David Skorton: I'm David Skorton, president and CEO of the Association of American Medical Colleges and thank you for listening. The COVID-19 pandemic has forced hospitals to make plans for the most severe ethical dilemma they can face: deciding what patients do and do not get critical medical care if there's not enough to go around. If blood is in short supply, do doctors give it to a young mother instead of an elderly man? Do doctors take a ventilator from one patient and give it to another who has a better chance to survive? Who decides and how?
Dr. Arthur Derse has been helping hospitals develop policies on how to make those decisions as the director of the Center for Bioethics and Medical Humanities at the Medical College of Wisconsin. He's here to talk about the ethics of rationing care in the time of COVID.
And I'm also joined my colleague Dr. Ross McKinney, the AAMC's chief scientific officer, an infectious disease specialist, and a member of the Duke University faculty for over 30 years. During his time at Duke he was director of the division of pediatric infectious diseases, vice-dean for research at Duke University School of Medicine, and director of the Trent Center for Bioethics, Humanities, and History of Medicine. Dr. McKinney leads the AAMC programs that support medical research and the training of physician scientists in academic medicine.
Thank you both for joining me today on "Beyond the White Coat."
David Skorton: So, Dr. Derse, how is COVID forcing hospitals to prepare for life and death decisions in ways that they have not done for other epidemics? After all, we do have ration medical care sometimes, for example after natural disasters.
Dr. Arthur Derse: Um, David, it's an excellent question because for the majority of hospitals in the United States we do not have to ration almost anything. We tend to provide everything we can for our patients under the circumstances, anything that can make them better. We have had natural disasters, hurricanes and other disasters, in which there have had to be rationing decisions made in the emergency circumstances. But in general, the cavalry came. We had more technology, more people, more help, and so those situations were rare, often in other countries besides ours. For the first time, we have to think about our technology and the fact that it may not be available at the time that we need it. We actually have faced this before in one way, and that is with organ transplantation where that is a limited resource as well and decisions are made about who to give them to, and people who don't get them actually die. About 20 people a day die due to lack of organs. So, we are used to it in that situation but we're not used to it for almost everything else.
David Skorton: Dr. McKinney, as physicians we are trained to do all we can for our patients, but ethical guidelines that have been developed for COVID say that the goal is to save the most lives, even at the expense of some virus victims if there are not enough resources. Tell me about the conversations you've had with physicians about that. This must be very hard for some of us.
Dr. Ross McKinney: Well, it is hard, 'cause you've spent your whole career focused on taking care of one person, one at a time, giving them your attention and all that's necessary for them to get better. And here you're in a situation where you may have to decide that that resource is better expended on a different person if there's a limited resource available than the person that you've been taking care of. So that's a real dilemma that we haven't had to face. Um, and – and it does create angst, um, and has been creating angst in the intensive care physicians who are working in those environments, um, where they're really at the limits of their resources. Um, I think a lot of them are very ingenious in finding other ways to solve problems, um, ability to use methods other than ventilators to provide oxygen. Um, but I think it's a, uh – it's a real challenge that creates, um, angst for our physicians. Uh, it's just so different from anything that we've had to confront before.
David Skorton: Dr. Derse, some hospitals have decided to establish uniform or nearly-uniform do-not-resuscitate policies rather than to use the usual individual discussions. What is the basis for these policies, and do you think they are justified?
Dr. Arthur Derse: The basis for these policies is the fact that patients with COVID, um, if they reach the point of cardiopulmonary arrest, are extremely unlikely to be resuscitated. And also, you add to that the fact that the response generally for a resuscitation is very quick, but for these resuscitations the, um, physicians and others have to put on personal protective equipment to be able to respond quickly. So suddenly there are these other things that show very low likelihood of success and the long lag with that, and so I think, um, they are justified under the, um, principle of medical futility. When this is not going to work and not going to help, it's justified. However, given the fact that everyone in a hospital during a COVID crisis is going to be looked at and treated, uh, in a similar fashion, I think that the DNR orders should be applied based on the individual diagnosis and not a blanket do-not-resuscitate order for everyone. Not all hospitals agree. But I do think that determination can be made and might apply more appropriately for COVID patients.
David Skorton: Dr. Derse, I see that hospitals are developing triage teams to decide whether to deny or withdraw medical care from a critically ill COVID patient instead of having the patient's doctor making the decision. Why is this happening?
Dr. Arthur Derse: Well, first of all, I probably would say that it's actually deciding whether or not the patient will get treatment, but they will get care no matter what. We're going to care under any circumstances. And I think of it less as denying a certain intervention than saying, "Under these circumstances, they're not a-appropriate." But the reason that they're creating triage teams is because of the, um, uh – the normal mission that Ross mentioned of our physicians acting in the best interests of our patients and treating physicians at the bedside aren't readily able to switch that on and off. So instead they're being created – triage teams that would look at medical factors of survivability and applicability, be blinded to certain personal aspects about the individual, look at those, and decide who could best benefit or who could better benefit from the intervention.
David Skorton: Dr. McKinney, following on this discussion of triage teams, what do you think these teams should base their decisions on? And similarly, what should they not consider?
Dr. Ross McKinney: The medical decision making is what the team should be focusing on. Is the particular intervention in question something that's going to be medically useful for the individual who they are looking at? And you could strip away all the other information, um, about the individual, in-information like, for example, how well off they are, how poor they are, what their race is. Um, but there may be information that is medically relevant. For example, I know in Italy they, uh, used, uh, body mass index as one of the criteria whether they would use ventilation, because people with higher body mass indexes did not respond well to ventilation and did not benefit from it. So, if you had a limited number of ventilators, that might be one of the factors that you would use, that somebody who was obese may not – it may not be medically suitable. It's not a judgment about who they are, but it's a medical judgment. They should not look at things like financial status, like race, like socioeconomic status.
David Skorton: Dr. McKinney, age might be the most sensitive issue of all, deciding who gets care when there's not enough for everyone. Now I'm 70 years old. When might my age become a factor in such a decision and why would it be a factor?
Dr. Ross McKinney: So, there are two reasons your age might be a factor. Um, one is just the medical, that we know that people who are older tend to get more ill with, um, COVID-19, and the probability of any intervention being successful becomes, um, lower the older somebody is. So, for people who are over the age of 80, the mortality with this disease is over 15 percent. Um, in the 70s it's around ten percent. So – so given that we know that mortality goes up, it is a factor that is worth considering in whether to offer an intervention. If somebody is, um, otherwise, uh, however equally likely to have, uh, therapeutic success, uh, then the question of age becomes one of fairness. And – and you might consider that you would give the younger individual the, uh, ventilator. If there's only one available, um, you might give it to the younger person because, um, they've had less chance to have a full life and it's a reason – it's a particularly good reason, um, to offer the ventilator to a younger person in this situation.
David Skorton: Dr. Derse, you've said in the past that people need to know that everyone, no matter their stature – the mayor or someone unemployed – is being treated the same way. But if the clinical outlook for two patients is basically the same, then the decision makers might rely on something called the ‘multiplier effect’ as a tiebreaker. How would that concept come into play?
Dr. Arthur Derse: So the multiplier effect is one in which, if you save an individual, that person can get up and now save four individuals, five individuals, so it multiplies the number of folks who can be saved under certain circumstances. And often that is applied when the person is a health care worker because those are the people who can turn around and save lives. The problem with this epidemic, or this pandemic, is that we don't know yet whether or not the multiplier effect is going to be able to be in place. So, we don't know whether or not we're going to be able to pull someone who is a health care worker – we'll use that example – all the way through on a ventilator, and we know once someone's on a ventilator with COVID-19, their mortality is taking everyone, about 50 percent. So about half the people who are on those ventilators are not going to be – get, uh, off soon, and we don't know how soon those people are gonna be able to be turned around and – and are back in the – the fray, sort of speak. The other part, of course, is fairness to individuals. So if someone says, "I don't like the fact that there's this rationing, but if everybody is subject to the same rules, then I think it's fair," is I think an important principle that we don't want to lose. And the last part I think is that individuals want to have the sense that their doctors are on their side and the people who are taking care of them are in the same boat that they are in.
David Skorton: Dr. Derse, I have a quick follow-up to that I'd like you to consider, if you would. Lately we've been finding out that health equity issues are playing a role in this pandemic. We've learned that minorities tend to enter the situation in poorer health and perhaps do more poorly. As we think about health equity issues, does that place those in these groups at greater risk of being told that they will not receive care?
Dr. Arthur Derse: Um, well, I would say that it places some people in these groups of greater risk because of the comorbidities that have gone along with those disparities. So there's no question that there are some effects as a result of that. In this pandemic there have been disparities that we obviously see. Some of them may be due to the historical inequities. Some of them, for instance, men fare more poorly than women in this, depending up – you know regardless of all strata of society, and those have a disparate impact as well. So we can't at this time completely sort those out.
Nonetheless, there are those who say we look at the clinical values, the medical values, known as sequential organ failure, assessment scores, and we look at that, and then we look at whether or not they can make it just to a year from now so that we equalize as much as we can those disparities, and that's one way to try to address them. But there's no question that this pandemic is showing us things like access to health care, things like health insurance, visits to doctors – disparities are playing a significant role.
David Skorton: Dr. McKinney, we've heard a lot about a potential shortage of ventilators in intensive care units throughout the country, especially in so-called hot spots. In a situation where there are not enough ventilators, most people would find it hard to imagine removing someone from a ventilator even when there is another patient who could benefit more because in some way their situation is less dire. Why is that concept so difficult for us?
Dr. Ross McKinney: We find it hard to actually knowingly do harm. And we are willing to do harm indirectly, um, much more than we are willing to, uh, directly create harm. The classic, uh, thought experiment that – that has been used by philosophers for a long time is, uh – I'll call it the football player on the bridge, that if there was a, uh, group of people standing on a railroad track ,down track, um, how would you feel if you were opposite a football player and could push him over the bridge and he'd be big enough to stop the train just by landing there? Would you do that if you knew that you could save five, ten people? And the answer is almost nobody is in a position to say, "You know, I would do that," in these thought experiments because we can't – we don't like to take a direct action. So removing somebody from a ventilator is knowingly creating harm to an individual and we find it much easier to do something – indirectly, passively, than to do it as a direct action like removing the ventilator.
Dr. Arthur Derse: I agree that this is unfortunately – every philosopher, ethicist, doctor's nightmare is the trolley problem is now, you know, real. I will say that I think that there is a a slight difference, and that is the ventilators that would be contemplated for removal would be from people who may not be benefiting from them and may not be showing that they can be benefited from them. So it's not like this is a known, um, lifesaving intervention that always works; instead I think that were there those decisions to be made, they would be made where there would be clear differences and where it was unlikely that the individual would've been helped by that. I certainly hope we're never in the situation where two people would have almost exactly equal possibilities of being helped.
But having said that, you're exactly right. We are not used to taking away interventions. However, I think ventilators in this case, of course, uh, might be beneficial but we don't know, and so I don't know that we can classify them as clear benefit. But it is true that in times of, um, uh, plenty, uh, doctors were always willing to do things that might have some chance of helping, even if surveys showed that they wouldn't have this done for themselves or the family, but they thought, you know, what's to lose other than time, money, and – and, you know, uh, trying to just see if it would work? Now we're in a different situation and I think we're really challenged by that.
David Skorton: Dr. McKinney, any further thoughts on that issue?
Dr. Ross McKinney: I actually think Art has made very good points. But I will say from my experiences, personal experiences, it is really hard when you reach that point where you have to think about either turning off the ventilator or pulling somebody off. Um, there's always that point of no return that you have a sense. Um, and yeah, we do that. We all have to do that when we're in intensive care situations, so it's not – it's not unexpected that you would be in that. But in this particular case you'll have that weight: Did I make the decision because of this other person? Did I value that other person more greatly than the person from whom I withdrew it? Which is part of the reason you need the triage teams. You need somebody other than the care provider, um, to sort of ameliorate the – the person guilt that you'd feel with pulling out the tube.
David Skorton: Dr. Derse, I know that you've talked with many doctors, countless doctors and hospital leaders over the past few weeks about the ethics of how to make these life and death decisions. If they get to that point, what do you think worries physicians and hospital executives the most?
Dr. Arthur Derse: I think the distress that we were just talking about, a real, inner, moral distress and moral injury from the fact that the patients for whom you are trying to accomplish the best may not be able to receive that. I think also, the public acceptance and understanding of this – pretty much every system agrees that something must be done, that it's not ethical to just say, "We're just gonna take first come, first serve, and when we're filled, that's too bad no matter the prognosis of the individuals who are on the current life support systems and no matter how young and deserving, uh, a person might be. We're just gonna come with first come, first serve." I don't think most systems think that that's an ethical approach. And yet any other approach is very difficult for the public to understand.
I think family inability to understand this of course is another factor, and family inability to be with their loved one at the point at which they are dying. So even if everything is done for some patients, they will die in the hospital on the ventilator, and these family members will not be able to be with their loved one and the loved one will all – often be unconscious and unaware of their concerns and presence. So I think that's a very difficult aspect.
And I do think that one thing that physicians should discuss with patients when they're conscious and alert is their wishes with regard to life-sustaining medical treatment, because no one should have these interventions if they don't want them, and a significant number of people tell us they do not want to die on a ventilator. So that option to refuse that is always the case, and these decisions are ones that clinicians and their patients should talk about early on in the process. It's possible that if they want these, they still might not be benefited by them and they still may not even get them if there is a major shortage. But there's no question that, um, they should at least be able to express their preferences before, uh, they reach the point where they're no longer able to tell us.
David Skorton: Well, I want to thank both of you, Dr. Derse and Dr. McKinney, for helping us think through some of these issues. Reflecting back on my own medical career, I did have to on very rare occasion, cease life support for a patient in a circumstance where it really had nothing to do with competing priorities. It just had to do with the helplessness of the situation. And, Dr. McKinney, as you mentioned, I found that extraordinarily, extraordinarily hard to do. I still think about it at times decades later.
I want to thank both of you for joining us today and for sharing your great insights and wisdom in these important and timely and very difficult situations.
Dr. Arthur Derse: Thank you so much. And let me say that Ross and I, I think I can talk with you hour about this, and um really appreciate your insight into these. I realize we already said this, but these are questions that we have not asked and since we don’t have a national system and a national answer to this it is both dependent about the states and we didn’t talk about liability protection and that’s yet another issue. And then of course it all falls on the various systems, but I do think it falls on academic medical centers more, so I really appreciate this topic being addressed.
David Skorton: Thanks to both of, you're both working overtime to do this.
Now to our listeners, if you have any questions or thoughts to share, we sure welcome your feedback and comments. And you can send them through the AAMC's social media channels using the hashtag #BeyondTheWhiteCoatPodcast. That's #BeyondTheWhiteCoatPodcast. Thank you very much to Dr. Derse. Thank you very much to Dr. McKinney. And we'll look forward to talking to you again soon in another episode of "Beyond the White Coat."
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