If the coronavirus pandemic causes a shortage of ventilators, who will be attached to these potentially life-saving machines and who won鈥檛?
This is the grim question doctors around the world are currently grappling with. Life-or-death choices are already being made in Italy, where covid-19 has claimed more than 7500 lives. Doctors in Bergamo in northern Italy that 鈥渙lder patients are not being resuscitated and die alone鈥� because hospital resources are so overstretched with cases.
According to , about 2 per cent of people who became infected with the covid-19 virus in the country before the end of January needed a ventilator to pump air with extra oxygen into their lungs via a tube, helping them to breathe. It normally takes a few weeks before the immune systems of people relying on such machines can clear the virus, allowing them to breathe on their own again.
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On 16 March, Italian recommended to the country鈥檚 hospital doctors that, if demand outstrips supply, ventilators should be preferentially given to patients with the best chance of recovery and the most years to live. Similar guidelines have also been published in and in .
Grey areas
This approach reflects an ethical framework called utilitarianism that aims to bring about the most good for the greatest number of people, says philosopher Julian Savulescu at the University of Oxford. But making these choices about who to save will be difficult, he says. One challenge is that we still don鈥檛 have a firm understanding of which health conditions affect the chance of surviving covid-19, he says.
One way around this kind of dilemma may be to implement a 鈥渢rial of treatment鈥� approach for people infected with the covid-19 virus whose outcomes are uncertain, says Savulescu. You could put them on a ventilator for a designated period 鈥� say a week 鈥� to see how they respond, before deciding whether to give it to someone else who may benefit more. 鈥淭hat way you give them a chance and you can also test your hypotheses,鈥� he says.
But it may be more traumatic for doctors to take patients off ventilators than to not put them on one in the first place, says medical ethicist David Hunter at the University of Adelaide in Australia. 鈥淧sychologically, that would be very tough on clinicians,鈥� he says.
Preferential access
When it comes to healthcare workers, front-line doctors and nurses who become seriously ill with covid-19 should be given preferential access to ventilators so they can recover and help others, according to a by an international group of doctors and medical ethicists.
This is the right call, says Hunter. 鈥淗ealthcare workers are putting themselves at risk, so there鈥檚 an obligation to take care of them,鈥� he says. In contrast, wealthy, famous or politically powerful people shouldn鈥檛 get special treatment, he says.
A tough question is whether people with children or other dependents should be prioritised, but it would be too hard to come up with fair criteria to decide this, says Savulescu. Another difficult situation would be if two people in the same circumstances both needed a ventilator, but only one was available, says bioethicist Wendy Rogers at Macquarie University in Australia. In such a situation, a lottery system may be the only way to make the decision, she says.
Race against time
At the moment, it is estimated that the UK, US and Australia have enough ventilators for all people with covid-19 who need them, but this could soon change.
The US has around that can be used at any one time, but it is that 240,000 to 5,250,000 people in the country will need a ventilator at some point during the covid-19 epidemic. If the virus has a similar impact in the UK, which has about , it is estimated that between 48,000 and 1,000,000 people may need one. In Australia, which has , between 18,000 and 400,000 people may need one. All three countries are trying to import and build more machines.
If countries are unable to source enough ventilators, their decisions about who will get access should be made transparent so that patients and their families can understand them, says Savulescu.
Moreover, guidelines should have enough flexibility to account for individual circumstances, he says. 鈥淭here鈥檚 no simple set of rules you can follow because each situation is going to be slightly different,鈥� he says.
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