COVID-19 fight may force choices of life and death

The Kansas City Star - - Opinion - BY JOHN D. LANTOS Spe­cial to The Star John D. Lantos is di­rec­tor of the Bioethics Cen­ter at Chil­dren’s Mercy Kansas City.

We are at war against COVID-19. The bat­tle re­quires an un­usual strat­egy. To win, we have to stay home and stay iso­lated to slow the spread of the virus. If we don’t, we won’t have the re­sources to care for our wounded and dy­ing. Our doc­tors and hos­pi­tals will have to de­cide who gets a breath­ing ma­chine or an in­ten­sive care unit bed.

The U.S has about 70,000 ICU beds for adults and an­other 5,000 for chil­dren, and they are al­ready mostly full most of the time. Mil­i­tary hospi­tal ships have a cou­ple hun­dred more. Our hos­pi­tals have roughly 160,000 breath­ing machines, with a na­tional stock­pile of an­other 12,700.

The goal of all the lock­downs and so­cial dis­tanc­ing poli­cies of the last few weeks has been to de­crease the num­ber of pa­tients who will need those ICU beds. We will soon know how well those mea­sures have worked.

In Europe, doc­tors are mak­ing tragic choices. One doc­tor in Italy wrote that “older pa­tients are not be­ing re­sus­ci­tated and die alone.” A nurse said, “We are not even count­ing the dead any­more.” Doc­tors and nurses here could soon be fac­ing those choices.

This week, two ar­ti­cles in The New Eng­land Jour­nal of Medicine pro­pose eth­i­cal guide­lines for de­ci­sions about who gets a ven­ti­la­tor. They make for chill­ing read­ing.

In nor­mal times, de­ci­sions about life-sus­tain­ing treat­ment are made in care­ful con­ver­sa­tions between doc­tors and pa­tients. The guid­ing eth­i­cal prin­ci­ple is re­spect for the pa­tient’s pref­er­ences. With pan­demic ethics, the guid­ing prin­ci­ple shifts to one of uti­liz­ing scarce re­sources in ways that will save the most lives. Pa­tient pref­er­ences no longer mat­ter. Ev­ery­one is treated equally with a goal of max­i­miz­ing over­all sur­vival.

Pan­demic ethics are sim­i­lar to those of triage on a bat­tle­field. A sol­dier whose in­juries are too se­vere to over­come is al­lowed to die so that lim­ited re­sources can be used to treat oth­ers with milder in­juries.

Coro­n­avirus is turn­ing our hos­pi­tals into bat­tle­fields. Our health pro­fes­sion­als are on the front lines, gird­ing for bat­tle. Elec­tive ser­vices and pro­ce­dures have been can­celed. Iso­la­tion wards have been cre­ated. Clin­i­cians are wear­ing the body ar­mor of gowns and masks (when they are avail­able). We are hop­ing for the best and brac­ing for the worst.

If our ef­forts to stop the in­vader have not worked, we will have to make tough choices. Pa­tients who are un­likely to be saved will be al­lowed to die. Good pal­lia­tive care can con­trol pain and suf­fer­ing and make deaths more peace­ful.


Th­ese de­ci­sions will be emo­tion­ally painful and eth­i­cally trou­bling. The pro­posed guide­lines sug­gest that they not be left to doc­tors at the bed­side. In­stead, they are to be made by triage com­mit­tees fol­low­ing strict pro­to­cols. Let’s be clear: Th­ese com­mit­tees are not “death pan­els.” Their goal is to use our scarce ICU re­sources to save as many lives as pos­si­ble when not all lives can be saved.

It may still be pos­si­ble to avoid pan­demic ethics. We all need to per­sist with and in­ten­sify our lock­downs and clo­sures to pre­vent the spread of the virus and de­crease the an­tic­i­pated strain on hos­pi­tals.

But we still may need to face the next col­lec­tive chal­lenges: sup­port­ing the dif­fi­cult work that clin­i­cians will have to do if the re­sources are not there to pro­vide all the care that pa­tients need. No doc­tor ever wants to let a pa­tient die from lack of re­sources. But such de­ci­sions may be nec­es­sary. To get through this, we need an in­formed pub­lic stand­ing in sol­i­dar­ity with a pre­pared health care sys­tem.

We can do this to­gether. We can only do this to­gether.

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