Ethical Aspects of Ventilator Triage During the COVID-19 Pandemic

Abstract

The article deals with the issues related to mechanical ventilation triage of critically ill patients during the current pandemic of COVID-19. A brief overview of the guidelines recently published in the United States and Europe is presented. The author points out at the sociocultural variability on the necessity and duration of ventilation, closely related to resources, which influence the approaches to triage. The principles and criteria for selecting critically ill patients to be admitted to intensive care units during the pandemic are analysed in comparison with regular situations. In particular, the principles of “first come — first served” and saving the maximum number of lives are considered. Special attention is paid to the problem of forced withdrawal of life support. If just a few decades ago weaning from mechanical ventilation was considered an act of killing, prohibited by both law and ethics, by now, long before the pandemic outbreak, the attitudes towards this procedure have begun to change. Under the extreme circumstances of the pandemic, some openly believe that withdrawing a ventilator from one patient for the sake of another is not an act of killing. The question about decision-makers is also raised. The author outlines two positions on to whom the responsibility for rationing scarce ventilators is recommended to be assigned. The first approach presumes that this responsibility has to be undertaken by intensivists directly involved in patient care, whereas the second one ascribes it to triage officers and committees who do not contact critically ill patients. The paper also discusses the risks of an utilitarian approach to triage, leading to implicit discrimination against the elderly and people with disabilities, including chronic critical patients on long-term mechanical ventilation in nursing homes or LTAC hospitals. The conclusion points to the conflict between the ethical principles of mercy and equity. Finally, the question is raised about the acceptability and limits of institutionalizing and algorithmizing life-and-death ethical choices regarding individual patients or population groups.