Quyen D. Chu, MD, MBA, FACS
The unprecedented COVID-19 crisis has challenged us, as a society, to evaluate our core values and philosophy. Ventilators, a precious and limited commodity, are now in short supply. Humanity is at a precipice, and we physicians are facing an ethical dilemma, how best to allocate ventilators, and, tangentially, a decision of who is “more worthy” of receiving these life-saving machines. In essence, we are being asked to play God, a role that, if history has taught us anything, is fraught with horrible consequences and regrets.
Realizing that clinicians are ethically torn with such a dilemma, distinguished bioethicists and select think tanks have codified a set of guidelines to help clinicians make such a decision. There are scoring systems created to determine who gets to be at the “top of the class” and who is relegated to the “bottom of the class”; hence, the top of the class are those worthy of life-saving measures, whereas those at the bottom of the class…well, sorry, our hands were tied.
“In essence, physicians are being asked to play God, a role that, if history has taught us anything, is fraught with horrible consequences and regrets.”— Quyen D. Chu, MD, MBA, FACS
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To further alleviate clinicians of the responsibility for making such sacrosanct decisions of life and death, these groups of experts, with the best of intentions, have also proposed to create an external committee to help with such decisions. The committee comprises individuals who are impartial to the patient and, in essence, devoid of any human attachments.
Although there are variations among the different guidelines, their utilitarian approaches are similar:
- Reserve intubation for those who have the best chance of survival.
- Those who are most critical to public health response (ie, those with instrumental value) take priority over those who are less critical (ie, first-responders, nurses, and doctors have top priority).
- The young should be given priority over the elderly.
- The healthy should be given priority over those with serious illnesses.
- The productive members of society should be given priority over the less productive ones (ie, those who have Alzheimer’s disease, terminal cancer, severe heart disease have low priority).
- Ventilators can be removed from one patient and given to another without patient’s consent.
Are Tangibles Really More Valuable Than Intangibles?
Although these guidelines were created to address trying times, in my humble opinion, they are fraught with dangers and go against the Hippocratic Oath: “Do no harm and, above all, I must not play at God.” Our responsibility, as clinicians, is to protect the vulnerable and the voiceless, not to create a “Brave New World.” These guidelines also appear to be self-serving; since we health-care workers have the key to life, we therefore get to use ventilators first. Is that really a noble endeavor? What will society think of us and our noble profession?
The utilitarian will have us believe tangibles are more valuable than intangibles. Elderly patients are mothers, fathers, grandfathers, grandmothers, aunts, and uncles, all of whom have intangible values. Who will offer us wisdom and help guide us out of this chaotic world? When the decision that intubation is needed, does one really have time to consult a committee, and will that committee be available at 3:00 AM? Finally, a decision devoid of emotional attachments is the very one we will come to regret later. I cannot think of a health-care worker who breathes a sigh of relief because some “committee” has made an “emotionally charged” decision for him/her. I do not believe we clinicians entered medicine to escape from having to make difficult ethical decisions.
The Greater Good
I remember growing up in a squalid neighborhood. As immigrants, we were dirt poor and did not have much to offer to our adopted country. What my parents lacked in material wealth, they made up with emotional and moral wealth. They ingrained into us kids the philosophy that the strong are responsible to care and look after the weak and that, during tough times, we look after each other and our neighbors.
I remember a time when we kids were hungry for a snack after swimming but were not able to afford it. My older sister’s friend gave her an oatmeal cookie, but instead of consuming it, she gave it to me. I told her I was not hungry and instead gave it to my younger sister. My younger sister also declined and said she too was not hungry and our oldest should take it. We went about like this for quite some time until my older sister divided the cookie into thirds. Were we still hungry? Absolutely, but we learned that even during trying times, it should never be “all for me and none for you.”
Staying True to Patient Autonomy and Nonmaleficence
I do not have all the answers to this perplexing problem, but I do know the current suggestions are not them. We need to reassess current guidelines and stay true to the principle of patient autonomy and nonmaleficence. The bond between the patient and the physician is a sacred one. Patients come to us, fully trusting we will treat them as if they were our own family members.
Thus, the decision to intubate or not to intubate can be made jointly between clinicians and patients. Clinicians can outline to patients and their loved ones the likelihood of success with intubation and allow the patients to arrive at such a shared decision. One will be surprised at how reasonable and understanding patients and their loved ones can be, especially in a time of crisis such as this. If intubation is a futile endeavor and patients wish to proceed, clinicians, patients, and their loved ones should agree upon a set of expectations, beyond which futile care should cease for the sake of the dignity of the patients.
“No other time in our life is more critical than now, and how we care for vulnerable patients will be judged by generations to come.”— Quyen D. Chu, MD, MBA, FACS
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No other time in our life is more critical than now, and how we care for vulnerable patients will be judged by generations to come. Will we be haunted by following guidelines that are modeled after The Hunger Games, or will we stand proud knowing we provided the best care for all to the best of our ability? In these unprecedented times, lives will be lost, but we, as a society, should take solace in being able to preserve our humanity. When all of this is over, and it will be, do we want our children to ask us, “I wish Grandpa was here to help me finish the bookcase. Why did the doctors let him die?”
DISCLOSURE: Dr. Chu reported no conflicts of interest.
Dr. Chu is Professor of Surgery and Chief of the Division of Surgical Oncology at Ochsner-LSU Health, Shreveport, Louisiana. He is a recipient of the ASCO Humanitarian Award, the Gazi B. Zibari Americas-Hepato-Pancreato-Biliary Association Humanitarian Award, and the Charles Black Humanitarian Award.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
