Jacob M. Appel, M.D, J.D., M.P.H.

The rationing of scarce resources has long posed one of the most challenging dilemmas in medical ethics. Much of the rationing in the American healthcare system occurs “invisibly” through the allocation of funding, especially with regard to preventive care:  Patients may never be offered smoking cessation therapy, for instance, and die years later of lung cancer without even realizing they are “victims” of a triage process. In contrast, “visible” victims—usually patients suffering from a serious illness who are denied care provided to others—prove far rarer, but as they are aware of  how they have been short-changed by the healthcare system, their plight usually generates far more controversy.

COVID-19 has once again brought the issue of “visible” rationing into the public eye.  During the early days of the pandemic, the limited supply of personal protective equipment (PPE) available to front-line providers made headlines. So did the question of how to allocate ventilators, which were widely believed would be life-saving for many patients, if, as predicted, demand inevitably exceeded supply during a “surge”.  (Ultimately, ventilators likely proved less helpful to many patients than had been anticipated and, in the United States, their number is sufficient to meet need even at the peak of the pandemic.) Acute kidney injury secondary to COVID also threatened the possibility that hemodialysis might need to be rationed. But how to do so?

Several proposals gained considerable traction. The State of Massachusetts issued “Crisis Standards of Care” that proposed allocation “based on two considerations: 1) saving the most lives; and 2) saving the most life-years.”¹ Another widely-considered model argued it was important for individuals to receive “equal opportunity to pass through the stages of life—childhood, young adulthood, middle age, and old age.”²   Some models explicitly excluded patients with certain diseases, such as heart failure, from ventilation. In Italy, at the height of the shortage, scarce machines were denied to patients on account of their advanced age. All of these disparate approaches shared one commonality: They started by considering every potential patient for care and then excluded a subset of less-worthy candidates.

This approach, rationing from below, makes sense when demand exceeds supply, yet supply still remains plentiful. The vast majority of patients in Italy who needed ventilator support did ultimately receive it and, even had New York City run short, many patients would still have received optimal care. One can debate whether the various criteria proposed for triage—short-term prognosis, life expectancy, comorbidities—are just. But at least there were meaningful ways of distinguishing among candidates.

A far different ethical dilemma arises when the pool of patients is large and the care required proves extremely scarce. COVID-19 initially appeared to offer this sort of rationing challenge as well. Extracorporeal membrane oxygenation (ECMO) is used in critical care as a therapy of last resort when ventilator support fails—and it was expected to prove a salvage remedy for corona patients. (In hindsight, the verdict on its efficacy is still out.) But while healthcare facilities may own scores or hundreds of ventilators, they usually only possess a handful of ECMO machines. Allocating space on these machines requires “rationing from above,” choosing a small number of patients from a larger pool of similarly situated candidates.

A reckoning of how ECMO machines were allocated is not yet available. Anecdotal evidence suggests it may have been done less than equitably. For instance, British Prime Minister Boris Johnson, during his bout with COVID-19, was reportedly taken to London’s St. Thomas’ Hospital in part because they had ECMO available on site. One wonders if he would have been given priority for such a machine over an ordinary citizen. And would the facility have kept a machine in reserve in case he required it urgently, even if that meant denying someone else acute care?   

Hospitals should release data on the use of ECMO during the early days of COVID-19.  How did they decide to place a patient on ECMO?  What are the demographics of those who received it? Do these figures reveal any preference for physicians or for hospital employees or for public officials? Even if the articulated eligibility criteria are strictly medical, with such an extreme scarcity, unconscious biases are likely to play a large role in the allocation process.

Medical ethicists have confronted very few cases in modern times that required rationing from above. The Allied Powers during the Second World War largely kept penicillin out of civilian hands, saving all available doses of the novel antibiotic for military purposes to maintain troop strength on the battlefield. During the early days of dialysis, the extremely scarce supply of life-saving machines led Swedish Hospital in Seattle to use perceived social worth as a criteria for eligibility, generating a sharp public backlash. But these have been rare exceptions. How to allocate scarce resources is the bread-and-butter of academic bioethics, but how to allocate extremely scarce resources is a conundrums largely ignored by policymakers. 

Clear policy is needed. Maybe our society will decide that the wealthy and powerful are more deserving of life-saving care in times of extreme scarcity—although I doubt it.  More likely, the most equitable approach will require either a first-come, first-served model or a raffle among candidates equally situated. But if ECMO wasn’t the answer this time around, it raised a profound question that inevitably will come up again—either in this pandemic or another crisis. How to ration from above, when necessary, is best resolved during times of relative health and tranquility rather than during the exigencies of a worldwide crisis. If we don’t address this issue the hard way now, we will have to address it the harder way later.     

Notes:

1. Massachusetts Department of Public Health guidance, “Crisis Standards of Care,” available at https://d279m997dpfwgl.cloudfront.net/wp/2020/04/CSC_April-7_2020.pdf.
2. White DB, Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. 2020;323(18):1773–1774. doi:10.1001/jama.2020.5046