Who Decides Who Lives and Dies?

As an audience filed into a Duke Hospital auditorium last week to hear Philip M. Rosoff talk about the ethical difficulties of apportioning scarce resources to fight a pandemic, a line of people waiting for flu shots in the hallway outside stretched out of sight.

Rosoff, a professor of Pediatrics and Medicine at the Trent Center for Bioethics, Humanities and History of Medicine, raised the same question as the flu shot queue: “How does one equitably distribute limited resources to as many as could benefit from them?”

Who will live and who will die? Who decides? As a result of improved technology and effectiveness of medicine, healthcare workers must make increasingly difficult decisions.

“Most of the dilemmas facing medicine in 2008 did not exist in 1918,” Rosoff said. “You either got better, or you died.”

“Our expectations of what modern scientific medicine can provide are totally different today. We expect ‘miracles’ every day and are vastly disappointed and even shocked when medicine doesn’t deliver,” Rosoff said.

With scarce resources in the emergency room, how would you choose between a 21-year-old honor student and an 86-year-old nursing home resident? Not a difficult choice for most in the audience. But how would you choose between a 21-year-old honor student and a 40-year-old mother of three young children? Between two 21-year-old honor students? Or between an honor student and the child of a colleague? The audience grew solemn as he went down the list.

“Everyone was happy to knock off granny,” Rosoff joked.

Planning for a potential epidemic reveals some critical problems. “Even during a regular flu season, about 100,000 medical ventilators are in use. In a worst-case human pandemic, the country would need as many as 742,500,” Rosoff said.

Duke Hospital has a supply of 150 ventilators, of which 90% are in use or in repair in any given time. Of those, a number are suitable only for infants or young children. The Strategic National Stockpile has 4,900 ventilators in strategic locations across the country and hospitals nationwide have about 105,000 ventilators.

“People will still get cancer, will still have heart attacks, acute appendicitis and premature babies and thus need hospitalization: what happens to them if we have a pandemic? Do we send the 65-year-old cancer patient home so we have a bed for the 35-year-old with influenza?”

Rosoff said some allocation systems have been proposed:

• Minor adaptations of standard emergency department triage systems for assigning ventilators
  
• The “life cycle principle” for rationing vaccine, privileging the young over the old (with the idea that each person should have an opportunity to live through the different cycles of life)
  
• A variation of the organ transplant distribution system, which is already widely accepted

“We should not ration care based on morally arbitrary and irrelevant features about people, such as skin color, ethnicity, religion, age, gender, etc. ... Social worth -- however you feel about people -- should not play into it.”

“Decision making and planning should be transparent and reasons for decisions should be available and defensible,” Rosoff said. “We should apportion care based upon substantiated and justified evidence of its efficacy. We can make societal decisions that anyone over a certain age, or anyone with certain types of disabilities or people not in the country legally will not be eligible for curative care, but this has to be a consensus decision.”

Most importantly, “we must be prepared and have thought through many of these issues ahead of time.”

His proposal for North Carolina, once a healthcare emergency has been declared and resources are scarce:

• Initiate the Hospital Emergency Incident Command System to coordinate resource allocation.
  
• Pre-existing conditions will exclude some patients from consideration for life-preserving care. For example: severe cognitive impairment, heart failure, liver disease, metastatic cancer with less than a year life expectancy and severe burns.
  
• Life preserving resources will be allocated to patients based upon a modified SOFA score with age component (younger patients privileged).
  
• There will be an appeals process available to patent families 24/7 to contest a decision.
  
• Healthcare workers with influenza would not be privileged to receive resources ahead of other patients (colleagues and coworkers do not jump to the head of line -- this is to bestow legitimacy for the public)

“We must reaffirm our moral commitments to serve as a guide for our actions,” Rosoff said. “Hard choices must be public, acceptable and justifiable.”