The doctor’s dilemma

Published by The i paper (30th March, 2020)

The death toll rises each day with the grim predictability of an exponential curve. Medical chiefs say we will do well to keep the final figure below 20,000, yet it might have been 12 times worse without the imposition of national lockdown. Those leading the fight to contain this virus believe they may have done just enough to ensure the health service can handle the crisis thanks to desperate tactics such as building huge field hospitals to boost capacity – so long as the public plays its part to reduce transmission.

I hope they are right and our nation is lucky. But many doctors ramping up critical care facilities fear they will be swamped by what one terms a ‘tsunami’ of cases. ‘Every hospital is expected to be overwhelmed,’ said a consultant in the North-west. ‘Most of us on the front line are petrified. There will be lots of patients dying and that is going to be horrible.’ They know they could soon be forced to confront the most hideous question: who will live and who will die if they have to ration their resources?

In Italy’s worst-struck areas, patients under 60 years old have been prioritised. In Catalonia – where a surge of cases has led to more deaths than in the whole of Britain – an emergency doctor told me they use a ‘fragility index’ based on age, underlying health conditions and chances of survival to determine who is given mechanical ventilation. ‘Age is important but if someone is 50 with diabetes and high blood pressure, they might be worse off than a 70-year-old with no other conditions,’ said Gina Culubret.

Bear in mind Italy had almost twice the number of critical care beds per person as Britain at the start of this crisis. Culubret’s hospital has stopped other treatments and almost doubled bed numbers, even converting operating theatres into temporary wards. This is why our own medical leaders, ethicists and politicians have to confront the darkest of dilemmas involving the sanctity and value of life.

Do they, for instance, save a young mother with breast cancer over a much older, but healthier, patient? And if the pandemic intensifies, should a patient be taken off a ventilator if someone with longer life expectancy or better survival chances arrives on their ward? These are unprecedented issues for the NHS. An article published last week in the New England Journal of Medicine said that unlike other questions of life-sustaining treatment ‘the decision about initiating or terminating mechanical ventilation is often truly a life-or-death decision’.

Authors of a second article in the publication argued it was ethical to remove ventilators without patient consent since it was ‘justifiable to give priority to maximising the number of patients that survive treatment with a reasonable life expectancy’. But it warned that some clinicians might refuse to do so. Adoption of such an extreme utilitarian approach makes me queasy. Last week the National Institute for Clinical Excellence (Nice) had to hastily ‘clarify’ critical care guidelines amid fears that people with disabilities might be denied treatment.

Its ‘rapid guidelines’ included a frailty scoring system with those judged ‘fittest for their age’ scoring one and patients ‘approaching the end of life’ given nine. After outrage that anyone ‘completely dependent for personal care’ scored seven, the document was amended to warn against use on patients with learning disabilities or cerebral palsy. A spokesperson said they were offering doctors only a framework: ‘These are not hard and fast rules.’

The furore exposed the awful choices doctors may face. One geriatrics specialist who routinely uses fragility scales told me they are a ‘very blunt test’ that can be carried out in less than a minute. He fears they might be misused by medics rushed to frontline duties who did not fully understand the limitations. ‘It is useful as a measure of a patient’s dependency, better than just age alone as seen in Italy, but we might see people with a score of seven who are physically robust and not in any acute danger if treated properly.’

Others warn of the impact on doctors forced to make impossible decisions under extreme pressure. ‘What happens if two patients of the same age arrive at the same time but there is only one ventilator?’ asks Neil Greenberg, a mental health professor at King’s College London. He published a paper in the BMJ highlighting his fears that such choices could spark ‘moral injury’ for medical staff by violating their ethical code, as well as severe post-traumatic stress. ‘Imagine the mental distress for doctors who thought they could have saved people if they’d had the equipment.’

Greenberg calls rightly for clear discussion of these tortuous issues. He believes they should not be left for doctors on the frontline since it could fuel psychological damage: ‘This is the conundrum over whose life is most valuable?’

Such questions terrify people with learning disabilities and their families, however, when studies show hundreds already die avoidable deaths each year in the health service due to mistakes and prejudice – and at least four in 10 of their fatalities last year were due to respiratory conditions. ‘There are real concerns about clinicians having to make quick decisions about the ‘frailty’ of people with autism and learning disabilities that may lead to them being denied access to life-saving intensive care,’ said Chris Hatton, professor of disability at Lancaster University.

So will this virus expose with savage brutality who we really value in society? For these are profound questions. Forget the foolish talk that we should sacrifice the old, the sick and the vulnerable to salvage the economy. We find ourselves trapped in a struggle in which we must all play our part to relieve the burden on health workers and hasten return to some sort of normality. This goes beyond social distancing to difficult discussions about confronting death, both within our families and beyond.

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