Normally, if five patients arrived in the ER with the same condition and roughly the same level of urgency, they would be treated in order of arrival. If they arrived at roughly the same time and with the same condition, they would be treated in order of urgency. But the panicked phone call about the five patients who all needed ventilators presented a vanishingly rare predicament: five patients, same arrival time, same problem, all critically ill.
The decision was “based on who was most likely to survive,” Fins told me. Drawing on a modified version of the save-the-most-lives method to which Wynia referred, the ethicist on call (one of Fins’s colleagues) advised the physician to prioritize the five patients using the sequential organ-failure assessment (SOFA), which predicts the likelihood of short-term survival. (Not all ethicists think SOFA is an adequate prognostic system for COVID‑19—Wynia has pointed out that it hasn’t been an accurate outcome predictor for pandemic flus.) The ethicist also reminded the physician to be vigilant for any implicit bias in the assessment (ageism, ableism, racism). This wasn’t rationing; it was prioritization: In what order would these patients get put on ventilators?
This distinction between prioritization and rationing may seem technical, or like doublespeak. What’s the difference when “deprioritizing” someone might mean he doesn’t survive long enough to get the care that could have saved him? But in this case, the prioritization seems to have made sense. The medical team was able to give the third, fourth, and fifth patients in line other kinds of mechanical respiratory support to bridge the gap. The fifth patient had end-stage dementia and multiple organ failure.
Fins said that situations like this, in which all of the options are bad but you have to make a decision, create “a kind of a moral scar for the clinician.” The clinical ethicist’s job is to help the scar fade, essentially by assuring health-care workers that they did the best they could given the circumstances. “The moral explication is a balm for the clinicians, who have to go back and do it again.” In this case, they avoided the absolute worst: All five people were eventually placed on a ventilator.
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