Rowland Stout answers the question about how we should assign limited healthcare resources to, and whether people who are younger should get priority, or the Taoiseach should get priority over a prisoner when it comes to questions like who we should put on the last available ventilator. His answer is that what you care about when you face medical emergencies is more whether you will get to fulfil your life goals, rather than the sheer number of years you live. We should not expect ethics to try to make the situation where one person gets to live only at the cost of another's life seem any less bad, and our first duty is to try and prevent such cases.

We have two questions here that overlap. One is from Mary who raises the question of who should have the benefit of ventilators to treat Covid-19 if there are not enough ventilators available for the number of patients who require them. She cites a speaker on Brendan O’Connor’s RTE Radio 1 programme saying that ventilators whould be prioritised for ‘productive members of society’ – namely those in their 40s and 50s.

Timothy raises a similar question through the following imaginary scenario. One day the 42 year-old Taioseach is brought to hospital and it is very quickly determined that his survival will require intubation. The probablity of complete recovery is assessed. There is unfortunately a competing candidate for the only available ventilator, a 35 year-old with the same probability of complete recovery. The rules indicate the anonymous 35-year old should get preference. Unfortuately, the arrival of the Taioseach has created such a buzz among everybody in the hospital that the decision-taker knows that the life of the Taioseach is in his hands. Distraught, he appeals to the hospital director for guidance. The director alone knows that the 35 year-old is a prisoner in Mountjoy in the penultimate year for a ten-year sentence for drug dealing. He turns to a moral philosopher for help. Timothy prefaces this example with the following observations.

  1. Asking physicians to determine subjectively the allocation of scarce medical resources invites abuse and corruption and also imposes an undue moral burden on the physician.
  2. It is especially important in a small city like Dublin that the doctor making the decision about allocating resources has no idea of the identity of the patient.
  3. One way a hospital might ensure that such decisions are taken on purely medical grounds is to assess the expected number of years of healthy life each patient would be expected to have if they had the benefit of the scarce resource. Of course when the chances of complete recovery are equal the younger patient would be expected to get more years of healthy life as a benefit, and this would be the basis of choosing the 35-year old drug dealer over the 42 year-old Taioseach.

The issue of allocating scarce resources is one that hospitals have always faced.  The most vivid example is the allocation of donor organs to people who need organ transplants.   As Timothy points out, the decision as to who gets the organ or the ventilator in this case is not one that the doctor is supposed to make based on their knowledge of the individuals in question, but  should be determined by criteria that are worked out in advance of any personal knowledge of the patients.  

What should these criteria be?  A simple one is the probablity that the scarce resource in question will actually do what it is supposed to do.  The patient with the better chance of having a successful organ transplant will be higher up in the queue than the patient whose body is more likely to reject the donated organ.  This is one reason why elderly patients with little chance of surviving the attack of Covid-19 might not be given access to a ventilator if a younger patient who is more likely to survive with its help needs it too.  

Should the fact that one patient is more likely to make a productive contribution to society count in their favour in the allocation of scarce medical resources?  I take it that behind Timothy’s question is the assumption that the Taioseach is more likely to make such a contribution than the drug dealer.  And behind Mary’s question is the assumption that someone in their 40s or 50s is more likely to make a productive contribution to society than someone in their 60s, 70s or 80s.  Putting aside the obvious difficulties with making such calculations, it has become a well established principle in medical ethics that this is not a factor to be taken into consideration.  Why not?  I think this question goes to the heart of what hospitals are for.  It turns out that they are not there for the good of society.  They are there to meet the needs of individuals who are sick and need help, and that’s a different thing.  So it is really irrelevant whether you are a Taoiseach or a drug dealer.

On this basis it is very clear that the Taoiseach should not be given preferential treatment over the drug dealer.  Indeed, as Timothy points out, the hospital might conceivably be employing a criterion that means the drug dealer gets preferential treatment over the Taioseach.  This is that the treatment will be more likely to do more good for the drug dealer than it will for the Taioseach, simply because it is more likely to give him more years of healthy life.  The point would be even more obvious if the Taioseach were in his 70s or 80s.  

But against this argument about how much benefit the treatment will give to the patient in terms of extra years of healthy life is a strong revulsion many of us feel about allocating scarce resources on this basis.  We are inclined to think that the 42 year-old Taioseach needs the ventilator just as much as the 35 year-old drug dealer even though he is going to get less beneift from it in terms of extra years.  And I think we feel that because we think of someone’s need to survive an illness more in terms of their specific life goals than in terms of the number of years they have left.  The questions you face in the ICU ward might be the following: Will I have the chance to live a happy life at all?  Will I spend some more time with my family and loved ones?  Will I get to do some of the things on my bucket list?  A question that has relatively little significance for you is: will I have 47 rather than 40 extra years of healthy life?

So if the priority of the hospital is to meet the health needs of individuals who present to the hospital then it is not clear that it should prioritise allocation of scarce ventilators to those who are younger just because they will have more life left to live.  Maximising the sheer number of years left to live is not really what a sick person presenting to hospital needs.  

Concerning Timothy’s dilemma of the doctor with the Taioseach and the drug dealer in their ward with just the one ventilator, if the hospital has a clear allocation criterion that the younger patient has priority, then the answer is unequivocal – the drug dealer gets the ventilator.  But, as I said, there may be no good reason to have this criterion, in which case there may be no answer to the question.  The best advice is to make sure you don’t get into that situation in the first place. And while that might sound like a bad joke, a lot of the best ethical thinking is working out ways to avoid dilemmas like this one rather than how to resolve them.  If against all everyone’s best efforts you ever do get into such a situation as Timothy’s doctor, you may just have to accept that ethics isn’t going to get you out of it.