Who should we prioritise in a pandemic?

A Christian ethicist talks healthcare rationing

As COVID-19 stretches national healthcare systems to their breaking point all across the globe, some ethical questions have become more relevant than ever.

In Australia, most of our public conversation has focused on whether it is right to rescind the freedoms of citizens in the short term (using various “lockdown” stages) in order to protect those most vulnerable from contracting the virus (such as the elderly and people with existing health conditions) – given the long-term consequences of doing so, like those on people’s livelihoods and the economy.

But in other countries where COVID outbreaks have been more extreme, even more weighty ethical questions have arisen.

Take, for example, the tragic case of Starr County Memorial Hospital in Rio Grande City, Texas, on the US-Mexico border. This tiny hospital had – and only needed – 45 beds before the pandemic, but now it is overwhelmed by patients with COVID-19.

Hospital management announced it will need to send coronavirus patients “home to die” due to limited resources.

At the end of July, hospital management announced it will need to send coronavirus patients “home to die by their loved ones” due to limited resources.

“The time of rationing medical care is a time that we all have feared from the beginning, but it looks like we are getting to that point now,” said a doctor from Starr County Memorial Hospital. He went on to describe the establishment of a new hospital committee that would weigh up patient cases in order to make these decisions.

But making ethical decisions like these can raise more questions than answers.

What factors should a committee like the one at Starr County Memorial consider? How can different factors be weighed against one another? And how can the people who are forced to make these calls possibly bear the moral weight of their decisions, given the life and death consequences?

Dr. Xavier Symons

Dr. Xavier Symons

In seeking answers to these questions, Eternity turned to Dr Xavier Symons, an ethicist and author of a PhD thesis in healthcare rationing. 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 says that, while there’s no concrete or “knock-down answers” for these kinds of difficult ethical questions, it’s important the “moral machinery” behind them is understood by decision makers.

Two considerations when rationing healthcare: utility and fairness

“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,” explains Symons.

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.

“How do we give people – human beings with dignity – what they are owed, in [terms of] justice?” – Dr Xavier Symons

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.

A 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”

This brings us to concepts like “age-based rationing”.

“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?”

It’s at this point Symons admits there’s no easy answers. Nonetheless, understanding the “moral machinery” involved in the analysis is essential.

What do we do when we just can’t meet everyone’s needs, and a choice has to be made?

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 through a utilitarian approach

During a time when resources are scarce and there’s a surge in need, a “cut and dried” utilitarian approach can seem attractive. Rationing healthcare solely on the basis of a patient’s capacity to benefit, for example, might seem to be a very “equal” way of making decisions that avoids the subjective factors which bring additional considerations into the process.

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 [by taking a purely utilitarian approach] 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.”

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.

“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?” – Dr Xavier Symons

“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 amongst 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 kind 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 – like the committee at Texas’ Starr County Memorial Hospital – actually make these decisions in a timely and consistent manner?

“What’s happened in the US over the past few months is 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.

“They don’t want [clinicians] to feel like they’re somehow totally, completely, morally responsible for the outcomes.” – Dr Xavier Symons

So, is there a state document guiding committees like the one that Texas’ Starr County Memorial Hospital?

“I haven’t seen Texas’ guidelines and I don’t know how that’s regulated. But, I’m presuming there would have been a document published recently because, basically, all the different health authorities were scrambling to get something together about two months ago when they saw what was happening in Italy and Spain.”

Do these ethical guidelines help healthcare professionals make difficult decisions?

Symons says yes, but qualifies “although my understanding is 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 having so much expertise specifically relevant to the world right now, 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, during which she talked about “body counts” and lauded Sweden’s relaxed response to the coronavirus pandemic as a model for Australia to follow.

Symons does not support Sweden’s approach at all.

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

“This is always a risk for economists. I mean, they’re doing macro-economics and they have that sort of disengagement where things are turned into numbers. 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.”

“People are turned into numbers and so they lose sight of the person.” – Dr Xavier Symons

However, 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.

“I think we’re at a stage – because COVID is still so new – that it’s really hard to know what is good policy. Like, what are the best policies for managing COVID outbreaks? I certainly suspect that lockdown life has a big impact and saves a lot of lives. As does wearing masks, etc. But unfortunately, it is true to say that the data is still just coming out now, in terms of what the benefits of these kinds of interventions are.”

“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 may be 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 “Christian vocabulary” that could be helpful in public conversations during these COVID times?

“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.”