With All Due Respect

[Update:  I am grateful to the Buffalo News for publishing a much-abbreviated version of this posting as a letter-to-the-editor in its Sunday print edition on April 26, 2020, under the headline, “Give health care workers more than just praise,” and then, on April 29, a more personal expression of my sentiments on this topic as a “My View” column, under the headline, “My living will is a way to aid medical workers.”  Here’s the on-line version of the letter-to-the-editor, as well as the on-line publication of the My View piece, under the headline, “Health care workers have my gratitude and – if needed – my ventilator.”]

CAVEAT: I’m a semi-retired lawyer, not a medical doctor or bioethicist. I have never represented health care officials, medical professionals, or other scientists concerning their legal and ethical duties. And, about 44 years have slipped by since I last thought about bioethical issues in an academic setting. In other words, I’m not an expert on bioethics or the subject matter of this post, and I’m certainly not attempting to give legal, ethical, or, for that matter, personal advice.

The Sunday edition of the Buffalo News includes an “Another Voice” column authored by the heads of three major Western New York health insurance companies. If you haven’t already, please read this thoughtful article. [Here’s a link, “Heroic health care workers deserve our gratitude.”]

I agree wholeheartedly with the premise and sentiment of the piece, aptly summarized in its final paragraph:

Each day – from prior to this pandemic, to well after it is resolved – we benefit from the selfless dedication of the people across our community who stand ready, when needed, to serve and care for the sick and injured. We owe them our thanks and our gratitude.

I also concur with the broad description of health care workers identified in the column as especially worthy of our gratitude during the coronavirus pandemic: doctors, nurses, health care aides, laboratory professionals, pharmacy personnel, the staff who clean and disinfect, the food service professionals, the staff that keep the buildings operational, the guards who keep the facilities safe and secure, and, importantly, the providers who serve the needs of the sick, injured and frail in patients’ own apartments and homes.

But, I would add the following risk-takers to that list: emergency medical technicians (EMTs), paramedics and ambulance personnel who transport the sick to acute care facilities.

And, along with thanking health care workers, I intend to show my gratitude by updating my “living will” to include the following advance care directive: If, during the pandemic, I become ill – due to Covid-19, an accident, or other health issue – and I require access to ventilator therapy to keep me alive, and, at that time, there is a scarcity of ventilators, I request that a front-line health care worker have priority over me to an available ventilator.

I encourage each of you to consider whether you are willing and able (given your personal situation) to join me in taking this tangible expression of gratitude.

This step – giving health care workers priority to a ventilator during the coronavirus pandemic – is consistent with a well-reasoned and comprehensively researched article published on March 23, 2020 in the New England Journal of Medicine, “Fair Allocation of Scarce Medical Resources in the Time of Covid-19,” by Ezekiel J. Emanuel, M.D., Ph.D., et al. This insightful piece convincingly argues that the “most important” ethical value when rationing limited resources in the context of a pandemic is “maximizing benefits” – that is, saving the most individual lives – and that this paramount goal is promoted by “giving priority to those who can save others.” As expressed by Dr. Emanuel et al.:

Critical Covid-19 interventions — testing, PPE, ICU beds, ventilators, therapeutics, and vaccines — should go first to front-line health care workers and others who care for ill patients and who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace. These workers should be given priority not because they are somehow more worthy, but because of their instrumental value: they are essential to pandemic response. If physicians and nurses are incapacitated, all patients — not just those with Covid-19 — will suffer greater mortality and years of life lost…

Certainly, our first goal in addressing the Covid-19 pandemic must be to take appropriate steps to reduce the spread of the virus. To the extent the viral spread is limited (or, at a minimum, slowed), we, in the words of Dr. Emanuel et al., “may make resource shortages less severe by narrowing the gap between medical need and the available supply of treatments.”

Each of us can assist in this effort by engaging in the well-publicized public health measures: self-isolation, social distancing when we do venture out of our homes, frequent washing of hands, wearing of face masks when appropriate, and the “cough etiquette” we teach our school-age children, coughing and sneezing into our elbows.

There is an additional action that we all can take – if we haven’t already – beyond the public health measures noted above, to limit the scarcity of ventilators, and to ensure that this critical life-saving therapy will be available when needed by a front-line health care worker: Make certain that you have an up-to-date health care proxy form – specifying the person who will make health care choices for you when you are unconscious or no longer mentally competent to communicate your health care wishes to your doctor – and document in a living will or advance directives the circumstances when you would refuse mechanical ventilation (or other life-sustaining interventions). By doing so, you will help to ensure that the staff at an acute care facility facing an onslaught of Covid-19 patients can more swiftly and efficiently utilize scarce resources.  [In the words of a resident currently caring for patients infected with COVID-19: “the worst allocation of a ventilator, is to a patient who wishes not to be ventilated.”]

If, like me, you need to take steps to update or create your health care proxy designation, “living will”/advance directives, etc., I suggest that you avail yourself to the information regarding Specific Advance Directives, prepared by End of Life Choices New York. This highly regarded not-for-profit organization can be reached on-line or by phone at (212) 726-2010. And, fortunately, the task of updating or creating a living will/advance directive in this time of self-isolation has been made a bit easier by the witness-related provisions in Gov. Andrew Cuomo’s Executive Order No. 202.14.

One final point. Not every effort to establish guidelines to address the allocation of ventilators in the midst of a pandemic has recommended that health care workers be given priority. In 2015, the N.Y.S. Department of Health issued, a 272-page document, “Ventilator Allocation Guidelines,” prepared by the New York State Task Force on Life and the Law. The goal of these voluntary guidelines is to “provide an ethical, clinical, and legal framework [to] assist health care workers and facilities and the general public in the ethical allocation of ventilators during an influence pandemic.” [Without providing a detailed explanation, the task force determined that prioritizing health care workers or other patient categories would be too “subjective” a method for allocating scarce resources. See Ventilator Allocation Guidelines 2015 Update, p. 13.] While these guidelines are not mandatory, their existence as a framework to aid decisions made by health care workers and facilities underscores the need to expressly include in your advance care directives – if you so desire – your request that health care workers (defined broadly) be given priority over you to an available ventilator during the Covid-19 pandemic.

Thank you.

With All Due Respect (and, Gratitude),

Art Giacalone

P.S.  If the topic of bioethics and the Covid-19 pandemic is of interest, you may also want to read another piece published on March 23, 2020 in the New England Journal of Medicine, “The Toughest Triage – Allocating Ventilators in a Pandemic,” by Robert D. Truog, M.D., Christine Mitchell, R.N., and Gregory Q. Daley, M.D.,PhD.