COVID-19 shines a spotlight on hospital bioethics

In early April, a group of Covenant College students in Bioethics 171 met on Google Hangouts to go through a drill for how to allocate scarce medical resources after a mass casualty. Pretending to be a hospital ethics committee, they had 20 minutes to decide who of 10 patients deserved three beds in an intensive care unit. The prompt read, “The triage officer complains that he has never had to make the decision to ‘kill someone by denying them care,’ and has frantically called the committee together to decide which of the victims should be given a bed.”

The students read through short biographical and medical details of each patient needing intensive care. Some patients were young, some old, some had children, some had insurance, some were uninsured. Two were already in intensive care beds—would the committee move them out of the intensive care unit (ICU) to make room for sicker patients?

“What a can of worms,” said Sam Miller, one of the students looking over the prompt.

“I really don’t like this,” said Noah McKay, another student.

Covenant philosophy professor Bill Davis, who serves on the ethics committee at a local hospital in Chattanooga, Tenn., assigned this exercise, which he has done many times with his bioethics classes over the years. But he had never done it in the middle of a pandemic when hospitals across the country were having the same deliberations about the real possibility of shortages.

Two days later, the local hospital called Davis to a meeting where the staff went over the real-life protocol for a shortage scenario in the COVID-19 pandemic. Shortly after the hospital meeting, Davis hosted his bioethics class.

“We’ve been practicing for this sort of thing for 10 years,” Davis told the class. The hospital has scripts for telling patients if they can’t get a ventilator. “We can literally pray that it doesn’t happen. I don’t want to spend time explaining to people, ‘No, this is why you didn’t get a ventilator, we love you, you’re going to die’… I’m trained to do it, I don’t want to do it.”

Bioethicists in hospitals across the country are preparing for shortages in ICU beds, limited ventilators, limited staff, and little time to make decisions about how to allocate care. In New York, public officials thought hospitals might run out of ventilators last week, as the city experienced what was supposed to be the peak of the virus outbreak.

A ventilator is displayed during a news conference at the New York City Emergency Management Warehouse. Mark Lennihan/AP

“Many hospitals came really close,” to ventilator shortages, said Dr. Tia Powell, head of the Center for Bioethics at Montefiore Medical Center in the Bronx. “I hate to say it out loud, but we may not be short of ventilators … I don’t think anyone thought such a massive increase in resources would be possible.” But, “as soon as you figure out you’re going to solve one problem—yay, we got ventilators—there are other tough challenges.”

While New York looks to have enough ventilators, many hospitals faced other shortage issues: overrun ICUs and not enough trained ICU staff. New York hospitals also at points had to put two patients on one ventilator. Emergency room doctors reported having to decide whether to override family wishes to resuscitate a COVID-19 patient. A Queens hospital had to do a mass evacuation of intubated COVID-19 patients last week because the demand for oxygen overwhelmed the hospital system. All of those are situations where hospitals need a bioethics framework for making decisions.

Montefiore Medical Center is one of the hospitals straining under a huge load of COVID-19 cases, in a borough that has the most virus deaths per capita in the city. Like many hard-hit hospitals in the city, it has run out of beds at points, and nurses have reported being overwhelmed with patients.

“People come to us: ‘Do you still have room for me?’” said Powell. “They’re very frightened. It’s a very scary illness.”

A hospital’s first ethical obligation in a shortage is expanding capacity and resources for patients, Powell said. New York Gov. Andrew Cuomo recently said about ventilators that “every hospital has what they need to date.” But now hospitals have been struggling with staffing for ICUs as staffers fall ill.

A medical worker directs a patient to enter a COVID-19 testing site at Elmhurst Hospital Center in New York. John Minchillo/AP

New York’s hospital admissions are down, which is good news, but hospital resources are still stretched to a breaking point. Many have converted operating rooms to intensive care units. Before the outbreak, New York had 3,000 ICU beds, 80 percent of which were already occupied. As of last Monday, 4,593 New Yorkers were in intensive care.

Ethics in a medical shortage are complicated, but in most hospitals—whether religious, public, or private—they boil down to providing the most medical benefit to the most people. That also means prioritizing the treatment and health of healthcare workers, since they can save others’ lives. Bioethicists also agree that doctors should not be making these difficult rationing decisions about their own patients.

“Anyone who is going to make a rationing decision should be a more public-facing group: a hospital that makes that decision, or a hospital system, state lawmakers,” said Rob MacDougall, a bioethicist and professor at New York City College of Technology. “That way at least you don’t have to interfere in the physician-patient relationship. The patient might not get the care they need or want but it’s not the fault of the physician. It’s a public agency that’s responsible to voters, or to a hospital board.”

To further shield hospitals making rationing decisions, New York in April quickly passed a new law protecting doctors and hospitals from liability during the coronavirus outbreak. Bioethicists I talked to thought this was a good move and came with good parameters exempting criminal or reckless misconduct.

The important thing is for hospitals to have a workable bioethics policy that doctors can use before a pandemic comes. Even with an abundance of ventilators, hospitals face other shortages that require a bioethics policy.

“Sorting and prioritizing can be done ethically, and should be done, or you will lose more lives,” said Powell.

Some hospitals take ethical disaster preparation more seriously than others. MacDougall said Catholic hospitals tend to have tight bioethics guidelines and plans: “Part of it is they have wanted to preserve their viewpoints on things like abortion, contraceptives, end of life care. They have highly developed, technical teachings on those matters.”

In 2015, New York released guidelines for ventilator allocation in a shortage, but the guidelines are 272 pages long, limiting their usefulness to clinical staff already overwhelmed in a pandemic.

Powell said Montefiore came to the crisis prepared with a concise policy for scarcity scenarios, but the state hasn’t allowed the hospital to implement that policy formally.

“Maybe it needed to be revised [to address COVID-19],” Powell said. “But if we can build new hospitals for 1,000 people, I think we can go through a 10-page document and revise it.”

With 20 minutes left on the clock and no bioethics framework ahead of time to triage patients, the Covenant students wrestled with their inclination to prioritize younger patients for the ICU beds, patients who had a better chance of recovery. Eight minutes left. After they designated children and a mother with three children for the ICU beds, they had to prepare for an imaginary press conference to answer questions about their choices.

“I can see a family member of a patient saying, ‘Why did you let a younger person live?’ Why did we prioritize children over older people when everyone is the same value of a person?” said Jonah Hitchcock, one of the students.

“Ideally we treat all people with perfect equality,” said McKay, coming up with a proposed answer. “But that wasn’t possible in this scenario because resources were so limited. We had to make a decision based on some criteria. We wish it hadn’t happened that way but we didn’t have any other option.”

Professor Davis logged into the video chat.

“Time is up,” he told the class.