Now I lay awake dreading what might be coming as the covid-19 pandemic sweeps the world. In China and now Italy, the stories of struggling hospitals are scary; they summon those decade-old memories.
In Haiti, there were too many patients, and we were too few. They needed so much, and we had so little to give. That’s not how it is supposed to be for doctors and nurses. We are trained to take care of everyone — it is our moral duty to do what’s best for each and every patient we see. Nobody dies until we have tried everything to save them. That’s how I was taught; that’s how I practice in my overstocked, well-staffed, technology-filled American emergency department. But it wasn’t like that after the earthquake. We couldn’t treat everyone. Some just died.
The first decision was easy: I gave the last of the antibiotics to the little girl with the fever, instead of the older man. He was my age; I wondered if, like me, he had sons. I was hoping we’d get more medicine the next day so we could treat him too. We didn’t. He died.
Then there was the young man paralyzed from a broken neck. We had no neurosurgeon, IV fluids, neck brace, wheelchair. And even if we did, anything we gave him wouldn’t be available for someone who might live. We moved him to the dark tomb-like ward with 50 patients and two nurses who didn’t have enough time to change all the dressings.
Then another choice, and another. The calculation seemed simple, “Who do I save?” But what eats at me even now was that it was actually, “Who do I let die?”
Shocking news is coming out of Italy about hospitals overwhelmed by the onslaught of covid-19 patients — not enough beds, not enough staff, not enough ventilators. I’ve always known this was coming, some horrible catastrophic event where there isn’t enough to care for everyone, and we would have to stand by and watch some die. Could this be it?
The situation in Italy has reached such a critical state that the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care published thoughtful guidelines to help doctors and nurses make the agonizing choice of who to treat, and who to not.
The guidelines warn that the next few weeks could bring “an enormous imbalance between the real clinical needs of the population and the actual availability of intensive care resources.” Then they proceed to describe how to make choices when the choice includes letting someone die. The Italian guidelines call it “disaster medicine.” In the United States, we have discussed it, too, under the soothing rubric: “crisis standards of care.” We used to say “altered standards of care” but were concerned about the lawyers, so we resorted to other euphemisms, always avoiding the grim reality: This is rationing.
A 2009 report by the Institute of Medicine offered recommendations that were encouraging but vague. “Healthcare practitioners must adhere to ethical norms,” the report advised; even in crisis situations, providers should give “the best care possible.” But the medical ethical norms I was taught were that I must provide the best care for every patient equally. That is not possible when you don’t have enough. I violated that norm as soon as I gave that child those antibiotics.
In truth, there are no “ethical norms” in these catastrophic settings. There is rationing, and what makes it so horrible is that we are rationing life. That’s wrong, I’ve been there, and that is what wakes me up on the darkest nights: Did I violate my duty as a physician? Did my patient have to die?
My Italian colleagues are now staring into the same abyss that we did 10 years ago. I applaud their bravery and wisdom, and their attempt to bring order and prevent the psychic damages these decisions cause to health-care workers. They recognized the core reality: Nobody wants to choose who dies. They wisely recommended that this most awful choice “should be shared as much as possible among the operators involved.”
In Haiti, we all suffered the psychic weight of deciding alone until we finally settled on a system where we discussed any case where we had to ration care. To all the health-care workers facing this new world, I say, the time to think about this is now. Talk with your colleagues about each patient. Form a committee to decide. Don’t make these choices alone. We do not have the right. We do not have the strength.