Rationing life: COVID-19 triage and end of life care

Many Australians are encountering the phenomenon of rationing for the first time in their lives. For the moment, rationing is sporadic and confined to items like toilet paper and beans. However, how will we respond when rationing moves from consumables to life itself?

Given the finite number of beds in intensive care units, respirators, etc. in Australia, the harsh truth is that if there is mass contagion, giving rise to critical illness on a broad scale, there will not be enough medical resources to sustain the lives of all who need care.

In those circumstances, medical staff and families will need to exercise triage – put simply, the practice of prioritising access to scarce medical resources. Not everyone will be chosen. Some of those at the end of the line will die.

This is the harsh reality behind abstract talk of ‘flattening the curve’. Governments and their advisers are now working to reduce the number of COVID-19 infections in the hope that they can prevent the overloading of our limited resources. In doing so, they recognise that the risks cannot be overcome by throwing money at the problem.

There is an upper limit in terms of equipment and trained personnel – there is just not an endless supply of either and no amount of money can solve that problem once the number of people seeking care exceeds the effective places available.

That is why every person must now do what they can to minimise the risk of mass infection. Doing so may not confer an individual benefit. However, the decision to wash one’s hands regularly and practice prudent forms of social distancing may make all the difference when it comes to avoiding the tipping point between a medical system that can cope and one that is forced to engage in triage.

So, how will clinicians choose if the worst fears are realised? In medical ethics, the general approach to triage is to prioritise according to two dimensions. First, a patient will be assessed in terms of their physical capacity to respond to the treatment that is available. Put simply, the less likely a person is to respond to medical care, the lower they will be ranked on the list. In a time of scarcity, there is little justification for devoting precious resources to cases that are judged to be futile.

Second, a patient will be assessed in terms of their relative circumstances – including age, stage of life, etc. For example, a forty year old parent of three children will rank higher than a seventy year old with no dependents. Both principal factors intersect – and will be qualified (to some degree) by secondary concerns – such as the relative burden of any proposed treatment on the patient.

If the worst predictions come true, such choices may need to be made on a daily basis. It will not only be the doctors who have to decide. Families will also be drawn into the decision making process. Should that time arise, it will be essential that we all embrace some fundamental distinctions. For example, there is a profound difference between preserving life on the one hand and merely extending the process of dying, on the other.

The medical technology used in both cases is the same. It is the ethical discernment that makes the difference. If pressure mounts on intensive care units, then we can expect more families and loved ones to be asked if continuing treatment is not only futile but also denying another person a chance of life. Who of us is prepared for such a conversation?

None of this is meant to suggest that some lives are intrinsically more valuable than others. They are not – we are all equal in our possession of fundamental dignity. Nor does resort to triage imply indifference to the wellbeing of those who cannot receive life saving care. Those who miss out will be given the most compassionate care available as they die. Nobody need suffer.

Finally, we should spare a thought for those who may be called to make these difficult decisions. The physical, emotional and spiritual toll will be immense.

No amount of reason or decision making aids can prevent the abrasive effects on the human psyche of triage. Medical professionals, families, members of the wider community … we will all need support.

I hope that we can avoid arriving at a point where such decisions have to be made. It is the job of government to ensure that we are protected from such times. Whether they have done enough, early enough is yet to be decided.

In the meantime, if ever you wondered about the relevance of ethics to everyday life – just look around you.

You can contact The Ethics Centre about any of the issues discussed in this article. We offer free counselling for individuals via Ethi-call; professional fee-for-service consulting, leadership and development services; and as a non-profit charity we rely heavily on donations to continue our work, which can be made via our website. Thank you.