Virus Ethics: Who Gets the Ventilator?

Resolving ethical dilemmas in pandemics requires attention to values.

Posted Mar 23, 2020

In Italy today (March 23, 2020), there are around 60,000 cases of COVID-19 that have caused more than 5,000 deaths. The medical system is overwhelmed and personnel is having to make horrible decisions about treatment, for example about which patients should be connected to ventilators that can keep them breathing. American, British, and Canadian hospitals are only weeks away from having to make similar decisions. How can such medical dilemmas be resolved ethically?  

Philosophy and psychology should work together with other fields to provide sound methods for ethical decision making. Besides the distribution of ventilators, pressing ethical issues include:

  • Given a shortage of test materials, who should be tested to see if they have COVID-19?
  • When doctors and nurses lack sufficient personal protection equipment such as masks, how can equipment be distributed and reused?
  • Which patients should be assigned to limited beds in intensive care units?
  • How much government control is legitimate to ensure that people isolate themselves to slow transmission rates?
  • What are the responsibilities of government leaders to deal with future pandemics?

The Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care has issued clinical ethics recommendations for the allocation of intensive care treatments such as the use of ventilators. They say that an age limit for admission to the intensive care unit may need to be set in order to save limited resources and maximize the benefits for the largest number of people. Doctors are already making decisions that favor younger patients over older ones. Is this fair? Is maximizing benefits for the largest number of people the best ethical principle to apply?

In 2003, the SARS coronavirus pandemic seriously affected Toronto and in 2006 a group of physicians and ethicists there published a thoughtful ethical framework for pandemic preparedness.   They argued that maximizing benefits is only one of the values that should go into ethical decisions and provided this long list of values in alphabetical order: duty to provide care, equity, individual liberty, privacy, proportionality, protection of the public from harm, reciprocity, solidarity, stewardship, and trust. These 10 values are all legitimate but are not easy to apply in emergencies such as a shortage of ventilators. Often they require complex tradeoffs, for example when liberty and privacy have to be restricted to prevent public harm from virus spread. 

I prefer a shorter list of four values derived from the key ethical principles often applied in medical ethics:

  1. Autonomy: Respect people’s freedom.
  2. Beneficence: Provide benefits to people.
  3. Nonmaleficence: Avoid harm to people.
  4. Justice: Distribute benefits, risks, and costs fairly.

These principles apply the values of freedom, benefits, avoiding harm, and fairness. The 10 values of the Toronto group fall under combinations of these four, for example when the duty to provide care is justified by the need to provide benefits, and privacy is justified by a combination of promoting freedom and avoiding harm. 

But what are benefits? The Italian group seems to assume the traditional utilitarian view that the goal of ethics is to promote the greatest good for the greatest number of people. In this tradition, good is pleasure and the avoidance of pain. I prefer a psychologically richer view of benefits that involves the satisfaction of human needs, including both biological needs such as oxygen and mental needs such as autonomy, relatedness, and competence that have been documented in research on self-determination. From this perspective, medical decisions should be based on the four principles of autonomy, beneficence, nonmaleficence, and justice where benefits are understood in terms of needs satisfaction. Doctors and bioethicists at Johns Hopkins University recently offered a framework for decision making about pandemics based primarily on age and prognosis for short-term and long-term survival that is less explicit about values. 

The Italian group recognizes that age is not the only factor to be taken into account in deciding who gets a ventilator. A younger patient with underlying health problems such as high blood pressure and diabetes may be a worse risk for survival than an older patient with fewer problems. Overall, however, giving a ventilator to younger patients will lead to overall greater needs satisfaction because they will have longer lifetimes to continue satisfactions of their biological and psychological needs.

I think that the policy for giving ventilators to younger patients is justifiable even if it causes harm to older ones. Alternative strategies such as lotteries and first-come-first-served bring less overall benefits. Not having a strategy leaves decision making to individual doctors whose intuitions may be biased by race or other unfair factors. 

Similarly, government decisions to restrict freedom by imposing quarantines and lockdowns are ethically justifiable because of the terrible harms suffered by large numbers of people who are sick or dying from COVID-19. Eventually, the waning of the pandemic will eliminate the need for these excruciating decisions, but future pandemics will bring them back.