Pandemic puts decision-making to the test. AMA offers expert advice.

Timothy M. Smith , Contributing News Writer

Anticipating dire shortages of ventilators and other supplies as a result of the COVID-19 pandemic, health care leaders across the U.S. are huddling to determine which patients will get the care they need if hospitals become overwhelmed with cases of the deadly disease. Two physician experts discussed the ethics of triaging critically ill patients and how to involve the public in creating decision-making protocols.

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Following are highlights from the AMA Journal of Ethics® (@JournalofEthics) March podcast featuring an interview with Matthew Wynia, MD, MPH, professor of medicine and public health and director of the Center for Bioethics and Humanities at the University of Colorado in Denver. Dr. Wynia also serves on the Forum on Medical and Public Health Preparedness for Disasters and Emergencies of the National Academies of Sciences, Engineering and Medicine. Earlier in his career, he directed the AMA Institute for Ethics.

In his conversation with journal editor-in-chief Audiey Kao, MD, PhD, Dr. Wynia also discussed the physician’s duty during deadly outbreaks and the relative effectiveness of voluntary and mandatory quarantines.

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Dr. Wynia noted that the medical community seems to generally agree on which criteria are reasonable for determining which patients will get, say, artificial respiratory support.

“The first one obviously is around—are you likely to survive?” Dr. Wynia said. “And someone who is very liable to die anyways, even if you give them a full-court press and all the access to all the resources, that person would be the first one that you would say [it’s] probably not worth continuing to provide that level of care to … because they are bound to pass away, regardless what you do.”

As difficult as such a medical triage choice would be, the situation becomes even more gut-wrenching, Dr. Wynia said, when you have two or more individuals with the same severity of illness and the same likelihood of survival. In that situation, physicians would consider years of life saved.

Doing so takes into account “a sort of utilitarian calculus of trying to get the most benefit from your limited resource, but it also, by its nature, privileges people who are younger and who have a longer life expectancy if they survive the illness,” Dr. Wynia said. He added that while no rationing protocol will satisfy everyone, “if you have two people who have equal likelihood of benefit, looking at the person who might have a longer duration of benefit is a valid, ethically defensible position.”

Read the AMA Code of Medical Ethics opinion on allocating limited health care resources. AMA experts also have collected relevant AMA Code of Medical Ethics ethical opinions to offer guidance in a pandemic

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Recalling a photo that circulated amid the COVID-19 pandemic showing a nurse in Italy collapsed at her computer with her mask on, Dr. Wynia noted that conversations about rationing are often driven by news media coverage of unfolding health care crises.

“Is that ideal? Maybe, maybe not,” he said. “I could imagine a scenario in which there were a more formalized process where people could provide input into triage decision-making protocols. It's a little difficult to envision how that would come into place in the middle of an epidemic where everyone is really overstretched, because I think it would take some work to put something like that together. But I could imagine it.”

Listen to previous episodes of the “Ethics Talk” podcast or subscribe in iTunes or other services.

Dr. Wynia recently co-wrote a column for Stat website on this topic, “If COVID-19 gets bad, triage will be needed. Are we ready for that?

The column notes that 36 states have worked on plans for crisis standards of care, seeking to implement guidance published by the National Academy of Medicine.

The AMA and the Centers for Disease Control and Prevention are closely monitoring the COVID-19 global pandemic. Learn more at the AMA COVID-19 resource center or the AMA Journal of Ethics’ COVID-19 Ethics Resource Center, and consult the AMA’s physician guide to COVID-19.