Case: Mrs Wong & Mrs Tam
Treatment Priority During The COVID-19 Pandemic
Suppose now you have two patients:
A) Mrs. Wong/63. She has metastatic cancer disease. She has previously tried two different anti-cancer treatments yet the cancer still progresses, and now she is on a trial of the third treatment. She has received two doses of COVID vaccine, but unfortunately she still contracted COVID and is now down with it.
B) Mrs. Tam/83. She lives alone, with a few common chronic diseases on medical treatment. Her basic ADL is ok but requires home helper services for household chores. She is most worried about the side effects of COVID vaccine and has not received one. Now she is down with COVID.
Both patients are now hospitalized with equally high viral load and require the same level of high flow oxygen. You have only one course of the new anti-viral therapy. Whom will you give the treatment to? A or B?
– Dr. Mok Chun Keung, Consultant, M&G, Tuen Mun Hospital
Prioritization of patient management is not uncommon in clinical practice because of the mismatch between supply and demand in health care. However, only in extreme crisis situation of resource scarcity (e.g. during wartime or the current COVID epidemic) can resource “rationing” be implemented. Rationing means that indicated patients are denied of such critical treatment because of resource scarcity. The underlying ethical principle of rationing is “Justice” (mainly “Distributive Justice”). It requires every patient to be treated with equal respect, avoiding value judgements based on one’s functioning level and quality of life, etc. Patients with an equal chance of benefiting from a treatment should have an equal chance of receiving it (1).
Facing the COVID crisis, Hospital Authority (HA) has issued “An Overarching Framework for Ethical Considerations in Resource Allocation of Intensive Care and Ventilator Support During COVID-19 Pandemic” in 2020 (2). It aimed to help frontline clinicians to face the difficult challenge of critical resources allocation to an overwhelming number of COVID patients. Although this is meant to be an internal guideline only, the principles behind should be applicable to not only HA, but also the entirety of medical professions. In the guideline, besides considering Justice together with Beneficence, Non-maleficence and Respect for Autonomy (i.e. the four bioethical principles), the following three factors were also taken into account (3).
- Maximization of the incremental health benefit to the patient population: treatment priority should be given to those whose conditions are “the most urgent, the least complex, and who are likely to live the longest, hereby maximizing overall benefit in terms of reduced mortality and morbidity”. Short-term benefits (hospital survival or similar short-term patient-centered outcomes, such as 3 to 6 month survival) should be the first consideration. Treatment priority should be given to patients of whom the treatment will likely make a significant difference in the survival. Longer-term benefits such as life-years saved are much more complex and should be of secondary priority.
- Efficiency: scarce resources should be used efficiently but a simple “cut-off” policy (e.g. based on age or disability) would be, albeit efficient, ethically unacceptable.
- Proportionality: stringency of rationing policy needs to be proportionate to the gravity of the crisis and be constantly reviewed. Rationing should only be taken as the last resort when other alternatives are not feasible.
It should be noted that the four bioethical principles are still applicable to individual doctor-patient relationship during the crisis. The use of “time-limited” trial in ICU care can be used to assess Beneficence vs. Non-maleficence for suitable patients, which is also in line with the principle of Justice. Proper communication with patients and relatives should be conducted before the trial. High treatment burden and mere prolongation of the dying phase are not appropriate at ordinary times, and even unethical during the crisis. As discussed, Justice is the core principle of rationing, and Respect for Autonomy is always a must. Additional principles as mentioned above (maximization of health benefit, efficiency, and proportionality) are put forth for broader considerations at the population and societal levels.
All these principles are prima facie principles and should be followed unless they conflict with each other, or with other equally strong or even stronger obligations. They are applicable to both COVID and non-COVID patients. A process of ethical analysis would be needed for individual case consideration, which would involve the judgment and weighting on all of the relevant principles. A fair, open, and transparent allocation process for the patients (involving the relevant stakeholders) should not only be done, but also be seen to be done.
Coming back to the two patients in the case, one should try to avoid discrimination on the basis of age, vaccination history, and social status, etc., which are common areas leading to discrimination. Physiological age, rather than the chronological one, is a better measurement of fitness for medical interventions. The older fit could have better prognosis than the younger sick. The clinical experience of COVID treatment in the local setting should be reviewed to compare the short-term prognoses of the two patients mentioned. The treatment decision should be in line with the overarching framework as mentioned above. The patient’s autonomy should be respected even if she is the one chosen to have the treatment. She may prefer not to receive the treatment if she perceives that the burden caused by the treatment or side-effects are too high. The assessment and treatment decision are better made by a separate and neutral panel, preferably including clinicians, infective disease experts, ethicists and community stakeholders. The hospital ethical committee is an appropriate body to serve this function. The clinical frontline team could then be spared from the stress of making the hard decision and the tension with the disappointed patients and relatives. No matter what the final decision is, the principle of “No Abandonment” of clinical care should be followed. Both patients should receive continuous medical support, including proper palliative care, throughout the trajectory of their illnesses.
Resource allocation with Justice involves several philosophical theories and approaches, including egalitarian, communitarian, libertarian, and utilitarian (4). However, no single theory could cover all the situations in all societies. The society needs to choose and study in depth the scenarios facing them. The approach should be communicated to the public at the outset to allow time for public discussion and buy-in. Interested readers can refer to the two related articles (5) (6).
- BMA. COVID-19 – ethical issues. A guidance note. https://www.bma.org.uk/media/2226/bma-covid-19-ethics-guidance.pdf (assessed on 6/8/22)
- Patient Safety & Risk Management Department /Quality & Safety Division, Hospital Authority. An Overarching Framework for Ethical Considerations in Resource Allocation of Intensive Care and Ventilator Support During COVID-19 Pandemic. Document No. CEC-GE-10; Issued on 1 October 2020
- Ibid P.6
- Tom L Beauchamp, James F. Childress. Principles of Biomedical Ethics, 5th Ed. (Oxford University Press, New York 2001). P.272
- Phua J, Li W et al. Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. Lancet 1 May 2020, 8(5): 506-517
- Maves RC, Downar J, Dichter JR et al. Triage of scarce critical care resources in COVID-19: An implementation guide for regional allocation. An expert panel report of the Task Force for Mass Critical Care and the American College of Chest Physicians. Chest 2020; 158(1): 212-225.