Who lives, who dies — and who decides?

The COVID-19 catastrophe is about to require Americans to make tough decisions for how to allocate scarce resources that can determine life and death.

This is especially true with ventilators and beds in intensive care units. Many hospitalized patients in ICUs are dying of cancer or advanced irreversible dementia, or are on ventilators because of irreversible heart, lung or liver failure. In a large proportion of these kinds of cases, physicians caring for the patient recognize that death is imminent, but treatment continues, often because families are unwilling to recognize the inevitable.

Americans value their autonomy in such situations, so persuading families to forgo further medical treatment is challenging and often elicits considerable anger. Doctors understandably tend to avoid these difficult conversations if they encounter resistance.

With the rapidly expanding COVID-19 pandemic, there is a strong likelihood that, despite heroic efforts by hospitals, we will run out of ICU beds and ventilators. If we continue to prioritize patients for whom meaningful recovery is virtually impossible, we may be doing this at the expense of patients with greater prospects of recovery with appropriate treatment.

Inappropriate use of criticalcare resources is not new. Intensive care that prolongs life without achieving an effect that the patient can appreciate as a benefit is all too common in the U.S. healthcare system. But the consequences of doing this have not been easy for the public to discern — like wasted resources, patients waiting longer in emergency rooms for critical-care beds or those needing organ transplants dying in small hospitals while waiting for a bed at the transplant center.

As is beginning to happen in New York City, and has already happened widely in

Italy, the demand for ICU beds for COVID-19 patients will overwhelm the supply, and lives will be lost as a result.

What are we to do? Some may say it’s impossible to put anyone in the position of making a “Sophie’s Choice”-type decision about who will live and who will die. But it is not just ethically acceptable to prioritize treatment for a patient more likely to benefit compared with another, it is an ethical imperative.

Medical care is a shared societal resource to be applied where it is most effective. Under conditions of criticalcare overload, we must ensure that patients who are most likely to benefit receive treatment. Triage choices must be based on the best possible objective models predicting clinical outcomes and never on irrelevant criteria such as ethnicity or gender, ability to pay or family insistence that their loved ones get the ICU beds.

Likewise, triage based on arrival time at the hospital is too blunt a way to allocate a valuable resource. All intensive care is a time-limited trial intended to save lives. Patients who get worse rather than better with optimal treatment, who are less likely to benefit compared with others in need who are waiting, or who may not benefit at all, must lose their spots.

In the COVID-19 crisis, this means that ventilators and

ICU beds should be denied to or withdrawn from patients for whom the benefits are minimal at best, and those resources given to patients who are more likely to survive. These gut-wrenching actions must be carried out with compassion, support and palliation.

When objective measures are not used to allocate a scarce resource, those with influence and wealth win out.

We have already seen this with coronavirus testing, with athletes and celebrities with no symptoms being tested, contrary to testing guidelines, while others exhibiting symptoms have not received the test. Fair distribution of scarce resources requires knowledge, unbiased implementation, ethical firmness and transparency.

The American public needs to be educated on the rules for medical decision-making so that it’s clear why some patients receive treatment while others do not. By standing together, we can achieve the best outcomes for the most people.

Neil S. Wenger is a professor of medicine at the David Geffen School of Medicine at UCLA. Martin F. Shapiro is a professor of medicine at Weill Cornell Medical College.

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