The COVID-19 pandemic has magnified many aspects of our society and opened them up to scrutiny. It has exposed the good, such as our ability to band together in the face of a common foe; our desire to volunteer our time to help those in need; and our willingness to set aside immediate personal gratifications for a greater good. Yet it has also exposed the bad, such as the disturbing increase in the popularity of conspiracy theories over reason and science; an insultingly stubborn resistance against face coverings; and vicious, racist violence. Most of all, the pandemic has revealed the short-handedness of our health care system and its ability to respond to a worst-case scenario. Deadly shortages of personal protective equipment (PPE) and ventilators, insufficient ICU bed space, and desperate bids to purchase the scarce resources that are available have forced politicians and health care practitioners alike to undertake incredibly difficult actions. American hospital directors have resorted to clandestine night-time checkups to ensure that essential deliveries aren’t snatched up by the Federal Emergency Management Agency. Physicians are pressured to make life-saving—and potentially life-ending—decisions.
Many of these issues would be easily resolved by an abundance of necessary resources. In an ideal world, PPE would be in such adequate supply that it need not be reused against sound medical protocol. There would be more than 24 critical care beds for a population of twelve million people in South Sudan. And car manufacturing giants would not need to be brought in to alleviate ventilator shortages. In this ideal world, #flattenthecurve would never have claimed its place as a top hashtag of 2020. Our healthcare systems would be able to completely accommodate greater influxes of patients, providing teams of experienced doctors and nurses whenever necessary. But, unfortunately, we live on a planet of scarcity. This is one reason why economics—a large part of which is the study of resource allocation under scarce conditions—is such a popular degree.
Yet economics, as developed and complex as it is, primarily deals with the measurement and optimization of simple, quantifiable units, be it profit, unemployment rates, inflation, and so on. The units that physicians must calculate are human, and therefore more sacred and immensurable: emotional anguish, human dignity, and the value of a life. It is with these considerations that we must answer the most difficult questions of the pandemic: how do we determine who gets a ventilator and who does not in a worse-case scenario? Who gets to decide? Beyond immediate questions of survival: if a vaccine is found, who should be inoculated first? At what point do the needs of a depressed economy outweigh the needs of public health, if ever? What is an “essential worker”? Should non-essential workplaces reopen, which sectors should be prioritized?
These questions have generally been answered from a distinctly utilitarian perspective, and the solution may appear to be self-evident. Let’s discuss the most immediate and the most critical problem of who to treat if treating everybody is infeasible, although it is important to note that this is only one of a multitude of ethical dilemmas that present themselves during a public health crisis. At first glance, the answer seems obvious: on a patient-by-patient basis, we should preferentially provide care to those who are most likely to benefit the most from treatment. However, if we attempt to pick apart the meaning of this simple statement, there are layers to unpack. Does “benefit the most” mean the largest increase in likelihood of survival with treatment, or the largest survival rate period? Basic math shows that the former results in more lives saved and thus should be adopted if one agrees with the utilitarian framework during a crisis. Next, the question of what “survival” means—lives saved, or life-years saved? Most would agree with the latter, but the line, once so delineated, blurs slightly. Both aforementioned principles were soberly incorporated in the prescription of a possible imposition of an age limit to medical access by SIAARTI, an Italian medical society that concerns itself with intensive care, in mid-March at the height of the Northern Italian pandemic.
More rarely—but also more ethically damning—if two individuals are judged to benefit equally from treatment, who should we select? It is in these edge-cases that we should perhaps be most wary of what we are valuing when we choose. The fundamental principle that all human beings are equal and in possession of a uniquely human dignity implies that the best decision would be no decision at all. There are indeed advocates for random selection of patients—all other factors equal—as it is among the fairer options. Alternatively, there are proponents of a “social usefulness” model of allocation, an extension of the utilitarian principle, which may be either retrospective or prospective. Prospective allocation involves allocating resources towards those most likely to go on to help others; this might take the form of electing to treat health care workers over other citizens, all else being equal. Few vocalize support for expanding prospective allocation beyond immediate medical personnel. Such a system would be controversial and vulnerable to exploitation. It is all too easy to see how this arrangement may tread too closely to the differential valuing of human lives.
The act of essentially sacrificing patients with the worst prognoses for the salvation of others is a messy one. Individuals alone are not tasked with this gruesome duty; rather, triaging committees composed of multiple physicians not directly involved with the patient attempt to deliver unbiased verdicts to save the most people. The grim nature of advanced triaging—that is, denying care to those deemed unlikely to survive—has led these panels to be derided as “death committees.” It is easy to condemn these faceless figures who impose life-or-death judgements, but harder to choose between a diabetic mother of four with a history of charity and a young economics major fresh out of university with his whole life ahead of him.
COVID-19 has forced every one of us to make sacrifices: a long-awaited vacation, a job, a meet-up with friends. As the tide of infection slowly abates, we must ensure that we are well-prepared for a second wave of infection—not only physically with the necessary supplies, but also ethically with appropriate moral protocol. It is extremely important that we understand why hospitals follow the guidelines they do so that we can respect the sanctity of human life, and may unite to preserve it as best as possible in times of disaster. If there is one thing we should not lose from the pandemic, it is our humanity.
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