As the United States careens along the coronavirus pandemic path a week behind Italy, medical providers are soon likely to face horrific decisions about rationing care as the nation literally runs out of ICU beds and ventilators. If there are 600 ventilators and 1,000 people who need them—a situation Wuhan faced—what do you do?
Decisions about rationing care are made every day in the United States, of course. They just happen on the basis of money—of who has insurance or the money to pay medical bills—and our system tells us this is natural and fair. The concept of rationing care because there literally aren’t enough beds or ventilators to go around is a new and terrifying one. “The public will accept triage and rationing if they understand the process,” one bioethicist told The Washington Post. “But if it’s secretive or looks like favoritism to politicians or the rich, they will not accept that—whatever the rules are.”
In Italy, doctors have decided to prioritize patients with a better chance of long-term survival over those who are the sickest. The Italian critical care society backed choices that “privilege greater life expectancy,” including age limits on access to forms of intensive care that are in short supply. But that won’t just apply to older people. Priority for care may be given to those “most likely to live a long life after they got though the current epidemic”—which means not to, for instance, cancer patients, Johns Hopkins associate professor of pulmonary and critical care Lee Daugherty Biddison told The Post. Another said that people who were not improving with treatment could be taken off of ventilators: “If a patient is not getting better, has little path to survival, at what point are we willing to move an intervention rather than lose two lives?”
Even if they’re theoretically impartial, though, these decisions could exacerbate some of the inequities of the U.S. medical system. People who haven’t received adequate care for years are more likely to have—and have extreme versions of—the underlying conditions that may disqualify them for care now. “So if you were to say, ‘Look, you are unwell because of diabetes and you’re also not going to get a ventilator,’ you are double penalizing someone who didn’t have access to care,” Daugherty Biddison said.
Before the U.S. gets to rationing (of a kind other than market-based), hospitals may try other strategies. “If the number of victims surges beyond that capacity, they say, they may try novel approaches such as having two patients on one ventilator,” The Post reports. “Tubing for ventilators, which is usually thrown out, could be sanitized and reused. Other types of hospital equipment, such as those used for sleep apnea, could be repurposed as makeshift ventilators. Only if those strategies fail and the sick continue to exceed capacity would rationing protocols be put into place.”
The problem is that this looks likely to be an all of the above crisis—creative solutions, re-using equipment … and still rationing.