COVID-19: when health care resources run short, how to pick who should (not) get treated?

Main Article Content

Gianluca Montanari Vergallo
Maria Cristina Varone
Alessandro Del Rio

Keywords

CoViD-19; allocation of resources; intensive care triage; quality adjusted life years; deontological approach

Abstract

The World Health Organization had long warned of the onset of a pandemic that could throw national health systems into a major crisis, even in wealthy developed nations. Nonetheless, almost a year and a half after its appearance, Covid-19 continues to make painful triage choices necessary in granting access intensive care. Based on the opinions of numerous ethics committees and scientific societies, the article aims to illustrate the difference between the utilitarian-collectivist approach and the ethical approach, which inspired the guidelines drawn up in Italy in 2021 by SIAARTI in collaboration with SIMLA. Only medical parameters should be evaluated to establish the prognosis through which to identify the patients to be treated as a priority. Otherwise, the patient's interest is subordinated to that of the community. But moral judgment cannot concern only the choices of doctors. According to the principle of beneficence, hospital directors and national and local health policy managers must also take action, in particular to eliminate waste of economic resources so as to allocate more of them to health protection, especially in consideration of the predictability with which infection rates increase, and in light of the fact that immunization through vaccination is only temporary.

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References

References
1. European Commission, State of Health in the EU Italia, 2019. https://ec.europa.eu/health/sites/health/files/state/docs/2019_chp_it_italy.pdf.
2. Signorelli C, Odone A, Gozzini A, Petrelli F, Tirani M, Zangrandi A, Zoni R, Florindo N. The missed Constitutional Reform and its possible impact on the sustainability of the Italian National Health Service. Acta Biomed. 2017;88:91-4.
3. Agenzia Italiana del Farmaco (AIFA), Parere CTS AIFA su anticorpi monoclonali, Roma, 4 febbraio 2021. https://www.aifa.gov.it.
4. World Health Organization, Guidelines for the global surveillance of severe acute respiratory syndrome (SARS). Updated recommendations, October 2004, § 1. https://www.who.int
5. World Health Organization (WHO 2004), WHO guidelines for the global surveillance of severe acute respiratory syndrome (SARS). Updated recommendations, October 2004, § 1. https://www.who.int.
6. World Health Organization, (WHO 2016) Guidance for managing ethical issues in infectious disease outbreaks, § 1. Obligations of governments and the international community. https://apps.who.int/iris/bitstream/handle/10665/250580/9789241549837-eng.pdf?sequence=1.
7. Signorelli C, Scognamiglio T, Odone A. COVID-19 in Italy: impact of containment measures and prevalence estimates of infection in the general population. Acta Biomed. 2020;91:175-79.
8. Riva L, Filia A, Floridia G, et al., Sorveglianza territoriale e tutela della salute pubblica: alcuni aspetti etico-giuridici, 25 maggio 2020, Rapporto ISS COVID-19 n. 34/2020, https://www.iss.it.
9. Consonni D, Bordini L, Nava C, Todaro A, Lunghi G, Lombardi A, Magioni D, De Palo F, Guerrieri L, Gatti M, Serra D, Polonioli M, Pratò S, Muscatello A, Bandera A, Auxilia F, Castaldi S. COVID-19: What happened to the healthcare workers of a research and teaching hospital in Milan, Italy? Acta Biomed. 2020;91:e2020016.
10. Fassari L, COVID. Contrordine: USCA attivate in tutte le Regioni ma non bastano per la seconda ondata. La nostra indagine in tutte le Regioni. Quotidiano Sanità, 27 novembre 2020.
11. Montanari Vergallo G, Zaami S, Marinelli E. The COVID-19 pandemic and contact tracing technologies, between upholding the right to health and personal data protection. Eur Rev Med Pharmacol Sci. 2021;25:2449-56.
12. Zaami S, Marinelli E, Varì MR. New Trends of Substance Abuse During COVID-19 Pandemic: An International Perspective. Front Psychiatry. 2020; 11:700.
13. Zaami S, New psychoactive substances: concerted efforts and common legislative answers for stemming a growing health hazard. Eur Rev Med Pharmacol Sci. 2019; 22:9681-90.
14. Maniscalco P, Ciatti C, Gattoni S, Quattrini F, Puma Pagliarello C, Patane' AC, Capelli P, Banchini F, Rivera F, Sanna F, Nonne D, Di Maggio B, Scaravilli G. Proximal humerus fractures in COVID-19 lockdown: the experience of three orthopedics and traumatology departments in the first ten weeks of the Italian epidemic. Acta Biomed. 2021;92:e2021104.
15. Rosenbaum L, Facing Covid-19 in Italy. Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line, March 18, 2020. https://bit.ly/3bKvFyy.
16. Marinelli E, Busardò FP, Zaami S. Intensive and pharmacological care in times of COVID-19: A "special ethics" for emergency? BMC Med Ethics. 2020;21:117.
17. Malerba M, Ragnoli B, Puca E, Pipero P. Supporting healthcare workers on front lines of the Covid-19 fight. Acta Biomed. 2020;91(4):e2020157.
18. World Medical Association, Statement on Medical Ethics in the event of disasters (Stockolm, September 1994), Bulletin of Medical Ethics, 1994, 102. https://www.wma.net/policies-post/wma-statement-on-medical-ethics-in-the-event-of-disasters/.
19. Zimmerman J.L, Sprung C.L, Medical procedures. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Intensive Care Medicine, 2010; 36: 65-9.
20. Joebges S, Biller-Andorno N, Ethics guidelines I, Ethics guidelines on COVID-19 triage: an emerging international consensus. Critical Care, 2020,24:201-05.
21. Fallucchi F, Faravelli M, Quercia S. Fair allocation of scarce medical resources in the time of COVID-19: what do people think? J Med Ethics. 2021;47:3-6.
22. Hall A, Quality of Life and Value Assessment in Health Care, Health Care Anal. 2020;28:45-61.
23. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C, Boyle C, Smith M, Phillips JP. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020;382:2049-55.
24. Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias. Grupo de trabajo de Bioética de la SEMICYUC. Recomendaciones éticas para la toma de decisiones en la situación excepcional de crisis por pandemia covid-19 en las unidades de cuidados intensivos. 2020 Marzo, paragraph 16. http s://semicyuc.org/wp-content/uploads/2020/03/%C3%89tica_SEMICYUC-COVID-19.pdf.
25. Accademia Svizzera delle Scienze Mediche (ASSM), Pandemia Covid-19: triage dei trattamenti di medicina intensiva in caso di scarsità di risorse, 24 march 2020.
26. Fallucchi F, Faravelli M, Quercia S. Fair allocation of scarce medical resources in the time of COVID-19: what do people think? J Med Ethics. 2021;47:3-6.
27. Comité de Bioética de España (CBE), Informe del Comité de Bioética de España sobre los aspectos bioéticos de la priorización de recursos sanitarios en el contexto de la crisis del coronavirus, Madrid, 23 marzo 2020, § 9.6: 9 .
28. Sociedad Española de Medicina Intensiva Crítica y Unidades Coronarias (SEMICYUC) y Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Plan de Contingencia para los Servicios de Medicina Intensiva frente a la pandemia COVID19.
29. Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) Recommendations of clinical ethics for the admission to intensive care and its withdrawal, in extraordinary conditions of imbalance between health care needs and available resources 6 march 2020).https://www.flipsnack.com/SIAARTI/siaarti-covid-19-clinicalethicsreccomendations/full-view.html.
30.Anelli F. Coronavirus. FNOMCeO sul documento anestesisti: “Nostra guida resta Codice deontologico. Non dobbiamo metterci nelle condizioni di applicare questi inaccettabili triage di guerra”. Quotidiano Sanità, 08 march 2020.
31. SIAARTI SIMLA "Decisioni per le cure intensive in caso di sproporzione tra necessità assistenziali e risorse disponibili in corso di pandemia di COVID-19", 13 january 2021 https://www.siaarti.it/news/382977
32. Berlinger N, Wynia M, Powell T, et al. Ethical framework for health care institutions responding to novel Coronavirus SARS-CoV-2 (COVID-19). Guidelines for institutional ethics services responding to COVID-19. Managing uncertainty, safeguarding communities, guiding practice. The Hastings Center 2020 March 16. https://www.thehastingscenter.org/ethicalframeworkcovid19/
33. Worldwide Hospice Paliative Care Alliance, Briefing note, http://www.icpcn.org/wp-content/uploads/2021/01/Palliative-Care-and-Covid-19-Series-Briefing-Notes-Compilation.pdf
34. Ferreyro B.L., Angriman F., Munshi L. et al. Association of non invasive oxygenation strategies with all-cause mortality in adults with acute hypoxemic respiratory failure. A systematic review and meta-analysis, Journal of the American Medical Association, 2020;324: 57-76
35. Emanuel E.J., Persad G., Upshur R. et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19, The New England Journal of Medicine, 2020;382:2049-2055. https://www.nejm.org.v..
36 Iacorossi L, Fauci AJ, Napoletano A, D'Angelo D, Salomone K, Latina R, Coclite D, Iannone P. Triage protocol for allocation of critical health resources during Covid-19 pandemic and public health emergencies. A narrative review. Acta Biomed. 2020;91:e2020162
37. Picozzi M., Nicoli F., Severgnini F, The role of the ethics consultant in triage: an Italian experience, Bioethics.net, June 16, 2020. http://www.bioethics.net/2020/06/the-role-of-the-ethics-consultant-in-triage-an-italian-experience
38. UNESCO’s International Bioethics Committee (IBC) and World Commission on the Ethics of Scientific Knowledge and Technology (COMEST), Statement on CoViD-19: ethical considerations from a global perspective, 31 marzo 2020. https://unesdoc.unesco.org
39. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C, Boyle C, Smith M, Phillips JP. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020;382:2049-2055
40. World Medical Association, Statement on Medical Ethics in the Event of Disasters, cit.
41. Bioethics Committee of Spain Management of scarce resources in healthcare in the context of the COVID-19 pandemic, 31 march 2020.
42. Società Italiana di Cure Palliative and FCP (Federazione di Cure Palliative, Ruolo delle cure palliative durante una pandemia, ottobre 2020. https://www.sicp.it.
43.Tambone V., Boudreau D., Ciccozzi M., Sanders K. Criteria for the Admission and Management of Patients in the ICU Under Conditions of Limited Medical Resources: A Shared International Proposal in View of the COVID-19 Pandemic. Front. Public Health, 16 June 2020. https://doi.org/10.3389/fpubh.2020.00284
44. Booke H, Booke M. Medical Triage During the COVID-19 Pandemic: A Medical and Ethical Burden. J Clin Ethics. 2021;32(1):73-76.
45. Comité de Bioética de España (CBE), Informe del Comité de Bioética de España sobre los aspectos bioéticos de la priorización de recursos sanitarios en el contexto de la crisis del coronavirus, cit.
46. Comité Consultatif National d’Étique pour les Sciences de la Vie et de la Santé (CCNE), Avis N° 106 – Questions étiques solilevées par une possible pandémie grippale, Paris, 5 february 2009.
47. Italian Committee for Bioethics, Covid 19: clinical decision-making in conditions of resource shortage and the “pandemic emergency triage” criterion 8 April 2020 §3. http://bioetica.governo.it
48 World Health Organization (WHO 2016), cit., 4. Allocating scarce resources.
49. Montanari Vergallo G. Advance healthcare directives: binding or international value? 2020; 29(1):98-09.
50. L’Angiocola PD, Monti M. COVID-19: the critical balance between appropriate governmental restrictions and expected economic, psychological and social consequences in Italy. Are we going in the right direction? Acta Bio Med 2020; 91(2).
51. Actis AG, Actis G. The rebirth of health system in Italy after COVID-19 pandemia: starting points. Acta Bio Med . 202091(3):e2020039