Difficult Circumstances Require Tough Decisions

Given the impending evisceration of Medicaid, potential cuts to Medicare, and reductions in medical foreign aid, many ill individuals will face decreased access to supplies, equipment, and staff, necessitating difficult decisions about who receives care and how much treatment they will receive. Those making these decisions will have the uncomfortable choice of refusing treatments. This is the opposite of what they trained to do, possibly creating a negative psychological impact. These pronouncements, though undesirable, can be justified through religious and secular theories of medical ethics. That justification requires that they are provided they are made on a rational basis. Responding to the Circumstances at Hand Utilitarian ethics are often viewed as a monolith associated with totalitarianism, restrictive of individual rights, and only valued when productive, rather than a societal burden. Nevertheless, it is not a single entity, but several theories, and while some fit the totalitarian mold, others do not, as they neither emphasize governmental control nor value people based on their productive value. Communitarianism One version, Communitarianism, focuses on maximizing individual well-being within the context of community welfare. It includes the concept that for each right an individual has, there is a corresponding communal responsibility. Over the last few decades, there has been a growing and disappointing emphasis on personal rights. This is tied to a corresponding decline in communal responsibilities. Compare the public’s enthusiastic response to the polio vaccine in the mid-1950s with the hesitancy to the COVID-19 vaccine of the last few years. Consider the willingness of people to cooperate with guidelines during the 1918 Influenza epidemic, with the antagonism to similar recommendations more recently. Both state and federal governments responded poorly and failed to support public health as forcefully as they should have. Given the anticipated scarcity of medical resources, the proposed model prioritizes community health. Individual care is determined by illness severity, with those having the poorest prognoses receiving the least care. This does not imply that one person’s worth is less than another’s. Instead, it emphasizes that the benefits derived from limited resources would be considered and allocated to those who will profit the most from them. These will be value judgments. Therefore, oversight would be essential to detect and eliminate discrimination through a committee of experts and community members. Jewish Medical Ethics Differential care has also been considered in Jewish medical ethics [pdf]. Suppose two individuals require the only available ventilator, a doctor may choose which patient receives its benefits. Here, too, the decision does not imply a different valuation of life. Rather, it asks who would best benefit from the only available ventilator. As with the Communitarian perspective, the decision must be rationally based. It must also be flexible and not driven by emotion or bias. This would necessitate an honest appraisal, for example, of whether a surgery would be beneficial rather than hoping it would. It would require quantifying, at least crudely, disorders or injuries in terms of number and severity. A 1% chance of improvement or survival may no longer be a justifiable rationale for prolonging Cardio-Pulmonary resuscitation, as argued in a recent JAMA article, but would require a higher threshold. In some instances, consideration may be given to not treating a secondary condition (e.g., a urinary tract infection) in a terminally ill patient. This could improve quality of life or even longevity and would likely be treated unhesitatingly under normal circumstances. Yet, given limited resources, it would be reasonable to question whether treatment served a meaningful purpose. After all, the antibiotics may preserve the life of a non-terminal individual. Although medical knowledge cannot guarantee endpoints with 100% accuracy, it remains a reasonable measure for decision-making as opposed to emotion or other non-quantifiable factors. Putting the Best Foot Forward A hospital’s ethics committee, or its equivalent, with community representatives, would be best suited to develop guidelines. The members will need training in rational decision-making and the criteria that inform their decisions [pdf], within the relevant cultural standards of each country or community. This is required, as researchers have reported that many existing committees lack ethical knowledge and community diversity. This would be a novel approach in countries where medical resource scarcity is a daily reality, but where there is often no ethical framework undergirding care decisions. These guidelines must be broad. Each case will require an individualized decision based on its unique circumstances. These circumstances must incorporate evolving knowledge and the availability of materials that will fluctuate daily. Conserving resources for an uncertain future would be unjustified. It could result in care deprivation for a patient who presently requires and can benefit from them. If it is known that resupply would not occur until a specific date, it would be appropriate to take this into account and allot a particular amount per day. Planning for Future Resource Scarcity Given the anticipated scarcity, patient or surrogate choice for treatments would likely become less relevant. Meanwhile, physician decisions would increase in prominence. As noted, case review for bias is necessary. However, other than bias, treatment decisions should not be questioned. This could hinder physicians’ ability to make choices, as they would be concerned about criticism, and this could impair system functioning. This type of review was recently conducted, examining the records of cardiac resuscitations to determine if managing physicians, despite following hospital protocols, discontinued treatment efforts too quickly. It was decided that, in a few cases, using a 1% criterion of survivability, they had stopped too soon. This assessment was unrealistic, as it is too easy to provide a critique when one has time for reflection and discussion. However, this is not comparable to a physician who has mere seconds to make decisions to prevent brain damage, and where hesitancy and second-guessing oneself can absorb valuable time. Additionally, medical records are not complete transcripts. They do not contain all the information a treating physician absorbs or the doctor’s decision-making process. Absent these, but for an egregious error or direct testimony of someone who witnessed and/or participated in the resuscitation, a panel reading notes cannot conclude that efforts were stopped too soon. As well, the validity of records as a review tool has been critiqued for their lack of standardization and incompleteness. What this All Means Having to make decisions about who is denied care will be deleterious to doctors, and they will need therapy. This should be mandatory, as, like first responders, they will not do this voluntarily, believing it to be unnecessary. Without this assistance, there will be increased burnout and suicides, however. Other staff members will also experience stress and should not be neglected. Only in this manner may the best be made of difficult times.