Science and Tech Columnist

There are not always the resources to treat everybody, so who should be saved?

We are living not only in a climate crisis, a health crisis, and an economic crisis: we also have the less mainstream ethical crisis to contend with of choosing who and what gets treated during this pandemic.

The ethics of healthcare is a topic I was nervous about entering into. There is no right answer - that is the difficulty with ethics in general. Who am I, a healthy university student, to outline who we treat? To illustrate the complexity of ethical problems, I will outline a classic one - the trolley problem, first postulated by Philippa Foot, and which fits very well into the current ethical crisis we face. The problem follows as such:

There is a runaway trolley barrelling down railway tracks. Further down the tracks, there are five people unable to move and the trolley is headed straight for them. There is another track with only one person on it and you have the power to pull the lever to diverge the trolley onto the side-track to only kill one person. Do you pull it?

Most likely you would. It makes sense; when faced with the possibility to save five lives or one, you save five. But what if we changed the scenario such that instead of pulling a lever, you had to push one person in front of the trolley to stop it from killing the five people ahead on the tracks? This time, people are much less likely to sacrifice the life of that one person, even though the outcome is the same. These thought experiments are interesting and have been used for decades, although have also received some criticism due to the fact the situation is so unrealistic. Yet when constructing this ethical dilemma in the 70s, the philosophers and scientists were unaware of an impending virus that would cause medical professionals to have to make choices that become strikingly similar to the trolley problem. 

Let’s take an example: Dave is a doctor and two patients are needing a ventilator, 20-year-old Lucy and 80-year-old Bert, but there is only one ventilator. He gives it to Lucy since her chances of survival are a lot higher. It is horrible and unthinkable, but most would agree it was the right call. In the second scenario, Bert is already on the ventilator and Lucy comes in requiring one. This time Dave would have to take Bert off the ventilator to save Lucy. This seems a lot more extreme and personal even though the outcome is the same: Lucy gets the ventilator and Bert doesn’t.

According to David Magnus, the director of the Stanford Centre for Biomedical Ethics, three ideologies underpin healthcare ethics: egalitarianism, utilitarianism and prioritarianism. Egalitarianism strives to treat patients equally, in every sense of the word. This could involve a lottery system for treatments for example. Utilitarianism involves maximising the total benefit of a decision. Normally, this is conceptualised as remaining life years, hence Lucy got the ventilator instead of Bert. Prioritarianism works on priority, treating the sickest people first, such as in A&E. There are, of course, pros and cons to each of these approaches. Egalitarianism is quite hard to put into practice and is usually not advised since most people can agree that treating someone for back pain over someone who has been shot doesn’t make much sense. The other theories pose an important question: what makes one life worth saving over another? In the UK, we have a system called quality-adjusted life-year (QALY) scores which are critical in health care decision making. They consist of a number that represents the years of life multiplied by the quality of life e.g. if following medical treatment a patient would get a year with "full" quality life, that patient would get a score of 1. This is along the lines of a utilitarian approach, but we also have some prioritarianism during the pandemic, since we are making sure the sickest patients are getting treatment, with most elective surgeries suspended. At the end of the day, the health systems try to balance four criteria: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness as outlined in a paper by Ezekiel Emanuel.

I don’t know the answer, but we have surpassed 100,000 Covid-19 deaths, and so it is evident that our current allocation system isn’t working well. I do know that the most ethical approach to a problem such as the pandemic would have been not to have to choose which ideology to follow, or whether to give the ventilator to Lucy over Bert, or having to decide between treating one Covid-19 patient or offer 12 hip replacements. The most ethical decision is always prevention, locking down early, tracing cases effectively, and following the lead of countries such as New Zealand and Australia. That way both Lucy and Bert would have been offered the health care they needed, and the ethical dilemma is reduced to practical solutions.

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