Page 31 - Delaware Medical Journal - July/August 2020

ETHICS
That seems like a very slippery legal and moral slope that is ungrounded
in the precepts of common law and
the canons of Judeo-Christian ethics. For those thoughtful caregivers who question sui generis ethics, Emanuel et al provide cover and absolution from blame (and anticipate criticism) by stating that what they are doing is “not an act of killing and does not require the patient’s consent.”1 However,
the British lawyer Kathleen Liddell strongly disagrees and believes that removing a ventilator from a patient without their consent “is a criminal offense” and “it could also be a
breach of Article 3 of the European Convention on Human Rights.”2 Article 3 prohibits “inhuman or degrading treatment or punishment.”
Programs to ease the psychological burden on health care providers
who are faced with the excruciating dilemma of whether to make morally questionable clinical judgments can seek refuge in shared responsibility
or in decisions deflected to a triage committee. But that may merely lead to charges of “death panels.”
In keeping with the generally agreed- upon triage principle to “save the most lives,” it is understandable if bioethicists sanction the rationing
of scarce medical resources a priori
on a need basis or on a first-come, first-served basis; however, it is not a morally indifferent act if a ventilator is committed to one patient and then withdrawn to serve the needs of another patient. Such an action in the setting of an ICU is cold-blooded, methodical, brutal, and usually a death sentence.
A death with dignity is an afterthought and becomes an unfulfilled wish as
the body bags pile up in hospitals overwhelmed by COVID-19.
Simplistic philosophical thought experiments such as the trolley problem (pull the lever to divert the trolley so that it kills one person rather than five) may give comfort to arm- chair bioethicists, but when many desperately ill COVID-19 patients are competing for a limited number of ventilators (as in ICUs in Bergamo, Italy), moral considerations often give way to very difficult and unpleasant practical decisions. But who can fault those who are caught in untenable, uncharted moral and legal minefields without maps or guidelines that are generally agreed upon?
As spring gives way to summer in this annus horribilis, those in the frontlines of treating coronavirus patients desperately need moral benchmarks to shield them from violating their duty not to harm.
Short of that, the same medico-legal issues will perforce be revisited in a possible second wave of the coronavirus or in what the writer Laurie Garrett calls the next “coming plague.”
CONTRIBUTOR
■ JAMES F. LALLY, MD is a retired radiologist and a member of the Medical Society of Delaware Editorial Board.
REFERENCES
1. Emanuel EJ, Persad G, Upshur R, Thome B. et al. Fair allocation of scarce medical resources in the time of COVID-19. N Eng J Med. 2020; 382: 2049-2055.
2. Truog, RD, Mitchell C, Daley GQ. The toughest triage — allocating ventilators in a pandemic. N Eng J Med. 2020; 382:1973-1975.
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