The speed at which people got sick with COVID-19 and overwhelmed unprepared medical systems in Spain and Italy left physicians with the impossible and unfair task of deciding who lives and who dies.
The dire warnings of this medical collapse hit North America before the virus had really taken hold, giving the health-care system a chance to shore up equipment and hospital beds, and medical ethicists, like Michael van Manen, the opportunity to revisit how the pandemic influences policy on medical equipment shortages.
"In the end, there is nothing really ethical about taking a resource away from one patient to give it to another," said van Manen, Endowed Chair in Health Ethics and director of the John Dossetor Health Ethics Centre at the University of Alberta.
"We have ethical responsibilities to all of our patients."
Van Manen said ethics guidelines for resource allocation are structured around principles such as utility, or saving the most lives, and equity, ensuring everyone is treated in a fair way where no one is disadvantaged because of gender or socioeconomic status.
With that in mind, he said decisions on resource allocation and triage should be made by applying policy enacted by someone not actively caring for a patient.
"That way there is independence between people who are looking at the system-wide resources and those directly providing care to patients. This avoids conflicts of interest, while allowing individuals to advocate asking, 'What's best for my patient?'"
Van Manen said it is also crucial that mechanisms exist for patients, families or others to appeal policy decisions. He explained that the appeal process should involve individuals not involved in patient care nor in the process of triage of health-care resources. Appeals also should be directed mainly at ensuring the decisions made follow the procedures and processes of the policy. In other words, the ultimate authority is founded in the policy itself rather than the people making the decisions.
"You want the people who would appeal a decision to be appealing the process in which the decision was arrived at, and not that they simply do not agree (with that decision)," he said. "Policy-makers need to ensure that there are opportunities for genuine stakeholder feedback during policy development from health-care professionals and the public."
Where there's an impasse, there is always the court. Health law researcher Timothy Caulfield said what's really interesting is that the entire ethical, legal framework is built around physicians doing what's in the best interest of the patient in front of them.
"The courts have, historically, said in situations of true scarcity, because you're in this unique relationship with your patient, you have an obligation to think what is in their best interest. These outside things should not influence your decision."
And while the COVID-19 pandemic is rewriting the standard of care in real time, Caulfield said there is some precedent to draw on.
"Think about rural settings where, in a best-case scenario, a physician would normally use a specific type of equipment, but it's just not available and the standard of care can't be met," said Caulfield.
"So the courts do have some wiggle room to allow for this kind of thinking."
Before it even gets to the point that hospitals need to turn to policy to decide who gets what, van Manen said the most ethically responsible thing to do is to avoid getting in that situation in the first place.
"That's really why all the emphasis has been made from a public health perspective around physical distancing or social distancing," he said. "Ultimately, we want to avoid getting into the situation of resource allocation in the first place."
He said that means implementing additional measures to free up more resources within a hospital, like cancelling elective surgeries, and then optimizing existing resources.
"We ask questions like, 'Do our existing patients really need ventilators or other equipment that might be scarce, or could their needs still be met by some other means?'"
Van Manen noted even non-critical care public health measures, such as physical distancing to help flatten the curve, have an ethical dimension to them.
"There's no question that these measures have a harm, but it ultimately comes down to whether the harms these measures inflict on the economy and society outweigh the harms of an uncontrolled outbreak similar to that in Spain or Italy," he said.
Van Manen said another encouraging ethical issue that is playing out is one of solidarity.
"When I drive to work in the morning and I find the streets are relatively empty, I know that means people are doing their best," he said. "If we can somehow see that not as social isolation but a form of social solidarity, I think then we can recognize that there is an ethical response in that in itself."