COVID stretches NSW health systems and raises tough ethical questions

Whose health should be prioritised when resources are limited?

As COVID case numbers surge in NSW, so too do the number of infected patients in hospital intensive care units (ICU) and those who are on ventilators. Amid warnings from Premier Gladys Berejiklian and Chief Health Officer Kerry Chant that these numbers are yet to peak, the state’s healthcare system is set to be stretched further as Australians face new ethical dilemmas.

Last week three hospitals in Sydney’s hardest-hit local government areas had to turn away ambulances with COVID patients and redirect them to other hospitals across the city.

According to figures released this week by the Australian and New Zealand Intensive Care Society, 667 of NSW’s 845 “fully staffed public and private hospital ICU beds” are occupied –  around 17 per cent by coronavirus patients. Encouragingly, this journal article from last year describes a surge capacity plan to increase the number of ICU beds.

Yet, according to Health Services Union Secretary Gerard Hayes, it’s the workforce that’s really critical. He says an average of 1,000 health workers in NSW are being furloughed every day due to exposure to COVID-19, requiring other staff to work longer hours.

Last week three hospitals in the hardest-hit LGAs had to turn ambulances with COVID patients away.

The increased workload prompted two ICU nurses from Sydney’s Royal Prince Alfred and St Vincent’s hospitals to tell the Guardian they were having to give the maximum acceptable doses of sedatives to non-COVID patients to allow them to attend to other patients.

Meanwhile, Michael Whaites, manager of the public health organising team of the NSW Nurses and Midwives Association, told the Guardian he had heard that the required one-on-one ratio of nurse to ventilated patient was not being met.

Ethical questions raised in a time of ‘healthcare scarcity’

On Friday, the NSW Premier said the state’s COVID numbers were not predicted to peak until mid-October.

In this environment of critical stress to healthcare systems across the globe, some ethical questions have become more relevant than ever. In Australia, most of our public conversation has focused on two questions.

The first is whether it is right to sacrifice individual freedoms in the short term to protect those most vulnerable from contracting the virus given the long-term consequences such as the impact on people’s livelihoods and mental health and the economy.

The second is whether it is appropriate to determine citizen’s freedoms – ie. eased restrictions – by their decision to be vaccinated and the consequent lessened risk they pose to others.

Whose health should be prioritised in a pandemic when resources need to be rationed?

Another important ethical question to consider is: whose health should be prioritised in a pandemic when resources need to be rationed?

Last year, when the United States faced its own healthcare crisis, Eternity turned for answers to Dr Xavier Symons, an ethicist and author of a PhD thesis in healthcare rationing. We asked how a Christian can wrestle with such difficult ethical questions. Symons is Research Associate at the Institute for Ethics and Society at University of Notre Dame Australia, Sydney, and convener of the university’s Bioethics and Healthcare Ethics research program. He’s also a Christian.

Symons explained that, while there are no concrete or “knock-down answers” for these kinds of difficult ethical questions, it’s important the “moral machinery” behind them be understood by decision-makers.

Now, as Australia faces the same issue, Eternity revisits his insights.

Two considerations when rationing healthcare: utility and fairness

Dr. Xavier Symons

Dr. Xavier Symons

“In healthcare rationing ethics, there’s usually two considerations that most people consider to be relevant when we’re thinking through these kinds of issues: there’s utility and there’s fairness,” Symons explained.

Utility, or utilitarianism, he says, is the idea that we should focus on the consequences or outcomes of our decisions. In the context of healthcare rationing, that involves thinking about what kind of benefits will be realised by choosing a particular course of action.

Then there’s fairness – and there’s a big debate about what fairness means. But according to Symons, one practical aspect of fairness is “the idea of giving everyone what they’re owed”.

“So you’ve got to think about how do we give people – human beings with dignity – what they are owed, in [terms of] justice, by us? That’s a difficult question and it is clearly going to grate against some of the values of utilitarian intuitions. Because it’s not then just a question of benefits, it’s also about respecting the dignity of people,” he says.

Consideration of fairness, he says, will often “lead us to adopt a course of action that may not necessarily bring about the best consequences but is at least respectful of the dignity of human beings.”

Age-based rationing – the ethics get “a bit more grey”

“In the case of age-based rationing, clearly you need to consider benefits and it would be imprudent to allocate, for example, a ventilator to someone who’s 105 years old and has absolutely no chance of benefiting from it. That’s when utilitarianism would kick in and guide our decision-making,” Symons says.

“But then it gets a bit more grey when you’re dealing with people who are 75 years old and they’ve got a 30 per cent chance of survival. Should they receive a ventilator? What if you’ve got to make a decision between that individual and someone who is a bit younger and maybe has a 40 to 50 per cent chance of survival?”

“What do you do in that case?” Symons asks. “Do you flip a coin? Or just go with the person who has the greatest capacity to benefit?”

With no easy answers, it gets even more complex when a person’s social profile is considered.

“So, who are they? What kind of contribution have they made or will they make to society? Have they done something which seems to make them less deserving or less worthy of receiving something like medical care?” he asks.

“But a lot of people would argue that medical care is something that people deserve, regardless of their history and circumstances. So even prisoners deserve access to, say, organ transplants, even if there’s scarcity.”

Yet, as Symons points out, the difficulty in this situation is not so much around the issue of whether everyone’s needs should be met when we have enough resources to do so. Rather, it’s a question of what we do when we just can’t meet everyone’s needs, and a choice has to be made between two people.

The risk of compounding injustice with a utilitarian approach

During a time of scarce resources amid a surge in need, a “cut and dried” utilitarian approach can seem attractive. Rationing healthcare on the basis of a patient’s capacity to benefit, for example, might seem egalitarian. But, as Symons points out, just because an approach is simpler, doesn’t mean it is fair.

“One of the risks of a purely utilitarian approach [ie. one that allocates resources based purely on a patient’s capacity to benefit] is that you are basically saying people who are over a certain age, or who have a certain disability, should not be given access to certain resources in a situation of surge or scarcity,” he explains.

“But the very persuasive argument against that is to recognise they are already suffering from a kind of disadvantage – that their disability comes with certain disadvantages for them in life and in society. So you’re actually compounding that disadvantage or imposing another form of disadvantage and discrimination on them by barring them from these resources. Far from doing justice, through your decisions, you are actually doing a double injustice to a minority group.”

“Far from doing justice, through your decisions, you are actually doing a double injustice to a minority group.”

He explains that social disadvantage often results in people having co-morbidities – the presence of one or more additional conditions often co-occurring with a primary condition.

“If you actually understand the idea of the social determinants of health, you’re going to realise that they tend to come from backgrounds of disadvantage. For example, the African-American community in the US has been disproportionately affected by the virus. There has been a far higher number of deaths as a proportion of population among African Americans than other ethnic groups in the US,” he says.

“If an ICU doctor says, ‘I’m just not going to give this person access to the results because they’ve got these kinds of other health problems’ – maybe they’ve got diabetes or another serious health problem, so they are less likely to benefit from it than someone who doesn’t have a concurrent health problem – they run the risk of reinforcing an injustice.

“So that’s a relevant consideration. You’ve got to not only think of benefits but also who is this person. Are they a minority? How should that figure in our rationale?”

Symons notes that in Australia, an equivalent example is Aboriginal and Torres Strait Islander people. He mentions a rationing protocol document by a Sydney University health ethics unit (which he read recently) that made provisions for social inequities in distributing healthcare resources.

“It basically said, ‘you need to bear in mind that Aboriginal and Torres Strait Islander people have health problems, but that’s not because they’ve been reckless. It’s because there’s massive sort of social injustice, a social inequality.’ So that’s an example of where you need to be careful of taking a crude, utilitarian approach to healthcare rationing.”

Wading through the murky waters of ethical complexity

So, with so many things that need to be considered, how do decision-makers act in a timely and consistent manner?

“In the US, each state – and different healthcare providers – have drawn up guidelines for intensive care specialists about how to make these sorts of decisions,” Symons explains.

In addition, he says, in the US, the Office for Civil Rights of the Department of Health and Human Services issued guidelines to all US health authorities in April. They instructed them not to disregard the rights of people with disabilities when making healthcare rationing decisions – essentially barring healthcare providers from taking a purely utilitarian approach.

While these ethical guidelines help healthcare professionals make difficult decisions, he qualifies “that there’s a lot left to individual discretion. That’s a common thing in medicine – that usually ethical guidelines tend not to be too prescriptive because they don’t want to be insensitive to the unique circumstances of individual cases.”

What healthcare ethical guidelines try to do, he says, is “take the moral distress away from the clinicians who have to make these decisions”.

“They don’t want them to feel like they’re somehow totally, completely, morally responsible for the outcomes. Because in the end, that leads to burnout, depression, demoralisation, and the sense that doctors are horrible people because they make these decisions – which is an unfair weight for them, in addition to the stress of their job already.”

Assessing Australia’s response – the good, the bad, and the need for a ‘subtle moral vocabulary’

Despite his expertise, Symons doesn’t purport to know what Australian authorities should be doing differently.

Throughout the pandemic, some have advocated for national governments to take a hard-core utilitarian approach to COVID. One Australian example is economist Gigi Foster, who came under fire after appearing on ABC TV’s Q+A program last year, during which she talked about “body counts” and lauded Sweden’s relaxed response to the coronavirus pandemic as a model for Australia to follow.

“Certainly the way she was talking conveyed a complete lack of moral sensitivity to the loss of human life and the seriousness of that,” Symons comments, adding it was as if she were speaking about a video game rather than people’s lives.

“This is always a risk for economists … People are turned into numbers and so they lose sight of the person,” he says.

“There is a sense in which a lot of these people can disregard the dignity of vulnerable populations. It’s as if somehow older people or people with disabilities, or who are immuno-compromised, are second-class citizens and their deaths matter less.

“I certainly am not on board with that.”

Symons says he is a little bit concerned about “jumping the gun scientifically or in terms of the public health debate” because of how little is still understood about the virus.

[Editor’s note: A reminder to readers that these comments were originally made in August 2020]. 

“I would obviously agree with the way the federal and state governments have handled the pandemic, in balancing all the different considerations,” he qualifies. “But it’s always prudent to bear in mind that there are still a lot of unknowns. There’s a healthy degree of sort of agnosticism one should have when thinking through these issues.”

And while Symons was cautious in drawing conclusions about the science around COVID, he’s utterly certain that Christians have something valuable to contribute to Australia’s public conversations about ethics during the pandemic: a “subtle moral vocabulary”.

“I think we’ve lost some of the Christian vocabulary that we used to have. Vocabulary that is very useful for moral debates,” he says. “Even if we’re living in a secular, liberal democracy now, I don’t think Christianity has been suddenly rendered entirely irrelevant.”

So what exactly does Symons mean about a helpful “Christian vocabulary”?

“I think ‘hope’ is an example of that vocabulary. ‘Dignity’ is another one. And then, the idea that – even if you don’t believe in God – we all do have value in the eyes of others,” he explains.

“And when you take God out of the picture, that [concept of value] becomes less of a presence in people’s minds, and less of a kind of underlying principle of meaning that can give people a sense of self-worth.”