Tragic choices in health care during Covid

“The world... is not an inn, but a hospital... a place, not to live, but to die in,” said Sir Thomas Browne in 1643. It is perhaps truer today than 377 years ago but incomplete. In a few months, the global landscape has turned into a hospital because of the tidal wave of Covid-19 pandemic. More tragic and poignant are images of piling dead bodies wrapped in white in improvised grave yards with relatives unable to bid their final farewell to their loved ones in USA, Italy and elsewhere. With a long draconian lockdown in India extended to May 31, 2020, the exponential growth of Covid-19 cases has slowed as also fatalities. There is no guarantee, however, that India will escape unscathed.

We focus on inept handling of health sector priorities. In a recent discourse on health priorities in the Covid-19 pandemic (with notable contributions by D. Bloom, Harvard, and E. J. Ezekiel, Johns Hopkins University), there is a consensus that the rapid surge has left health care resources overstretched, and rationing of the growing scarcity of these resources is inevitable. Unless the epidemic curve of infected individuals is flattened — far from imminent — the Covid-19 pandemic is likely to further aggravate acute shortages of hospital beds, ICU beds, and ventilators. Besides, diagnostic, therapeutic, and preventive interventions will be much harder. 

Pharmaceuticals like chloroquine, remdesivir (approved for emergency use in USA), and favipiravir are undergoing clinical trials, and other experimental treatments are at earlier stages of study. Even if one proves effective, scaling up its supply will be slow. If an effective vaccine is developed, it will take time to produce and distribute it among the needy. However, before rationing is applied, a set of ethical priorities needs to be agreed on.

There are four principles of rationing: maximising the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.

Maximisation of benefits implies saving the most individual lives or as saving the most life-years by giving priority to patients likely to survive longest after treatment. This favours the young over the old with the same pre-existing medical conditions and low survival prospects, as the former are likely to live longer. Giving equal treatment to all may seem attractive, as it involves a lottery or first-come-first-served principle, but it ignores stronger claims of patients requiring urgent intensive care. Nor is the market test of ability-to-pay relevant or appropriate, as it favours the wealthy. Promoting and rewarding instrumental value involves protection and promotion of doctors and other health care staff, ensuring that they get necessary equipment for testing, PPE, ICU beds, ventilators, as they are highly vulnerable to Covid-19 risk, and key to the pandemic response. Finally, the worst-off-anybody suffering from multiple medical conditions deserve greater priority as their chances of survival are low.

Between a youth and an old man who are victims of Covid-19 and in a critical condition, and also suffering from, say, cancer, greater priority is given to the youth who, if cured, is likely to contribute more to national well-being. But this means discrimination against the old, or on the basis of age, which is ruled out in any ethical framework. Nor should there be any discrimination between a near fatal cancer case or a patient requiring dialysis, and someone on the verge of dying from Covid-19.

We strongly disagree with the ordering of the rationing priorities, with maximisation of lives saved or maximum life-years saved at the top, as it involves a perverse choice favouring the young over the old with similar medical conditions and low survival prospects. We recommend its supersession by the last principle of giving priority to the worst off, in light of the (controversial but persuasive) difference principle propounded by John Rawls (1971). Social and economic inequalities are fair, he argued, if they are of the greatest benefit to the least advantaged members of society. So regardless of whether the most critically ill are young or old, and poor, they deserve highest priority, encompassing also patients suffering from near fatal illnesses (for instance, cancer). Next in order of priority is protection and promotion of doctors and other health care staff, as they have a vital instrumental role in saving lives of the most vulnerable.

In brief, a deliberate rationing strategy with a much higher priority to those more likely to die from Covid-19 and other near fatal diseases is tragic but compelling, as many will die but far more of the poor and vulnerable will survive.
Kulkarni is lecturer in Sociology, University of Pennsylvania; Gaiha is research affiliate, Population Studies Centre, University of Pennsylvania, USA, and (hon.) professorial research fellow, Global Development Institute, University of Manchester, England

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