Whose Life Do You Save?

These days, people are having to make really hard decisions. With the  COVID-19 virus overwhelming Italy, doctors are having to make decisions about who lives and who dies. It raises the great moral question, “Given limited resources, who do you save?”⁽¹⁾Italy has published guidelines for this. They are in Italian but I found an English article about them. Also, there’s an interview of the Italian selection at 12 minutes into this podcast. https://www.google.com/amp/s/www.nytimes.com/2020/03/17/podcasts/the-daily/italy-coronavirus.amp.html — 12 min About selection

When I was doing my MBA, I took a great class in Decision Making from Dr. Anna Gunnthorsdottir. As part of the class, we were given the following problem to tackle in small groups: “Five people were dying of kidney disease and we only had the ability to save one of the five.” We were given short bios of each person, e.g., a 50-year-old doctor with 3 children who is working to cure cancer. We were to rank order which of the people we should save. We looked at criteria like age, family, and social value.

As it turns out, this exercise was done in real life when kidney dialysis started. In dialysis, blood is moved outside of the body and cleansed by a machine allowing patients to live with kidney failure. The Seattle Artificial Kidney Center was one of the first experimental machines. It was greatly oversubscribed due to their lifesaving nature and extremely limited availability.

To determine who could get this critical treatment, the head of the center created a committee. It was a cross-section of society composed of seven laypeople—a lawyer, a minister, a housewife, a state government official, a banker, a labor leader, and a surgeon who served as a “doctor-citizen.” The group considered the prospective patient’s age, sex, marital status, net worth, income, emotional stability, nature of occupation, extent of education, past performance, and future potential, to determine which of these people’s lives was “worth” the most.

At the time, the solution was a pretty good one. It created a proxy for society-at-large and let them make the decision on society’s behalf. However, in November 1962, Life magazine ran an article called, “They Decide Who Lives, Who Dies.”⁽²⁾This American Life did a nice little audio story about the Seattle Artificial Kidney Center and they also added the story of the creation of the dialysis machine which I hadn’t heard before. While the article started as a study into this new wonderful and life-saving technique of dialysis, it quickly became a study of the committee, which the author called The Life and Death Committee. This article sparked a national conversation and led to the creation and popularization of bioethics.

Eventually, organ donation settled into the common framework we have today, the United Network for Organ Sharing Standard (UNOS) for organ donation. This is a system that uses a first-come, first served process and factors in criteria like the severity of illness.

When I learned about The Seattle Artificial Kidney debacle, I thought that the UNOS guidelines had solved it. I mean, these bioethics people clearly know the right way to do this. Then, I came across Principles for allocation of scarce medical interventions in The Lancet. I was surprised to learn that the UNOS guidelines are only part of the story. There are eight principles that can be used to apportion scarce medical resources and some are better than others.

As it turns out, there are a lot of different ways to decide on which person gets life-saving treatment including Quality-Adjusted Life-Years (QALY), Disability-Adjusted Life-Years (DALY), and Complete Lives System.

Until I read The Lancet article, I thought that UNOS was the “right” system for organ donation; however,  there are many problems with the UNOS model. It is based on a first-come,  first served model that lets richer people get on the list earlier.  It uses a sickest first principle which means that someone may get an organ who can’t use it as effectively as someone else with a better prognosis.⁽³⁾In this case prognosis refers to how long and successfully a person will live with the organ donation.

Overall, there are a few things that we can learn from the research on organ donation. First, in the earliest days, having a committee makes sense to help define the rules. Having people discuss how to handle a case is necessary in order to come up with good rules. Second, it’s important to publish rules that meet the medical objectives. Even though the rules will never be perfect, published rules are fairer that treating each case individually. Third, certain rules, that seem good at first, can harm the overall system. This is most clear in the Life Magazine article when the housewife says, “I do wish we could somehow see the patient and get a personal impression. It is so hard to judge from a sheet of paper whether or not a man could take the treatment and hold on.”

Finally, the authors of The Lancet article wrote a new article in The New York Times, How the Coronavirus May Force Doctors to Decide Who Can Live and Who Dies.⁽⁴⁾Unfortunately, there are now a number of articles, like The Hardest Questions Doctors May Face: Who Will Be Saved? Who Won’t?, about the real-life decisions that hospitals are making. Given the limited number of ventilators and ICU beds that will be available to treat critical patients with COVID-19, the authors argue that these decisions need to be made early on. We need to decide what we want to prioritize and set rules like who to vaccinate first, like which healthcare workers and which at-risk populations. We need to determine if we operate on a first-come, first served basis or prioritize based on some other method. Making these decisions during the crisis will lead to worse outcomes. It will also cause emotional burnout for doctors who will be forced to make difficult ethical decisions under extreme pressure.