Ethical concerns in the COVID-19 era

The intensivists are responsible for admission or non-admission of patients to the ICU, to withhold or not withhold life support, and to communicate with families. The decision of an intensivist to refuse admission to an ICU bed is part of regular intensivists'  work to triage patients, and it is done so by following the guidelines that ensure fairness, respect for the patient's wishes, and transparency with the patient's family (Robert et al., 2020). Theoretically, these same principles should apply even during a pandemic; however, in this pandemic, the number of ICU admission requests increased dramatically, and so did the scarcity of ICU beds. Decision-making is no longer based on individual ethics but on utilitarian ethics, to maximize benefit for the greatest number of people (Robert et al., 2020). This approach to triage may bot be the best course of action because it ignores other relevant ethical considerations. Essentially, the new strategies that have been proposed and are implemented right now are there to justify prioritizing based on the likelihood to survive the illness and to live the longest after recovery (Robert et al., 2020). This would justify the youngest individuals to receive priority. Moreover, how they calculate the probability of death is by giving the SOFA score; the problem is that this lacks specificity at the individual level. Another problem is that the score for the ratio of true positive rate to false positive rate for the SOFA score is 0.753, which means that out of four patients, one will receive an inappropriate decision (Robert et al., 2020). How they calculate life expectancy or risk of mortality is generally poor and a lot of patients can be wrongly predicted. These are ethically flawed approaches; therefore, what should be done to improve on these decision-making techniques is to incorporate a frailty score, comorbidities, and quality of life evaluations, as well as to leave room for physician judgement and offer these options to the intensivists in order for them to make the best decisions.

When we look at what other countries have done, such as China, we see that they overcame the problem of ICU bed shortage by simply setting up new ICU beds wherever there were any available rooms or by quickly constructing new units outside hospital walls (Robert et al., 2020). Although it solves the problem of admission decision-making, the problem this creates is that there is a significant risk of reduced quality of care for multiple reasons. First of all, these new ICUs are not adequately designed for all the equipment and organization critical care requires. They also lack highly sophisticated devices such as ventilators, which patients with severe symptoms of COVID-19 desperately need. In their place, other devices might be used, which are not appropriate for a patient in acute respiratory distress (Robert et al., 2020). Moreover, this type of organization favors those who arrive first to receive care, and when in-hospital ICUs are no longer available, the rest of the patients who did not arrive in time must be placed inside downgraded quality care ICUs. This is more like "first-come, best-served" type of situation (Robert et al., 2020).

Another solution to the lack of ICU beds could be transferring of patients to a different facility with more available ICUs, or to regions less affected by the outbreak. Such transfers require special helicopters or trains adapted to the care of the critically ill patients. It would not be ethical to charge the patient or the patient's family for such as service; nevertheless, this is not the only problem. The most important ethical issue would be the benefit/risk balance (Robert et al., 2020). For the patient, the benefit of being cared for by highly qualified healthcare workers is counterbalanced by the risk of worsening clinical symptoms during the transfer. Another ethical concern is about bringing an infected patient to an area less affected by COVID-19 and increase the risk of spreading the virus there (Robert et al., 2020). There is always a risk of infection, despite all the protective equipment used.

In conclusion, there is a lot to be learned from these experiences and a lot of ethical dilemmas need to be addressed and reflected upon so that we may better serve those who fall ill to COVID-19, as well as the families of the patients. Let's no also forget the healthcare workers who are undergoing immense psychological stress. The uncertainty of the duration of the pandemic, the lack of an effective treatment, the risk of transmitting the disease to their friends or families, and being under strict containment are experiences that healthcare workers need to constantly adapt to and must cope with the situation of feeling powerless and ineffective (Robert et al., 2020). A COVID-19 vaccine would lift this burden and solve the crisis that is currently happening. Who should receive the vaccine first is another ethical dilemma that needs to be discussed, now that two potential vaccines are about to enter the market for the general population.

Sources:

Robert, R., Kentish-Barnes, N., Boyer, A., Laurent, A., Azoulay, E., & Reignier, J. (2020). Ethical    dilemmas due to the Covid-19 pandemic. Annals of intensive care, 10(1), 84. https://doi.org/10.1186/s13613-020-00702-7