Who should decide which patients live and which ones die?

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APRIL 17, 2020 — Flashes of red and blue light reflect off the wet pavement as the ambulance speeds to the hospital, leaving behind crumpled cars, still smoldering from the accident.

In the back of the ambulance, it’s your mother or your father, or maybe your grandparent.

Minutes later you get the call. You gather your family and rush to the hospital, but when you arrive you are turned away. In the world of COVID-19, visitors are no longer allowed.

Inside, the hospital is overrun with patients. Providing your loved one the ventilator they need may require letting someone else die. If your loved one were younger, the doctors would make this choice. But your loved one is old, and scarce health care resources are no longer spent on the venerable. Hours later, without friends or family by their side and with lifesaving care just yards away, your loved one breathes their last breath.

Such stories are no longer reserved for dystopian literature. COVID-19 has forced hospitals to deny lifesaving care and turn away visitors, including family. Everyone deserves access to lifesaving care, but there are more people dying than there are ventilators to save them.

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“There is a world of difference between the ethical rules that govern the care of patients and the ethical rules that govern public health.”

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In times like these, there is no avoiding unpleasant decisions. But we can decide who makes those decisions.

A doctor cannot deny a patient lifesaving care without breaking the promise to heal. Health care providers cannot force a patient to die alone, separated from friends and family, without breaking their promise to help.

There is a world of difference between the ethical rules that govern the care of patients and the ethical rules that govern public health. Clinical ethics prioritize each individual and leave little room for utilitarian calculations. By contrast, from the perspective of public health ethics, the value of each individual life is outweighed by the needs of society.

Health care providers are not trained to think ethically about tension between an individual patient’s care and overall societal good, nor does their ethical training allow them to disregard the well-being of their patients.

When health care providers break their promise to help, there are long-term costs. Well after COVID-19 is gone, the memory of broken promises will linger.

What sick patient would go to a hospital that chose to deny their father lifesaving care? Who would go to a place where their mother was forced to face her life-and-death struggle alone?

Equally as important, once our faith in our health care institutions is broken, how will we handle our ongoing health crises of obesity, diabetes and opioid addiction, much less the next pandemic?

Though physicians must focus on the well-being of their patients, there are institutions tasked with balancing the good of society against the good of the individual. During a pandemic, government agencies come to mind—the U.S. Centers for Disease Control and Prevention, the National Institutes of Health, and the National Institute of Allergy and Infectious Diseases. There is similarly a wealth of institutions closer to home: local, county and state governments.

Across a range of functions, each of these institutions is tasked with striking the balance between individual and societal interests. In the face of a pandemic, it is institutions like these—duly advised by medical and public health experts—that must take the lead.

It is deeply uncomfortable to imagine the government making decisions about who will live and who will die. But in times like these, it is not a question of if these decisions will be made but rather who will make them.

Health care providers should not carry this burden. They lack both the expertise and the ethical permission.

Though federal and state agencies have the expertise, they are too far removed from the realities on the ground.

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In a world where policies are needed to ration lifesaving care, these policies should be developed by local governments. Input from public health experts, federal agencies and health care providers should be heeded, but only local governments have both the mandate to strike the balance between individual and societal interests and, by the power of the ballot, can be held reasonably accountable for their decisions.

Sometimes there are no good choices. When there are not enough ventilators to go around, there is no way to avoid the act of deciding who will die. We can, however, control who makes the policy decisions that will determine who will live and who will die.

Policies that balance the welfare of individual patients against the greater societal good should be made by our public health experts, our cities and our state, not by our doctors, our hospitals or our health care providers.

— Abraham Graber

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