Coronavirus ethics: How do we choose who lives, who dies?

Opponents of "government-run" health care often argue that such oversight would lead to delays in needed care and widespread rationing.

The irony of the anti-regulation ideology is that it's because of insufficient health care oversight that our nation now faces severe rationing of critically needed health care resources during a foreseeable global pandemic.

For nurses, respiratory therapists, physicians and those who clean up after them, being told there are "millions" of masks and "wonderful" supplies of ventilators on the way in a few weeks, perhaps from inexperienced ventilator factories, means very little to the immediate crises health care professionals face as you read these words.

The "R word" — rationing — is scarcely heard from podiums and pundits. But it accurately applies to what happens when presidential procrastination and science skepticism leave lifesavers at risk of losing their own lives. Caregiver distress is compounded by the burden of making life-or-death decisions for those in their care because of crises beyond their control.

If we are a nation at war, as the administration keeps saying, our clinicians must be able to make triage decisions that are transparently and fairly applied because they are supported by community engagement and explicit health care system policy.

Those at government podiums and media anchor desks keep telling us we are in this pandemic together. If so, then we must also be together in the fundamental values and principles used by providers making unavoidable rationing decisions. They may justifiably feel they have been stranded twice: once by system procurement failure and again by insufficient support in making heart-wrenching choices.

Should a dying patient with failing heart, lungs, liver, kidneys and brain be resuscitated and kept on a ventilator that could go to an otherwise healthy patient with acute but reversible lung injury from COVID-19? Too often, the grief of the hopeless patient's loved ones keeps them from allowing caregivers to transition treatment from extraordinary mechanical support, in the face of overwhelming biological deterioration, to loving comfort and a dignified death.

Minnesotans years ago supported, through their nationally recognized state health department, the Minnesota Pandemic Ethics Project, guided by experts from the University of Minnesota Center for Bioethics and the Minnesota Center for Health Care Ethics. Leaders of those two bioethics hubs are experts on the good, right and fair foundations for critical decisions needed when normal standards of care must be augmented by crisis care standards and massive ICU needs.

The project's hallmark is the combination of scientific evidence and broad community input. The Minnesota Pandemic Ethics Project included engagement with members of the Leech Lake Band of Ojibwe, residents of Minneapolis's North Side and Phillips neighborhoods, folks from the Courage Center and citizens in the towns of Worthington, Moorhead and Virginia, among others. Such efforts serve as a solid start for the public, candid, evidence-based rationing discussions that we urgently need.

Now is not the time for facility ethics committees and health care system ethics councils to operate behind closed doors, if they operate at all. In the words of the American College of Chest Physicians statement on care during pandemics, focusing on ethical principles is not a luxury. It is "an obligation to provide ethics guidance for the benefit of both patients and those providing care under austere circumstances. Such guidance, supported by data (when possible), expert opinion and community values, may help minimize inconsistency in decisionmaking and therefore unfair treatment of patients. It may also help engender trust and alleviate moral distress and burnout in providers."

Trust in the highest levels of our government is as scarce as the personal protective equipment those responsible failed to make sure caregivers would have, despite adequate warning it was needed. In contrast, trust in our health care professionals' crisis care decisions must be bolstered by explicit emergency policies that are ethically grounded and publicly shared.