Doctors may have to choose which patients to prioritise, ethics document says

A Department of Health ethical framework for operating during a pandemic makes clear doctors may have to make decisions on which patients should be prioritised for treatment.

Drawn up last March and updated in September, the document also points out that introducing surge capacity in hospitals is likely to have a knock-on effect on other services. It says that under normal circumstances, all individuals have an equal claim to healthcare. However during a pandemic, healthcare resources, particularly critical care resources, are likely to become limited over time.

Once the healthcare system reaches capacity, everybody will be cared for, but may not have the same access to different levels of medical intervention, it says.

“Decisions will, therefore, have to be made regarding who should be prioritised to receive intervention.

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“Patients with Covid-19 as a cohort should not be given preferential treatment over other patient cohorts requiring acute care; neither should they be treated any less favourably.”

The document says ultimately measures to deal with a surge in patients will require difficult decisions to be made in relation to which services to maintain and which to defer.

“Certain services will have to be maintained during a pandemic, eg emergency treatment, obstetrics. ”

It says in cases where all patients cannot be treated, notwithstanding surge capacity, it is essential that the process of differentiating between those who should and should not receive a particular intervention is conducted in a consistent manner, taking account of the local context.

“Decisions will have to be made about the level of care offered, eg admission to ICU, initiation of life-sustaining treatment eg, ventilation, as well as withholding or withdrawal of life-sustaining treatment, necessitating referral to palliative care services.”

Decisions

“Decisions should be principally based on the health-related benefits of allocation mechanisms. Thus, the starting point for any rationing decision is to consider which patients are most likely to benefit from the intervention. Consideration of the patient’s pre-morbid health status, their will and preferences (if known), the presence of co-morbidities and their frailty status (independent of age) are all relevant in this context.”

It says that “categorical exclusion, eg on the basis of age, should be avoided as this can imply that some groups are worth saving more than others and creates a perception of unfairness”.

“The principle of solidarity dictates that while all patients may not receive critical care, those who do not should continue to be cared for with alternative levels of care, including palliative care.”

“It is not appropriate to prioritise based on social status or other social value considerations, eg income, ethnicity, [or] gender. However, it may be ethical to prioritise certain at-risk groups and those essential to managing a pandemic for treatment.”