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TORONTO—Imagine a scenario where there are two patients with COVID-19 who are having difficulty breathing. They’re both in desperate need of a ventilator to help them breathe, but the hospital only has one machine available.
One of the patients is a 12-year-old child, while the other one is a 74-year-old doctor.
While some might assume the machine should be given to the younger patient, health-care professionals say it’s not that simple …
WHO LIVES? WHO DIES?
In the hypothetical case of the 74-year-old patient in need of a ventilator, Christie said that person could still live for another 15 to 20 years and that age, alone, should not be the only consideration when health-care workers are faced with these difficult decisions.
In fact, the medical ethicist said there isn’t going to be one clear set of guidelines outlining what factors will be taken into account to decide who gets to live and who gets to die during a pandemic. “I don’t think there’s going to be any formula that everyone’s going to be able to live with,” he explained.
Importantly, Christie said health-care providers can’t base their decisions on discriminatory reasons, such as age, race, religion, sex, prejudices, and arbitrary criteria, such as the patient’s influence or who they know. Instead, the medical ethicist said it will most likely have to come down to outcomes and who is more likely to survive for longer if they receive the treatment. It’s a departure for health-care workers who typically consider the patient’s values and goals.
For example, Christie said doctors may provide ventilation to a terminally ill patient with cancer because that person wants to live long enough to see their daughter get married, even though they know they won’t be able to cure the disease. “In a pandemic, I think we’re going to be in a situation where if we’re not going to be able to prevent death for you, regardless of what your life goals are, we might have to give that resource to someone for whom we can get a better outcome,” he said.
Migneault said that health authorities try to be fair to everybody and consistent in the sense that they treat similar situations the same way every time. However, in a health emergency, information can quickly change and Migneault said health-care workers have to be able to adapt on the fly. “We say one thing one day and the next day we learn
something, say something else so within all that ethical framework, you have to be flexible with it and try to adapt yourself as things move along,” he said.
In the U.S., health authorities across the country are developing strategies with the general principle to provide the most benefit to the greatest number of people and prioritize those with the best chance of recovery.
Dr. Douglas White, from the University of Pittsburgh, has developed a framework for rationing ventilators and critical care beds during the COVID-19 pandemic. He said categorically excluding groups of people, based on their age or other underlying health issues for example, from receiving care is ethically problematic.
Instead, White recommends that all patients be assigned a priority scale based on a number of factors including their likelihood of surviving hospital discharge and their longer-term survival. He also said individuals who perform tasks vital to the emergency response, such as doctors and nurses, should receive extra points.
In the event of tie in priority scores, White said the younger patient should be given priority because “they have had less opportunity to live through life’s stages.”
While some American hospitals have already adopted White’s framework, Christie said Canadian health authorities still have time to look at best practices and confer with their ethical committees to develop their own strategies if they’re faced with supply shortages. He said by planning ahead of time, health authorities can increase their capacity to treat as many patients as they can and prevent frontline health-care workers from having to make these difficult decisions.
“We’re doing all that planning now, so that we can delay these tragic choices as much as we can,” he explained. Part of that planning includes the distribution of personal protective equipment (PPE) to protect health-care workers, Migneault said.
“We talk a lot about ventilators, but it actually goes way beyond ventilators,” he said. “You can have as many ventilators as you want, but if you don’t have the human resources to provide the care, for example, if you don’t have the nurses to provide the care, then you’re not providing the care.”
Migneault said health authorities have to co-ordinate the distribution of resources on a provincial level to ensure hospitals have the supplies they need to respond to the pandemic.
“It’s important to pay attention [to] where are the ventilators, who has access to the ventilators, or critical care resources, and you don’t want to forget people that may have more challenging access to them,” he said.
Who should get the ventilator? Be sure to explain your reasons.

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