. Such abuses will undermine trust in the allocation framework”.(2) This warning is particularly pertinent in our context in which corruption and nepotism are rife. Policies and procedures for the allocation of resources in this crisis need to clearly emphasize equity and fairness and exclude the prioritizing of persons of high social status, solely on the grounds of their status.
Recommendation three deals with handling patients whose prognosis is much the same. The authors assert that the best way to ensure equality in these cases is to use a random method of allocation, such as lottery. They reject a first-come, first-served process on the grounds that this advantages those closest to health facilities and could encourage crowding at facilities in a time when social distancing is crucial.(2) This recommendation is particularly apt in South Africa where transport challenges and distance to health facilities already severely disadvantage some of our most vulnerable citizens.
Recommendation six asserts that fairness requires that “there should be no difference in allocating scarce resources between patients with Covid-19 and those with other medical conditions”.(2) Since we already have a high burden of disease in this country, it is clear that there will continue to be patients that will face serious and life-threatening conditions, not related to the corona virus. They have the same right to fair treatment as Covid-19 patients.
Another important recommendation made in several recent publications is that treating clinicians should not be the decision-makers in rationing processes at all, but rather that a multidisciplinary triage team of experts be appointed to fulfil this role.(4–6) The Critical Care Society of South Africa (CCSSA) acknowledges that this may be difficult in many contexts in South Africa but advises finding other ways of ensuring that treating clinicians are kept at a remove from these decisions, such as co-opting experts from other institutions or geographical areas to perform this task.(6)
Recent publications also raise the ethically fraught issue of possibly needing to make decisions to discharging patients from ICU beds or ventilators to make way for other patients with better prognoses, despite the risk of critical consequences. Generally, they propose that this is not only ethically justified but also it is, in fact, morally obligatory.(2,4–6) Furthermore, Emanuel et al. claim that “the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient's consent”. By now, it has become commonplace to make decisions to withdraw life-sustaining treatment where patient or proxy consent is given, or (with or without consent) in cases where continued treatment is futile. Decisions of this nature are made in South Africa all the time. It is rare to make decisions to withdraw treatment that is not futile in order to make way for a patient with a better prognosis. However, this is clearly in-line with the principle of saving the most lives and maximizing the benefits of scarce resources in an emergency. If decisions like these will need to be made, it only serves to amplify the need for treating physicians to be protected by giving the responsibility for triage decisions to a separate committee. Furthermore, patients from whom treatment is withdrawn should be provided with appropriate palliative and supportive care.(4–6)
This short article provides little more than some general principles and recommendations. For an excellent, adaptable example of a practical rationing procedure for South Africa, see the CCSSA recommendations(6) and a useful summary flow chart.(7) Additional ethics resources related to the crisis can be found at https://www.thehastingscenter.org/ethics-resources-on-the-coronavirus/ and https://www.nuffieldbioethics.org/topics/health-and-society/covid-19.