Blueprint for medical crises must be re-examined, says bioethicist


A physician task force recently proposed guidelines for hospitals to follow in the face of a medical crisis.  The recommendations made by the doctors describe the characteristics of patients who should be denied treatment in order to save those who are more likely to survive.

These physicians are concerned with the possibility of a flu pandemic, an atrocity like 9-11 or other states of emergency.  As one task force member told the AP, “The idea is to try to make sure that scarce resources — including ventilators, medicine and doctors and nurses — are used in a uniform, objective way.”

In an effort to avoid this type of disaster, the group of physicians recommended in the May issue of Chest, the medical journal of the American College of Chest Physicians that treatment be denied to:

• People older than 85
• Those with severe trauma, which could include critical injuries from car crashes and shootings
• Severely burned patients older than 60
• Those with severe mental impairment, which could include advanced Alzheimer's disease
• Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes

CNA spoke to the founder and executive director of Bioethics International, Jennifer Miller, for comment on the task force’s recommendations.  While she praised the physicians for their efforts, she pointed out the deficiencies of allowing a national task force to select which patients will live or die.

“The task force is to be commended for its courageous and necessary efforts to work through the difficult questions of who is to receive what resources when and under what conditions in the event of a disaster such as a hurricane Katrina, a 9-11 and/or a pandemic flu – with the dual aim of protecting patients and practitioners.”

However, Miller pointed out that, “in some instances the framework has an imbalanced focus on benefiting the stronger majority while discriminating against the weaker minority populations and/or individuals such as the elderly and patients with mental impairments. To a certain extent it uses a social-utility based metric rather than valuing every patient.”

Lawrence Gostin, a public-health law expert  at Georgetown University told the AP that while the report is important, it is also "a political minefield and a legal minefield.”  Gostin continued by saying that the proposed rules would likely violate discrimination laws, causing an exclusion of care for the poor and disadvantaged.

Instead of deciding who will or will not be treated at a task force meeting, Miller argued that the decisions “need to be made at the most appropriate level,” says Miller.  “Generally deciding whether an individual patient will/won’t receive a needed resource is best made patient-side not desk-side at a task force meeting.”

She continued, “while it may be true that in many cases patients over 85 will be less likely to benefit from receiving a ventilator, it will not always be the case and the attending healthcare provider will be better able than a national task force to determine the medical benefit upon examination.  In times of scarcity, resources and care should be first allocated to those most in need and most likely to benefit.  This framework generally does a good job identifying the correct level for these triage decisions, except for when it provides blanket exclusions of groups of patients such as the elderly.”

“It is not ethical to allow for the automatic and routine disconnection from ventilators of otherwise stable 85 yr olds to reallocate to younger patients,” Miller concludes.  “However, in some cases it may be justifiable to allocate to a younger patient who is more likely to benefit over an older less likely to benefit patient.” One instance in which Miller could see this being done is “if the elderly patient has chosen to forgo the life-saving treatment – an example of heroic charity.”

The Director of the Office for Social Ministry for the Archdiocese of Denver, Al Hooper told CNA that the task force’s “blueprint” is not surprising because of the current eugenic policies already in place:  “We do not need a designed comprehensive framework to optimize and manage critical services to the ill or injured when a major disaster or pandemic occurs we already have such priorities and preferences.”

He further explained that “our current accommodating health public policies on abortion, euthanasia, and assisted suicide have already framed the ‘appropriate’ response even with ample infrastructures, supplies and medical personnel at hand.  The rot of social Darwinism proceeds unabated, disaster or no disaster and I surely doubt that we would apply this policy to people of importance, influence and notoriety.”