Sunday, August 9, 2009

Medical ethics in the era of H1N1: A need for a national conversation

In the UK the H1N1 pandemic is bringing to the forefront the public's concerns for healthcare rationing. In a recent article for the BBC news, Daniel Sokol, a medical ethicist, discusses the issue with frightening lucidity. He cites several probable scenarios and asks how they should be handled. For example, when 5 critically ill patients are "competing" for a single ICU bed, how should the allocation decision be made? Should it be on the basis of viability? Age? Value to society (that is, should a healthcare worker take precedence over another patient?) While he argues for transparency in such choices, he acknowledges the uncertainties inherent in our understanding of disease. Thus, a patient who is 99% likely to die may still surprise us 1% of the time and survive.

These are very thorny issues that we very well may get confronted with in this coming flu season. How will we handle them? The Brits at least appear to have the emotional maturity to start the discussion in explicit terms, so that they can wrestle with some of these issues before the 11th hour. Are we? In the US we cannot even seem to get beyond the demagoguery of grandma killings at this most important healthcare juncture. What will we do when we are actually confronted with having to make these very real and concrete choices? The culture of "me-me-me" will only impede us from electing the rational path.

The time to think through these conundrums is now because come fall and winter it will be too late. Revolts have been fomented over lesser issues; do we really want to leave this to the last minute? As a nation we need to take a deep breath, arm ourselves with courage and open our eyes and ears. Not everyone will be pleased with everything, but at least we will have a clearer idea of what we can expect and, perhaps, in turn this clarity will allow for better personal and societal choices. The press needs to help lead this discussion in a measured non-sensationalized way. This is our opportunity to grow up as a nation. If we do not take it now, the results may be more devastating than we can imagine.


  1. 1. Whose responsibility is it to "sell" pandemic triage to the public?

    a. The Feds: CDC? ASPR? Sebellius? DHS?
    b. Local and state public health?
    c. Hospitals and the AHA?
    d. the docs? the AMA? individual specialties?
    e. the nurses and the ANA?
    f. emergency management?
    g. All of the above

    2. If g. is your choice, How?

  2. Dear dr. len,

    Thanks for your comment -- I have been thinking a lot about this very issue. This is the job for everyone. How we do it is not a straight-forward question. There are many techniques used in community health education, and they would all have to be employed here. The one component that is missing from your list is the press: they could be very helpful. Another is social media, where available. This requires community organizing and participation, obviously. I wrote more about it in yesterday's post, and linked out to some relevant resources.