key: cord-0969553-c12aag2q
authors: Angelos, Peter
title: Tragic choices and the reallocation of ventilators
date: 2020-06-12
journal: Surgery
DOI: 10.1016/j.surg.2020.05.005
sha: 10ec22bebaa99950a615526747f00d536ec2fb34
doc_id: 969553
cord_uid: c12aag2q

nan

Tragic choices and the reallocation of ventilators Chu et al have written on the important topic of reallocating a ventilator from one patient to another during the COVID-19 pandemic. 1 Although I disagree with many aspects of this paper, I commend the authors for their attempt to use philosophical arguments to defend their position. It is important to acknowledge that there are different ways to interpret ethical theories, and it is sometimes difficult to clearly show that one interpretation is better than others. Nevertheless, I believe that this is a problematic paper because it interprets multiple ethical theories in a particular manner to support a specific point of viewdnamely that removing one patient from a ventilator for another patient is inherently unethical even in periods of absolute ventilator scarcity. I enumerate here a few specific concerns.

Under the section "Ethics and Medicine," the authors state that of the 4 principles of medical ethics (autonomy, beneficence, nonmaleficence, and justice), nonmaleficence "takes precedence when in conflict with others." 1 Although this is a position that some may believe, it is not inherently true, and much of the subsequent argument is based on accepting this specific weighting of the principles. I believe that many people would disagree with the argument that taking a ventilator from one person in favor of another is like "pushing the fat man off the bridge." In my opinion, the interpretation of positive and negative duties is more nuanced than the authors describe. Thus, it is not clear to me that removing an endotracheal tube from one patient is always morally inferior to supportive care.

The authors discuss the harm to the public trust in the system if patients have their ventilators removed in favor of others. I am not convinced that this would be worse than the public finding out, for example, that one patient was kept on a ventilator in the midst of multisystem organ failure for weeks even when there were multiple other people who could have benefited from a short course of ventilator support. The authors seem to ignore the fact that in the face of absolute scarcity of resources, tragic choices are needed that do not make anyone feel good. Nevertheless, they may be ethically justified. The authors' proposed solution is one that I find problematic and lacking. They refer to the "sacred relationship" between patient and physician, but then allow doctors to define when further treatment is "futile" and to stop it even if the family wants the treatment to continue. This "solution" simply allows doctors to define when their patients should no longer receive the ventilator. I am not certain what makes this solution better than the same decision made for the sake of saving someone else. Furthermore, once the decision is made that further ventilation is futile, what makes taking the ventilator away from the patient in that case better? I find the concluding paragraph to be overly simplistic. To suggest that what is wrong with triage protocols in the COVID pandemic is that it asks doctors to "play God" seems to me to be an unfounded argument. There are many situations when surgeons decide that a patient may be too sick to tolerate an operation. Families sometimes accuse us of playing God when we say that there is no medical indication for surgery. I would argue that we are not "playing God" in those circumstances, but rather making the best medical/surgical judgment we can in the circumstances.

The authors seem to suggest that any triage decisions will be inherently unethical because they are subject to the unconscious biases that we all have. However, by keeping everyone who is ventilated on a ventilator even beyond the point that they might be salvageable creates a different type of potential discrimination. It means that those who have the greatest opportunity to get to a hospital the soonest (eg, those patients with the greatest financial means) will get the longest time on the ventilator regardless of the condition of those who arrive afterwards.

There is no easy fix for tough triage decisions. They are literally tragic choices. However, I would argue that it is better to make those decisions based on some assessment of likelihood of successful treatment rather than just using "first come, first served" with ventilators. The outright rejection of any utilitarian approach to making tough decisions strikes me as running counter to all the wartime decisions that surgeons have had to make for generations when they cannot save everyone.

Reallocating ventilators during the coronavirus disease 2019 pandemic: Is it ethical? Surgery

Contents lists available at ScienceDirect Surgery journal homepage