Who decides who gets treatment?
Two motor vehicle accident victims are brought to an E.R. Both are bleeding to death. Only one doctor is available.
Who gets treatment? Who decides? Using what criteria?
These questions refer to medical triage of patients, from French trier, meaning to separate out or categorize. The practice started during the Napoleonic wars when decisions were made among multiple sick or injured soldiers: who gets care and lives, and who doesn't get care and dies?
The state of Idaho has just activated its "crisis standards of care" to allow hospitals to ration care (viz., ICU beds or medications) amidst a deluge of COVID patients. This should terrify everyone. In defense of their patients' right to choose, physicians should adamantly oppose hospitals taking over triage.
Crisis standards of care "prioritize survival of the group over survival of an individual patient during disasters." As an emergency physician in Denver said, "[n]ormally, we operate with the individual patient's best interest at heart." But during this pandemic, "You're looking for the most good for the greatest number — it really is a shift."
This is a shift all must vigorously oppose.
Both the Hippocratic Oath and the American ethos reject such a shift. Doctors swear to give the best care possible to the patient before them, not to society at large. If doctors did the latter, they would not provide medical care to a convicted murderer or an injured terrorist, but they do (and they should). Doctors do not make value judgments regarding value to society. If a person is sick, physicians try to heal. Period. No qualifiers.
Americans believe in individualism, not collectivism. One physician is responsible for one patient, not for patients collectively, AKA society. Survival of the group is the group's concern, not the concern of an individual physician with a critically ill patient.
Beware of guidance statements or advisories from state or federal agencies. Bureaucrats may say these are only suggestions, but hospitals turn official suggestions into orders — mandates that take medical decision-making out of doctors' hands.
In Ohio, Jeffrey Smith, 51, is critically ill with COVID on a ventilator and unlikely to survive. His doctor and his wife want to treat him with ivermectin, but the hospital refused to fill the prescription, claiming that the FDA had not approved the drug for that use. One judge ordered the hospital to provide the medication. Two days later, a different judge reversed the earlier order, saying his review of the medical literature did not confirm the effectiveness of ivermectin.
When did judges become experts in medical research and biostatistics?
Who should decide your care, especially in a triage, life-or-death situation: a district court judge, a government bureaucrat, an insurance executive, Big Pharma, a hospital administrator, or some medical committee? None of the above!
The decision-maker for critical care should be the patient, in consultation with the doctor on the scene. If the patient is unable, then the person with medical power of attorney should decide. No one else!
In the summer of 2020, there was a shortage of the drug Remdesivir at a time when COVID patients were flooding hospital ICUs. Pennsylvania had a plan called "weighted lottery." This was undoubtedly the most "woke" and least ethical way to triage care or ration a limited amount of a drug that had proven at least 62 percent effective in treating severely ill COVID patients. The proposed Keystone State lottery — their crisis standard of care — would be weighted to favor people "of color" and the poor, thus weighted against white people and middle-class or wealthy individuals. Medical triage would be decided by skin color and socioeconomic status.
The only proper American crisis standard of care is no standard at all. There is no such thing as "standard" care or medicine that is universally applicable. Every patient and situation is unique unto itself. Medical decisions, most especially life and death ones such as triage, should be made by a committee of two: patient and doctor. Nobody else.
Deane Waldman, M.D., MBA is professor emeritus of pediatrics, pathology, and decision science; former director of the Center for Healthcare Policy at Texas Public Policy Foundation; and author of the multi-award-winning book Curing the Cancer in U.S. Healthcare: StatesCare and Market-Based Medicine.
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