In the coronavirus pandemic, hospital bioethics committees — and doctors and nurses — find themselves in confusion over rationing necessary supplies. And the principles of bioethics — doing good, doing no harm, doing justice and allowing patients to make their own health care decisions — offer little clear guidance.
By what measure of justice should hospitals decide who should receive precious personal protective equipment? Because of shortages, some hospitals have asked staff to place their disposable gowns in paper bags labeled with their names at the end of the day so that, the next day, they can reuse them, even though they may be laden with coronavirus. Are hospitals doing harm to staff by asking them to do this?
And some hospitals have had to consider giving ventilators only to the sickest of the sick or having two sick patients share one, as there just are not enough to give to every patient who may benefit from one. How do doctors and nurses balance allowing patients to make their own health care decisions when these doctors and nurses have to make decisions for patients because there are not enough ventilators?
What if, instead of trying to make sense of these intractable decisions through principles of bioethics, we consider our obligations?
Governments’ and hospitals’ first obligation is to the lives of health care workers, without whose safety no coronavirus patient can be cared for. It strains credulity that governments and hospitals did not see this pandemic coming — and cannot find the resources now to scale up production of personal protective equipment, of which some health care workers have resorted to making substandard versions for themselves.
The same goes for ventilators. President Donald J. Trump reported on Tuesday that the U.S. government is sitting on 10,000 ventilators and will distribute them only when the crisis worsens. That same day, in New York City alone, 332 people died from the effects of being infected with the coronavirus. Not to have anticipated that this pandemic would march across the globe, and not to have distributed those waiting-in-the-wings ventilators before it felled thousands and thousands of American lives, is the grossest failure of obligation.
When considering whom to give a finite set of ventilators to, we have an obligation to give them to people who are most likely to survive, regardless of wealth or status.
And yes, length of survival matters. Any parent would instinctively seek to save a child in large part because parents know that children have longer to live and more chance of propagating life. This is not to say that any patient over a certain age should never be placed on a ventilator.
While I would hope all would be done to save me, I would hope more that, if it were between me and someone younger, the younger person would be given the ventilator. There may be a younger person in the bed next to me who has it worse and, if a ventilator would not save his life, it would make sense to give it to me. But all other things being equal, we have an obligation to the future of human life when deciding who gets ventilators when there are not enough to go around.
This is not a utilitarian argument to increase the good compared to the bad, even though there is a lot of bad right now and anything good that can be done should be done. Rather, it is a guiding question, a way of thinking: How ought we act in this pandemic such that we best fulfill our obligations to health care workers and to the next generation?
This way of thinking will not make doctors’ and nurses’ difficult decisions any easier. But it will give them — and us, the public — more clarity than the confusion we currently find ourselves in.
Mark Lazenby is a professor of philosophy and nursing at the University of Connecticut.