“Place age limit for access to intensive care, [that is] based on greatest possibilities of survival.” – early last month, the Italian Society of Anesthesia was forced to publish this guideline to the country’s hospitals. On top of the rising infections, the doctors realised that patients required up to 15-20 days of intensive care as the disease progressed (Rosenbaum, 2020).
In the face of medical resource scarcity, the guidelines established that not everyone could be saved from coronavirus.
In the weeks that followed, similar decisions were being made in Italy’s neighbouring countries. Then, these decisions began being made 8,000 kilometres away from Italy – in the United States.
Till today, a solid 700-800 lives are being lost from the virus in these countries on a daily basis. However, because of the explicit nature of these rationing decisions, societies are accepting this as the bitter reality. And key decision-makers are being trusted to make these decisions.
But with regard to these rationing decisions, developing countries face a different challenge. In the context of an absent social, economic and psychological safety net, these rationing decisions should include other non-medical concerns and be explicit.
Existing Challenges & the Magnitude of the Problem
About 6,500 kilometers away from Italy, the fear of making such decisions looms over Indian doctors and government officials. Although the Indian government has moved fast to curb its spread, there are currently 4000+ cases in the country. It is also likely that community transmission of the virus already exists in certain areas in India. Due to the high population density and its community-based lifestyle, it is feared that social distancing measures are unlikely to be as effective as they are in the other Western countries.
Moreover, it is widely acknowledged that the virus would result in higher deaths in all developing countries because of their large populations and weak health systems.
Besides these issues, India already faces social and economic challenges in healthcare utilisation and access. Like other developing countries, the medical system favours those who are rich and well connected. In addition, the absence of health literacy among a large segment of the population prevents patients in getting the care they need. Lastly, the social stigma associated with infectious diseases prevents patients from going to the hospitals for the fear of social shaming.
Many people working high risk jobs and travellers from abroad have already been ostracised by their communities even when they didn’t have the virus. Given the status of healthcare as a fundamental human right, these issues need to be addressed through systematic public health campaigns. But those campaigns could not be enough to prevent these rationing decisions from being made.
Whose Lives Matter Most?
Given these challenges, rationing decisions in the country need to be well thought out. Especially because a number of hospitalised patients are young, and come from all strands of society. To those affected, immense emotional and financial losses are being caused to the families. Besides medical reasons of looking at who could benefit most from the treatment, age-based and financial factors could help decide whose lives matter most in the face of these rationing challenges. This is especially important in the absence of a social, economic and psychological safety net.
- In A Fair Innings (1997), Alan Williams developed ‘a fair innings approach’ in which he argues for a higher value to the lives of the young. Using a cricketing analogy, he argued that those who have already lived a long life need to be given less value than someone who has not yet lived his life. Other than the potential to benefit from the treatment, age-related weights guide the triage of patients so that young patients can have a fair innings.
- Providers of the Family: The World Bank’s policies argue for a higher weight for the lives of those who are in the 30-40 age range, as they work and sustain their families (Wagstaff, 1991). They provide for both the young as well as the old. In this way, the entire family is dependent on them. Losing their lives would put their entire families in financial distress.
Why The Poor Should Be Saved
- Less well off: Since the poor and less well-off are in poor health, it is possible that they are more likely to die from the virus; it makes sense to prioritise their treatment. In the Indian context, the less well-off also live in conditions where it is possible for them to spread the virus to others in the area who are also in poor health. Saving their lives could mean saving a lot more lives. From both a utilitarian and social justice perspective, it is essential stop the virus.
In conclusion, it is possible that the rationing decisions would be made to treat coronavirus patients in the coming times. From an ethical perspective as well, one needs to look at these considerations to make rationing decisions. Whatever the decisions may be, decision-makers would need to explain the trade-offs in an explicit and rational way in order to prevent worsening the impact of the virus.
(Arnav Mahurkar is a student of Health Economics, Policy and Law at Erasmus University in Rotterdam. This is an opinion piece and the views expressed are the author’s own. The Quint neither endorses nor is responsible for them.)
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