Pandemics create a high demand for health care. What happens if we can’t take care of everyone? That’s where ethics comes in. How would we prioritize health care in times of scarce resources?
Ethics is a generic term for several ways of examining the moral life. Ethics can be complicated and biomedical ethics can become very complicated.
There are different theoretical approaches to ethics. Ethical theories are important in that they really form the backbone of our thinking as we navigate through the process of discerning the best approach to life. I like to think about ethical theories as being like wearing different types of glasses. Depending on which type of glasses you are wearing, you see the world a bit differently. If you wear regular glasses, you see the world one way. If you put on 3-D glasses, you see the world differently.
There are two dominant categories of ethical theories:
• Utilitarianism theories – What is right is what is most useful.
• Deontological theories – What is right, is right, always.
Volumes are written on various ethical theories, but just know that these theories are the underlying basis for the different way people view the world.
These various ethical theories form the platform for ethical principles, which form the platform for ethical rules. Based on those rules, we make judgements and take specific actions.
Ethical Theories Principles Rules Particular Judgements and Actions
There are three basic ethical principles that we balance in our approach to living an ethical life.
• Respect for Autonomy – The individual has the right to self-determination, liberty rights, individual choice, privacy, following one’s own will and being one’s own person.
• Nonmaleficence – “Above all (or first) do no harm”
• Beneficence – What should be done is that which produces the most benefit.
An ethical dilemma exists when a certain behavior can be justified under one principle but conflicts with another principle. For example, let’s consider guns. There are many perspectives:
• Individuals have the right to own guns. (Respect for autonomy)
• Guns, especially some types of guns, are very harmful and should be illegal because they are too dangerous. Therefore, we should restrict at least some gun ownership. (Nonmaleficence)
• Gun ownership is vital to maintaining our democracy. The fact that individuals own guns helps us keep our democracy in check and therefore is in the best interest of our democracy in the long run. (Beneficence).
These are just a few of the arguments for and against gun ownership. You can see how an issue like gun ownership presents an ethical dilemma – There are arguments, for and against, that are supported by ethical principles. So, what do I do? Do I honor the principle to respect autonomy? Or, do I honor the principle of nonmaleficence, first do no harm?
Health care: When we apply ethics to health care you can see how the three principles above quickly become fraught with ethical dilemmas. We, as health care organizations and as clinicians, want to be respectful of a patient’s wishes (Respect for Autonomy), we do not want to cause harm (Nonmaleficence) and we want to do what is of the most benefit (Beneficence) to ….. to whom? That is where we really struggle. Should we do what is the most benefit to the patient in front of us now? Should we do what is the most benefit to all patients, collectively, present and future? Should we do what is the most benefit to society as a whole? And, how do we possibly define what is of the most benefit to society as a whole? Consensus amongst experts in bio-medical ethics is that, in the face of scarce resources, we should determine benefit based on three principles:
• Save the most lives – give priority to those who have the best prognosis for short term survival.
• Opportunity to live through the phases of life – give priority to those who have not lived through life’s stages.
• Maximizing most life years – give priority to those with the best prognosis for long term survival (fewer comorbidities).
At Western Wisconsin Health, we, like other hospitals, have developed ethical guidelines for the prioritization of care delivery in times of scarce resources. These guidelines apply to any situation in which health care providers find themselves in a situation where they cannot provide all the health care that is needed to all the people who need it. It could be a mass casualty event like a storm or a major car accident. Right now, it is a pandemic. We hope we will never need to use these guidelines.
There are many, deeper ethical and moral issues related to the allocation of health care in this country that we, as a people, need to address in the coming months and years. These issues have nothing to do with a pandemic, but some have been brought to light as the SARS CoV-2 virus ravages our country. The most striking to date is the fact that people of color are dying of COVID-19 at a much higher rate than white people. Why? The reality is that we know the answer to this question, and we know how to fix the problem. The question is, will we, as a country, have the will to do what is right for the most people, to provide the greatest benefit to society?