Page last updated at 07:39 GMT, Thursday, 23 July 2009 08:39 UK

If swine flu bites, who gets care?

By Dr Daniel Sokol
Medical ethicist

Intensive care
Intensive care wards could be over-stretched

If severely ill with swine flu, your life may be saved if you get an intensive care bed.

If hundreds of patients need a handful of beds, how should we decide who lives and who dies?

Across the country and no doubt in many parts of the world, groups of people are meeting in hospitals to discuss a matter of life and death.

These committees are deciding who should get the few intensive care beds when, as a result of the swine flu pandemic, demand exceeds supply.

Hospitals in the UK are admitting an increasing number of swine flu patients and experts believe that we will soon follow the experience of Australia, where intensive care units are struggling to cope with the influx of flu patients.

Transparent decision-making

One of the values espoused by many of these committees is transparency.

Five patients need an intensive care bed, but only one is available - to whom should we give it?

The committees' conclusions and reasoning on this monumental issue must be clear to all.

It is clear, however, that no system will be beyond reproach.

Please imagine this scenario. It sounds dramatic but it is not, I'm afraid, improbable.

Five patients need an intensive care bed, but only one is available - to whom should we give it?

It seems reasonable to rule out those patients who are unlikely to survive or who have a poor prognosis even if admitted to ICU.

If one candidate has a weak immune system because of an underlying condition or has multiple organ failure, his chances of survival are lower than those of the other patients.

The difficulty, at this early stage, is deciding how to work out the probability of survival.

To establish prognosis, some doctors have suggested a scoring system based on the state of the patient's organs, but experts disagree over the accuracy of the method.

Tough choices

An ethicist colleague has suggested that we should reject those patients who might survive but who would spend a long time in intensive care.

It would be difficult for clinicians to let patients die, knowing that they have a reversible condition
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A prolonged stay would prevent others from obtaining a bed and result in deaths that could have been saved.

Perhaps, then, we could put limits on how much time a patient can spend in intensive care?

On a psychological, level, it would be difficult for clinicians to let such patients die, knowing that they have a reversible condition.

This abandonment goes against the instincts of loyalty and compassion of clinicians.

At least one Trust in the UK will take into account life expectancy, as well as probability of survival.

This means that if a 20-year-old and a 40-year-old, both with an equal chance of survival and otherwise healthy, are candidates for one bed, the younger person would win because he has more years of life ahead of him.

The 40-year-old, however, may have a spouse and young children.

Clinicians' privilege

Doctors and nurses caring for flu patients put themselves at risk of infection.

Giving preference to clinicians may help boost staff morale and reduce absenteeism

If one of the five patients was an intensive care nurse, should he or she get priority?

Would it be possible for her colleagues not to treat her preferentially?

During the SARS outbreaks in Toronto, one of the most distressing aspects for clinicians was seeing their colleagues by their side one day and fighting for survival in intensive care the next.

Giving preference to clinicians may help boost staff morale and reduce absenteeism.

But should we extend this privilege to their relatives?

In the military, doctors must think about 'preserving the fighting force'.

This means treating soldiers so that they can be returned to the front where they can fight and help win the war.

One argument for preferential treatment is that clinicians are our frontline soldiers who, once recovered, can be redeployed to help others.

Key workers

In a pandemic, we will need key workers. People to keep our cities clean.

People to transport essential goods.

For society, hospitals, clinicians, patients and relatives, the moment of truth is nearly upon us

People to get rid of the bodies of the four patients who did not get the intensive care bed.

Should they get priority? If so, who should be included in this exclusive list and how should the professions be weighted?

This very brief overview reveals the complexity of finding a fair and workable method of selection.

There may be more than one morally defensible method, but each will attract bitter criticism from those who stand to lose from the criteria.

Hospitals will need solid security measures to protect staff and patients.

The angry relatives of our four patients who will receive palliative care may not accept the hospital's decision to let their loved one die.

For society, hospitals, clinicians, patients and relatives, the moment of truth is nearly upon us. We must face it with courage, dignity and solidarity.

I would welcome your views. Please contact me via my website .

Daniel K. Sokol is a medical ethicist at St George's, University of London. He sits on two clinical ethics committees, each involved in pandemic flu preparation.



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