Who Should Be Saved First? Experts Offer Ethical Guidance

from NYTs

How do doctors and hospitals decide who gets potentially lifesaving treatment and who doesn’t?

A lot of thought has been given to just such a predicament, well before critical shortages from the coronavirus pandemic.

“It would be irresponsible at this point not to get ready to make tragic decisions about who lives and who dies,” said Dr. Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado.

Facing this dilemma recently — who gets a ventilator or a hospital bed — Italian doctors sought ethical counsel and were told to consider an approach that draws on utilitarian principles.

In layman’s terms, a utilitarian approach would maximize overall health by directing care toward those most likely to benefit the most from it. If you had only one ventilator, it would go to someone more likely to survive instead of someone deemed unlikely to do so. It would not go to whichever patient was first admitted, and it would not be assigned via a lottery system. (If there are ties within classes of people, then a lottery — choosing at random — is what ethicists recommend.)

More here.

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15 Comments

  1. I was sadden upon reading this article because it is difficult to think of where we are. Not only were we unprepared, but the worst part is that we saw this coming and did nothing to change the trajectory of the virus. We completely underestimated the legitimacy and seriousness of such illness and it has consequently led us to where are now, choosing between those infected. As stated in the article, researchers and experts serving as ethical counsel told doctors to consider utilitarian principles in order to maximize total heath as well as survival rates.The utilitarian approach really is directed towards those that are more likely to benefit from medical treatment. While this approach is not necessarily out of the ordinary when you consider those who await for organ transplants, we are experiencing it under different circumstances. Although it is awful for those of us to think about, I imagine it to be extremely more difficult for doctors (and other in the medical profession)
    to make the call as to who lives and who dies. The worst part about it is that there is nothing that we can do to save everyone.However, it is something that we are all facing together. And when this all ends, we all will come out of it together.

  2. It is difficult to think about making a decision about who will live and who will die. There are so many factors that can go into such a heavy choice and this is something that healthcare workers in the US will have to make if they haven’t already. As of right now, the guidelines that are in place are following utilitarian views of choosing the individual that will be able to benefit most from treatment. Obviously, this makes sense purely from a factual standpoint, but it is easy to assume this is incredibly different when you are in the moment, looking at the people, and needing to make the decision. When thinking of a 20-year-old vs a 50-year-old who are both in the same condition, the resources are going to likely be allocated to the 20-year-old because they are more likely to recover better and will presumably have a longer life ahead of them. However, I can’t help but think about what if the 50-year-old was my father; yes it seems fair on paper to allocate the resources to a 20-year-old, but is it really possible to quantify the value of someone’s life based on their age?
    While hospitals and healthcare professionals are wise in making these decisions before the situation reaches a point where people are already doing this, it is a bit heart wrenching to think about how difficult it is probably going to be to carry out these decisions. I have family members and friends who are in healthcare or heading into healthcare and I know that none of them want to have to play God and make decisions that will affect many people’s lives forever. However, we are left with no other choice. Italy has already faced this situation and the US is getting closer as more and more people are getting sick and hospitals are filling up.

  3. The hardest part of this epidemic is arguably not the gathering of supplies or the quarantining of millions and millions of people, but rather the difficult decisions doctors must make when faced with medical shortages and an influx of acute cases. It is inevitable that doctors will eventually need to pick and choose who will be able to receive critical healthcare. In Italy, certain medical institutions have released guidelines on how to deal with the situation as it gets worse. These guidelines relate the pandemic to almost wartime-like medical procedures and utilize a more utilitarian view of our medical resources; distributing care to those who will receive the most benefit from such care.
    The obvious issue with this is that unhealthy individuals are less likely to receive care if they are not expected to recover, and there have also been recommendations as to putting an age limit on those allowed to receive intensive care. This has been taking place already in Italy, where the amount of infected individuals is rising starkly every day, as well as the death toll.
    As the virus has begun to spread more globally, especially in the United States, these preparations are taking place everywhere. I believe that this preemptive approach is far better than a reactionary one, since such a huge ethical and moral obstacle like this needs to be thought through as thoroughly as possible to prevent society from collapsing as people are denied live-saving medical attention.
    Another issue with the lack of supplies isn’t only affecting the patients, it is also negatively affecting our physicians , who work on the frontlines to fight the pandemic. Health workers and doctors are facing shortages of ppe supplies to keep themselves safe, and due to this more and more are succumbing to the disease. Many are seriously worried about how many health workers are falling ill, as it puts an even heavier strain on a system that is already projected to fail at meeting everyone’s needs.

  4. The question “who should be saved first” divides a lot of people just because it is a sensitive topic, and most people can think a person from all of the brackets. People can think of their sick aunt, or their super old grandma or their little brother who has some conditions. This causes people to think that it is unfair as who should be saved because that might mean they won’t be saving someone who is dear to me.
    To me, the utilitarian approach makes the most sense. “The greatest good for the greatest amount of people”. I do believe that it is important to focus the resources on the people who have the best chance of survival, even though I was a bit shocked when my mother first mentioned it. If we prioritize those who are deadly sick, they will need more care than others, and they take more work and employees to hopefully save them. This sounds like a horrible system and in normal circumstances it is, but we are in the middle of a pandemic and these are not normal times. We need to make these kinds of difficult decisions to be able to function and hopefully have a better tomorrow.

  5. It is unfortunate that what started as a distant problem has now occupied the daily lives of ordinary citizens in such a significant way. Once upon a time, the only contact we had with the virus was through social media and the news, in which we watched the virus take over China, Italy, and more. Now, this virus has taken over grandparents, parents, and children in life-threatening or fatal ways as well. Hospitals and public health workers struggle to support those hundreds of thousands infected, leaving them no choice but to decide who gets to live or who has to die.

    My Business Ethics and Contemporary Moral Issues courses have taught me the basics of these ethical theories that are applied in everyday life. Utilitarianism is well-known in that the main concept suggests that people must always act to produce the greatest good for the greatest number. Now I can see this concept being utilized ad nauseam. Albeit, many of us saw this day coming due to our lack of preparedness but the situation is just as traumatizing. My partial support for the utilitarianist theory has been challenged significantly. How can someone choose who they feel should live or die? Imagine the stress that medical professionals go through every day in an effort to contribute to a greater good. Are the lives of grandparents and parents less important than the younger population who are seen to deserve ventilators more just because their chances of surviving are higher? The short answer would be no, but this virus corrupts these decisions in unfortunate ways.

    One day, the coronavirus pandemic will stop. Before I understood the severity of it, I yearned for life to return back to normal as quickly as possible, but I understand that that wish is no longer possible. Even if the virus is gone, its effect on the world will linger forever. Whether that be emotionally or mentally, the coronavirus is here to stay.

  6. This issue is most definitely a tough subject to speak about. I think that this type of ethical question could have been prevented primarily if the federal government better prepared for this epidemic and thought more in depth than looking at the price tag. If this was handled correctly there would not be such a shortage of medical supplies and ventilators. Regardless, I have to agree with the main way of thought that suggests that people who have a better chance of surviving should take priority when it comes to receiving ventilators. It’s a brutal way of thought but it only seems fair. It truly would be an abomination if someone who could have lived did not receive a ventilator only for someone under a ventilator to pass away as well. However, this raises a number of questions as to what truly is right. One concern I have is that what if a primary breadwinner for a family passes away due to this triage system and an entire family loses everything because of a younger person need for a ventilator. Similarly, I think in some instances age should not be a factor in which someone get a ventilator. Perhaps the younger person in this situation is a convicted felon or a notorious drug user. In some state, prisoners have been granted an early release to get care for contracting the virus. I think that in this case age should not play a factor in which someone could lose their life. Another concern I have is that there is the inevitable situation in which two people of the same relative age are both in need of a ventilator. Then comes the question as to who’s life is considered more valuable. In my opinion, there is nothing that one can truly place a value on a human life. This is a painful and harsh reality that our society must face due to the pandemic we face. At the end of the day, I believe that this issue is the fault of the federal government who is now playing catch up with the virus and scrambling to make ventilators.

  7. It is upsetting to read some of the decisions medical workers now have to make because of the corona virus. Austin Frakt writes in his article “Who Should be Saved First? Experts Offer Ethical Guidance” that hospital workers have to choose between who gets to the potential lifesaving treatment and who does not. Not everyone is cut out for this work, I definitely know I am not cut out for that line of work. I can barely stand the sight of blood, imagine the emotional trauma that comes with caring for patients and having to let some of them go. I have always been thankful for health professionals and my respect for them grows higher each day. They are burdened with life threatening decisions on a daily and I will not judge them on what they believed was for the best.
    I can understand why some places like Italy are being advised to make decisions based off utilitarian principles. They seem to me to be a good guide to follow. During this time where beds and ventilators become scarce, if one person is more in need of one than another, I understand why it has to go to them. Something others like the British researcher who was mentioned in the article may be uncomfortable with is prioritizing the young over the old. In the case where it is a decision between a 20-year-old patient and 50-year-old patient, they are both at healthy ages in their lives and have many years ahead of them. Personally, if it were me a 19-year-old and a 10-year-old who needed treatment I would rather the 10-year-old get help first. Something does not sit well with me knowing that someone who had not lived as long as I have could not get treatment because I was. Again, that is my opinion and I don’t judge others who feel differently. Either way I see these health care professionals as heroes and respect that they are doing everything they can to help the sick. That is also another point that I agree with in the utilitarian principles. The health care professionals are not sick, they are essential to treating patients and helping contain the virus. They need to protect themselves at all costs.

  8. The shortage of medical equipment in the United States presents health clinicians a difficult problem. If there is only one ventilator available, but there is two patients, how do you decide which one gets the medical attention? During normal times (no ongoing pandemic), those with the most money get first priority. This is due to the fact that doctors can anticipate a re-up on supplies. They know that everyone will eventually get treatment, so in order to go first, you have to have the most to offer in return. However, this method isnt an option during a global pandemic. Hospitals all over the world cant even supply their staff with appropriate medical supplies, never-mind the patients. With an event of this magnitude, money goes out the door, and it becomes an ethical issue.

    The author brings up the utilitarian view to this dilemma. This viewpoint implores healthcare to be given to those who have the best prospects at the longest remaining life. Doctors are ultimately forced to choose between two people, and decide which life is more worth saving. The example the article presents is: who should be saved, a 20 year old with a better chance at surviving, or a 50 year old with a slightly weaker immune system. The utilitarian would save the 20 year old, because there is a better chance he would be saved with treatment, and if he does get saved he has more of his life to live. Objectors have problems with young people being seen as “more valuable” than older people. The 50 year old could be a father of 5, with more experience and knowledge, so why isn’t he more valuable?

    If there was a best choice in this case scenario, then it would have been applied long ago, and there wouldn’t be any discussion about it. Thinking about it objectively, I tend to side with the utilitarian approach for this argument. If I cast aside all emotion and focus on the facts then it would seem smarter to choose the person who is most likely to gain from treatment. I would rather use my resources on someone who has a 75% to live than a person who has a 25% to live, because I want to make sure my resources are not used in vain.

  9. This article very much reminded me of the photos on Twitter, Instagram, and Facebook where it shows a subway with its passengers being different people of different ages, genders, and physical abilities. For instance, the picture may include a pregnant woman, an elderly woman, a man with crutches, and a small boy with one seat available for only one of them to sit in. The food for thought usually asked is “who gets the seat if there is only one seat?” Many people have different answers but in reality, is there truly a right or wrong answer? Which leads to my interest in Austin Frakt’s first question, ”How do doctors and hospitals decide who gets potentially life-saving treatment and who doesn’t?” Is there a right or wrong answer? Or is it just judged on the
    I do agree with the point mentioned in the article that states, “It would be irresponsible at this point not to get ready to make tragic decisions about who lives and who dies.” But on the other hand, I understand that resources are scarce and not everyone can be helped. The article also mentions a very strong point that “If you had only one ventilator, it would go to someone more likely to survive instead of someone deemed unlikely to do so. It would not go to whichever patient was first admitted, and it would not be assigned via a lottery system. (If there are ties within classes of people, then a lottery — choosing at random — is what ethicists recommend.)” Also, because we only know but so much about the Corona Virus, how is this level of survival measured? Is there a spectrum to judge survival off of? Or again is this judged by a case by case basis?

  10. A few months ago, it would have been almost impossible to imagine the circumstances that our nation is facing now. The idea that Americans now need to begin deciding who gets to live and who must die after our country has been exposed to the Coronavirus for a few months is absolutely terrifying; yet it is evident that it is something that has to been regardless. Personally, the most experience I have with ethical guidelines were the ones I learned in my business ethics class; the risks people are facing today are far greater than anything I’ve learned in class. That being said, I do value the idea that minimal amount of supplies will not be allocated by a lottery system. This article focuses on the idea that many economist and ethicists believe that it is best to use a utilitarian approach when it comes to choosing who gets to live because of our current supply shortages. The author, Austin Frakt describes that this approach analyzes scenarios where if there was only ventilator available, it should be given to the patient most likely to survive. At first, this makes the most sense. In my mind I imagine a child and an elderly person, and the choice to give the extra supplies to a child makes clear sense. Unfortunately, many of these scenarios are not as simple. Because there is such a wide range of people infected and little is currently known about the virus, it seems like it may be very difficult to determine for sure who has the greater chance of survival.
    Frakt also mentions the numerous articles published and studies done that foresaw a lot of current pandemic. These publications have illustrated clearly our lack of preparation for the Covid-19 outbreak. Most of the conversations I have with family and friends about the Coronavirus revolve around the idea that “ No one could have seen this coming” ; according to these studies published in 2015 and earlier, multiple people saw this coming. It is astonishing how many people were able to predict a sort of flu like epidemic, yet not action was taken government officials or civilians to try and evaluate the future of society. Now everyone is paying the price.

  11. In this article, Austin Frakt interviews various doctors on their opinion as to who should have priority for scarce resources such as ventilators during this coronavirus crisis. Many doctors who are interviewed agree that the priority should go to those who have the best chance of beating the virus. In other words if there is one ventilator left and the choice is between a ninety year old patient with prior respiratory issues or a healthy seventeen year old, then the priority would go to the seventeen year old with no prior health issues. Everyday doctors literally hold their patients’ lives in their hands and many times, they are forced to make decisions like this everyday during the pandemic.

    Although doctors want to save everyone, it is impossible to save everyone because there is only so much that can be done without a vaccine or cure. The idea of saving the patient that is most likely to survive ties in with the Darwanian evolutionary theory of survival of the fittest. Unfortunately not everyone can access a ventilator during this time so when it comes down to it, the main goal is to save as many lives as possible.

    I read an article today about an eighty-nine year old woman in Belgium who denied a ventilator because she wanted it to go to someone younger who has not lived life as much yet. As sad as it is, it seems like in this case in particular the woman had a similar idea to doctors about prioritizing those who have a chance of having the ventilator save their life.

  12. About a week ago I was on the phone with my aunt who was a hospital nurse for many years before she became a school nurse when her children were born. As the days go by hospitals are asking for any certified individuals to lend a hand in the hospitals. With each day that passes these hospitals are also offering more money, some more then $100 an hour to nurses who volunteer. Even with the enticing price tag my aunt has chosen not to volunteer because of the high-risk factor due to lack of proper protective equipment. Regardless, she was explaining to me emergency protocol in hospitals during times of crisis. She explained a three-step question protocol the nurses must ask themselves before deciding to fully attend to a patient. Part of this protocol was to decide on the spot if the patient had a good chance of responding to treatment. If it was obvious time and supplies would be wasted on the patient, they would be left to try and survive on their own in a bed without full treatment. Thankfully, while hospitals are reaching full capacity, we have gotten to this most patients are still receiving care of some form in America.

    I came across an article while on social media the other day about an elderly woman diagnosed with COVID-19 in Belgium. The lady, Suzanne Hoylartes refused to be put on a ventilator. She urged nurses and doctors not to treat her, saying “I’ve had a good life”. At the age of 90 she wanted the resources the hospital had left to be used on younger and more likely to survive patients. Hoylartes died in the hospital two days later and her family was unable to be there with her and are not able to hold a proper ceremony for her during this time. I think stories like this are important for people to hear. Yesterday in my town a young father with three children passed away, I went to high school with his son. Patients and medical staff are put in jeopardy every day and still people are going outside. I can only hope that no more people must sacrifice themselves or die in order for people to actually realize just how serious this virus is.

  13. This article should really widen the eyes of the world on the severity of this pandemic. Not only is there no “wonder drug” to definitely help or cure a patient, now people will have to worry whether or not their life value is worth saving. To me, this is not fair. However, I do understand why medical staff now have come to this conclusion. The way I see it, someone’s life value may not mean anything to a complete stranger but to a parent or child this person could mean the entire world to them. I feel this situation on a person level since my own mother has underlying health issues and is no longer a young, spring chicken. It upsets me to think that if she was to contract this virus that her life will be diminished by strangers that are supposed to help her. Although these medical professionals may not see her life worth as much as a 20 year old’s, my mother’s life is worth the world to me. She is my therapist, support system, and best friend. My heart goes out to those who have lost parents, siblings, spouses, or even children from this pandemic.

    Another thought that crosses my mind is whose consent are these medical professionals getting in order to “not save” these older patients? When someone is on life support it is usually the patient’s next of kin to give consent to turn off the machines. Some patients in extreme conditions in hospitals give their own consent that if they were to code, they wish to not be resuscitated. My question is, are these older patients or their next of kin (spouse, parent, sibling, child, etc.) giving their consent to allow these people to be given up on? Meanwhile, a 104-year-old World War II veteran who has not only survived two wars and the Spanish flu has also now contracted and survived the coronavirus. To me, this would have been a life unethically wasted if doctors were to decide this man’s life was not worth as much as a Gen Z individual. This man needs to be celebrated for his service, his history, and his ability to survive to the amazing age of 104.

    Nevertheless, I do understand why these medical professionals need to make these dismal decisions due to resource shortages but personally, I still view them as unethical. However, what other choice do they have? First come, first serve cannot apply here. A person’s monetary wealth may not even apply here. I would say this is the true reason why this pandemic is so scary.

  14. While we live in an age where we somehow are completely unprepared for a global pandemic when 100 years ago, a pandemic wreaked havoc across the world, it is unsurprising that doctors and nurses may find themselves in situations where they have to determine who lives or dies. The article talks about factors, particularly in a scenario of having to choose between a 20 year old and a 50 year old. “Is a 20 year old really more valuable than a 50 year old, or are 50 year olds more important to the economy?” The fact we have to consider life or death based off of economic factors is ridiculous. While yes older people can contribute more to the economy, the older people are the same people who consistently strike down proposals of universal healthcare, which would help guarantee such resources to ensure there would be enough to help both the 20 year old and the 50 year old, and they also strike down proposals to invest in renewable energy and proposals such as the green new deal, to help combat climate change, because it would be a long term investment, that would not benefit them, but the younger people, and considering they feel all the younger people get everything handed to them, they do not want to combat long term issues that will cause huge economic issues in the future, they would rather maintain lower taxes so they can keep all their money in their pocket. Based on this simple fact, it is quite obvious who deserves saving. I understand there are ethical issues based on the fact these doctors are stuck between choosing who lives and dies, but the older people had so many opportunities but messed up time and time again. The older people elected an orange for president, fought affordable healthcare, made the younger generation fight an ongoing, unwinnable war in the middle east that has cost the government roughly 1 trillion dollars, caused an economic recession in 2008, and made sure we were underprepared for an issue like this because they did not think it was something they would see in their lifetime so it would not be their problem. In terms of saving people, and determining who should be saved first? It should definitely be the younger people, considering this mess was exacerbated by the lack of preparation due to a consistent string of mistakes by the older generations.

  15. After reading this article, I must admit that I’m puzzled and also pondering on who should be treated and saved first in this worldwide pandemic where thousands are in need of medical attention in an already limited medical shortage society. This article comes from where COVID-19 ill patients are in dire need of medical attention even when medical supplies and staff are already being stretched to it’s limit to the point where hospitals are planning to split a ventilator for two patients.

    The New York Times article described how Italian doctors were suggested to merge utilitarian principles with the current COVID-19 crisis meaning utilizing a utilitarian approach would mean giving care to those who would benefit from it the most such as those who are more likely to survive the disease or a pregnant woman compared to an old and frail man. It may seem like it’s a bit messed up to be biased towards the ones who are more likely to survive the disease (which I agree it factually is). But if you think of it this way that a healthier person who is more likely to survive compared to one who isn’t, allocating medical resources to the healthier person would likely get him out of the hospital faster than an unhealthy one leading to less crowding in the hospital and overall creating a much more efficient system in the hospital for the sick.

    I interpret this to be similar to that of social distancing guidelines where we must forgo normal social behavior in exchange for a stay at home isolation to prevent infection among the general population. Both concepts are to forgo one thing in exchange for another (that’s typically beneficial for everyone as a whole such as saving/treating health care workers before others). It may seem like it is evil to be biased towards the healthier person, but in the long run, it may save a dozen more lives.

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