Introduction
With limited resources to allocate, healthcare providers often have to make decisions about patients’ life and death. Especially with the covid pandemic, which places a significant burden on the healthcare system, it is essential to correctly assess the patient’s chances of recovery and the outcome of the decision. Thus, it is necessary to consider a set of ethical principles, identify ethical issues and their participants, and follow standards and guidelines to deal with ethical dilemmas effectively.
Ethical Principles, Issues, and Stakeholders
Solving the presented ethical dilemma, it is first necessary to define the ethical principles on which it is based. Healthcare professionals’ ethical behavior includes aspects both in terms of the moral values and principles of professional conduct (1 p. 643). To make ethical decisions, healthcare providers need to use critical and logical thinking skills gathering and evaluating key factors. Ethical principles vary depending on the situation; however, in terms of morality, they include consideration of ‘equality, honesty, diversity, fairness, individual rights, and dignity (1 p. 643). In terms of ethical behavior, in turn, adherence to the responsible authorities’ guidelines is implied. Ethical principles aim to improve the patient’s condition and regulate relations between members of the healthcare system. The emergence of dilemmas can be associated with the rationalization of limited resources allocation, which is illustrated in the presented case.
In the presented case, healthcare professionals need to decide which patient is in a deteriorating condition to provide a ventilator. First of all, the basic beneficence principle is relevant, implying preventing or removing harm, promoting well-being, as well as maximizing good. The principle of dignity is also relevant in the situation since doctors and nurses need to consider the moral values involved. The principle of equality is also essential, which implies the exclusion of discrimination of any kind. The utility principle in the situation aims at maximizing the possible benefit to the patient. Finally, the principle of transparency is important, as health professionals must clearly explain the decision-making process and the factors considered. Although the principle of confidentiality is fundamental to healthcare, during a pandemic, this duty ‘can be superseded by a duty to protect other members of society known to be at risk’ (2 p. 115). Thus, it is necessary to consider a spectrum of basic health principles based on morality and others’ benefit.
To make a decision, it is also necessary to determine ethical issues and the range of stakeholders. The ethical dilemma presented in the case presents the issue of allocating limited medical resources and triage decisions. Therefore, the decision-making process involves primarily health workers (physicians and nurses), patients in need of assistance, and their relatives. Therefore, the decision should be made based on consideration of the ethical principles, the presented issue, and the stakeholders’ interests.
College Practice Standards or Guidelines
Different standards and guidelines often regulate medical workers’ activities, but in the context of a pandemic of a virus new to humanity, their development is challenging. However, access to ventilators in a pandemic is a matter of life and death, which is why many countries offer guidelines for resource allocation (3). These standards aim to facilitate the decision-making process and remove the moral burden of healthcare providers. The prescriptions vary slightly from country to country and are based on criteria of justice and benefit maximization. Existing guidelines shift focus from ‘an individualistic approach to a triage decision-making in the context of the pandemic’ (3 p. 7). All but Canadian standards prescribe a medical criterion consideration in triage decisions (3). However, all guidelines involve considering the patient’s current condition and predictions of short-term and long-term survival, which are difficult to determine in the case of covid.
Age is also a criterion for consideration, but it can be a basis for a decision only in combination with other factors and comorbidities. Thus, age is considered in ‘Australia/New Zealand, South Africa, and Canada in cases of similar ranking, as a tiebreaker’ (3 p. 8). The principle of transparency is indicated in all standards as an integral part of decision-making: the patient and family members must be informed about all key factors. Moreover, the patient’s will and the preferences of his family should be considered when evaluating the situation (3). Thus, in conditions of limited resource allocation during the pandemic, the guidelines narrow the range of principles under consideration to benefit maximization and justice. Moreover, they offer different criteria for assessing the patient’s current condition and making predictions about the beneficial effect of treatment for him.
Legal Standards or Guidelines
In a pandemic, resource allocation decisions must follow specific protocols and guidelines based. Thus, if the physician made a decision not to provide the ventilator to the patient by the triage principles, then he will not bear criminal liability (4). Moreover, a medical worker cannot be held liable for failure to provide equipment that does not exist, for example, in conditions of shortage (4). Thus, from a legal perspective, the physician is ordered to make a decision only based on ethical principles.
Steps to Solve the Case
- Identify the Facts.
- Determine the Relevant Ethical Principles.
- Explore the Options.
- Act.
The first patient is 82 years old and has no diseases, while the second patient, at the age of 41, has several comorbidities: obesity, type II diabetes. The first patient has no relatives interested in his treatment; the second patient has two children. In addition, the first patient does not have negative habits, while the second patient is a smoker and also has poor diabetes control. Therefore, the ethical issue is to evaluate the effectiveness of providing a ventilator to one of the patients, the prognosis of the chances of recovery, and the negative consequences in case of failure.
In the case of the first patient, the stakeholders are the patient himself, the physician, and the second patient. In the case of the first patient, the stakeholders are the patient himself, the physician, the first patient, and the patient’s family. Relevant ethical principles are justice and benefit maximization, from the physician’s perspective, since other relevant participants’ opinions have not been sought.
Option one: providing a ventilator to the first patient may be justified because he is healthy and can tolerate treatment well; however, his age raises concerns regarding the result. Option two: providing a ventilator to a second patient may be justified due to the younger age and more stakeholders. However, the presence of complicating diseases and smoking raises concerns regarding the effectiveness of treatment. Therefore, the most ethically justified option is the choice of a second patient, since, with a successful outcome of treatment, the physician will help more people, including the patient himself and his family.
Conclusion
It is necessary to document or communicate the decision taken at this stage, including the criteria considered in the decision-making process. Then the physician should develop a plan for the implementation of appropriate measures and carefully evaluate it. It is also essential to involve a colleague who can review the final solution and elicit agreement and disagreement with it. Finally, it is important to understand whether the physician feels comfortable with the decision and whether all the relevant factors were considered.
References
- Ahmed A, Ali H, Mahmoud MA. Prioritizing well-being of patients through consideration of ethical principles in healthcare settings: concepts and practices. Sys Rev Pharm. 2020. Web.
- Kramer JB, Douglas BE, Piroska KK. Ethics in the time of coronavirus: recommendations in the COVID-19 pandemic. J Am Coll Surg. 2020. Web.
- Jöbges S, Vinay R, Luyckx V, Biller-Andorno N. Recommendations on COVID-19 triage: international comparison and ethical analysis. Bioethics. 2020. Web.
- Cohen G, Crespo AM, White DB. Potential legal liability for withdrawing or withholding ventilators during COVID-19: assessing the risks and identifying needed reforms. JAMA. 2020. Web.