The ongoing H1N1 "swine flu" pandemic has proven rather mild. However, the rapid rate at which an estimated one million Americans have already contracted this illness should have our political and medical leaders urgently examining how they will eventually handle a more severe form of the influenza virus. One of the questions that will face our society when a future pandemic proves more deadly -- and one that has largely avoided public discussing during the current crisis -- is how our public health authorities ought to allocate ventilators. To a patient whose lungs are temporarily compromised, short-term ventilator support is often the difference between life and death. Unfortunately, if a future pandemic leaves millions of Americans temporarily unable to breath -- vastly exceeding the number of mechanical ventilation machines or the trained staff needed to operate them -- our hospitals will be forced to decide which patients to help breathe and which to let die. Needless to say, in a culture that values human life highly, such choices raise unsettling ethical questions.
The American health care system already rations life saving treatment, of course -- by necessity, in transplant cases where a limited supply of donor organs is available, and by economic choice in those relatively rare (and often highly-publicized) cases where patients cannot afford surgeries or experimental therapies costing hundreds of thousands of dollars. Oregon's Medicaid system overtly rations care -- refusing, for example, to pay for certain late-stage cancer treatments. Texas has a futile care law that allows health care facilities to halt life-support, even over the objections of the patient or family, when a case appears hopeless. However, the number of individuals whose deaths have been accelerated by these rationing regimes is relatively small. In contrast, twice in our nation's history, medical authorities have been forced to allocate new technologies in a manner that demanded life-and-dead decisions about patients on a large scale. During the polio epidemics of the 1940s and 1950s, physicians were asked to ration life-saving iron lungs, an allocation which was often performed on a "first-come, first-served" basis. Between 1962 and 1967, Seattle's "God Committee" used factors related to perceived social worth in assigning scarce slots on dialysis machines. Patients rejected for shifts on these artificial kidneys, like those deemed ineligible for heart transplants today, inevitably died.
A ventilator shortage during a flu pandemic could threaten the lives of far more Americans that all of these other rationing episodes combined. What is not yet clear is what criteria public health authorities should use to allocate ventilators during such a crisis. The most comprehensive approach appears in the guidelines proposed in 2007 by the New York State Workgroup on Ventilator Allocation in an Influenza Pandemic, a joint enterprise of the New York State Department of Health and the New York State Task Force on Life & the Law. This committee, headed by the eminent psychiatrist Tia Powell, proposed a triage system for providing ventilator care during a potential pandemic. The committee's final report argued that the primary test for determining who received ventilation ought to be prognosis for survival -- without regard to such factors as age, status as a health care provider, or perceived social value. As a result, a group of patients was explicitly excluded from such life support, including those with chronic cardiac arrests, metastatic cancer with a poor prognosis, severe burns, severe and irreversible neurological damage, end-stage organ failure and -- most controversially -- otherwise healthy patients dependent on dialysis. Why dialysis patients who might live long, fruitful lives, and eventually receive transplants were included on this list, is not entirely clear. While the care for such patients involves high-intensity staffing, so does care for patients with psychotic disorders -- many of whom have shorter life expectancies -- yet the Workgroup decided that end-stage renal patients were to be excluded but refractory schizophrenics were not. The committee may have made the correct call. Or maybe not. What is essential to emphasize is the complexity of medical and ethical issues raised by any form of ventilator rationing.
One area in which the Workgroup's approach differs from earlier efforts to address this dilemma was its reluctance to sanction the removal of ventilator therapy from a patient when another patient with a better prognosis arrives in need. Similarly, the Workgroup's approach overtly confined its triage guidelines to those patients in hospitals or in need of acute care, and excluded patients on long-term ventilator support in long-term care facilities. However, if our society's goal is to preserve as many human lives as possible, then not including nursing home and chronic care ventilators in the pool of available machines may be ethically indefensible. The vast majority of these machines are paid for, directly or indirectly, by public funds. Commandeering a living long-term patient's ventilator (eg. a quadriplegic) for the treatment of acutely-ill flu victim is, in essence, exchanging the life of one institutionalized, chronically-ventilated patient for those of several (or even many) temporarily incapacitated individuals. This is certainly not a choice any public official would ever wish to face. But preserving one life while letting many others die -- simply because the long-term patient had acquired use of the machine first -- is incompatible with the goal of maximizing the welfare of the largest number of sick individuals. Surely, anybody setting up a moral society a priori, and not knowing whether he would be one of the long-term patients or one of the victims of the flu, would prefer a system that saved as many lives as possible. Removing long-term patients from ventilators would never be a light decision. That does not mean that, in the extreme crisis of pandemic-induced ventilator shortage, extubating chronic patients would not be the moral choice.
A ventilator crisis is likely, if not inevitable. Moreover, this is not the sort of shortage that can be avoided: stockpiling tens of millions of ventilators is not feasible, nor is training sufficient staff to operate them, and attempting to do so would rapidly bankrupt the entire health care system. If by some stroke of good fortune our civilization avoids such a crisis, then we will eventually face a acute scarcity of another life-saving technology or medication that raises similar ethical concerns. We desperately need a public discussion on how to handle this crisis before it arises. Under what circumstances should health care providers and first-responders jump to the front of the line? Because even if these doctors and firefighters would be unable to recover in time to help in a particular crisis, saving their lives might indirectly help others in future pandemics or emergencies. Should age be a factor in allocating machines? And if so, should such an approach favor adults or children? These are not questions with easy answers. However, answers will be required. Most likely, some unfortunate individuals will have to be removed from life support so that others may live. These decisions will be difficult and emotionally challenging. Yet if rendered on a case by case basis during a crisis, rather than according to long-established and well-publicized rules, their effects will be far more devastating to both the patients involved, their survivors, and the integrity of the health care system as a whole. The current pandemic should serve as a wakeup call. The United States requires a national plan for handling such a future crisis, rather than ad hoc state-by-state guidelines, and we need a widespread public dialogue on how it will be implemented.