Does younger people get priority if there are few IC beds?

The script was June 16 published by the medical organizations KNMG and the Federation of Medical Specialists. It is not final yet, because it is still under discussion for the rank and file of doctors who are members of these organizations. Before publication, the umbrella organizations have discussed the document with, among others, the senior citizens’ associations ANBO, KBP-PCOB and the Patient Federation.

In any case, the cabinet was immediately opposed to age as a selection criterion. Minister for Medical Care Martin van Rijn wrote in a letter to the Chamber: ‘While I have no doubts whatsoever about the genuine good intentions, I believe that this is a distinction based solely on age and I cannot support that. For me, for this cabinet, every life is equal and if an older patient has the same chance of recovery on medical grounds as a younger patient, he or she cannot be denied the right to life-saving care.’

But what about that? A closer look at the scenario learns more about the trade-offs.

Code black

Suppose there are two patients in life-threatening condition and they both urgently need an IC bed. The doctors are used to giving priority on medical grounds (triage). Who will be the first to see a doctor at the emergency room? But also: who will receive a donor kidney and who will not? Who gets a very expensive drug and who doesn’t? But that is not possible in this scenario. The patients are medically equivalent and due to a new covid outbreak, only one bed is available. The IC departments in other regions are also full. One patient must therefore be denied care, there is no other way. This scenario is called Phase 3 or Code Black. Fortunately, it has not yet occurred in the corona outbreak. But if it does happen, doctors should not be alone in their choice, according to the umbrella organizations. That’s why she a script have made, with the help of professors of ethics and philosophy.

Short stay first

Back to the two seriously ill patients. It does not matter whether they have covid or not, according to the playbook. The point is that they need an IC bed. First, doctors look at how long someone needs IC care. ‘Patients who are expected to spend less time in the ICU are given priority. In this way, more patients are helped and thus more lives saved,’ according to the script.

Care worker sometimes first

Is one of the two patients a healthcare worker with covid, such as a nurse? Then this patient will be given priority if he contracted the virus during work, because he was unable to protect himself sufficiently. It is therefore not a question of the ICU nurse being rescued first, so that she can return to work quickly. The recovery takes a long time anyway, so that’s not a criterion, according to the script.

Than age

If both patients would be in the ICU for the same amount of time and would not be working in healthcare, the principle would apply that a younger generation takes precedence over an older generation. “This trade-off stems from the idea that everyone should be able to go through the same stages of life throughout their lives,” the news release said. ‘The condition is that both patients are equal in all other relevant respects, such as the chance of survival and length of stay.’

The generations are classified as follows: 0-20 years, 20-40 years, 40-60 years, 60-80 years and 80+ years. And what if the two patients are both in their sixties? Then ‘first come, first served’ applies, and if they are reported at the same time: drawing lots. Two choice methods that have greater ethical objections, according to the doctors. This is not discussed much further in the document.

Is there already an older patient in an IC bed and a new younger patient arrives – what then? Then the elderly patient keeps the bed. ‘Discontinuing treatment of, for example, older IC patients to admit a younger patient is not acceptable’, according to the script.

Need help

And what if one patient cannot walk on their own and the other can? Doctors can estimate how fit and independent someone is with the ‘clinical frailty scale’. This script states that doctors may use this scale in this black scenario to estimate the chances of survival. But they must ‘prevent its use from precluding people who do not have medical characteristics that would limit their prognosis’.

The main purpose of this cryptic sentence is not to exclude people with a disability, whether mental or physical. But what about if you have difficulty walking due to osteoarthritis, a problem that many elderly people have? Then that actually counts for you medical estimate. And this scenario involves two patients who are medically equivalent.

People who have so many limitations and ailments that an IC treatment would do more harm than good, are not advised at all to undergo another heavy IC treatment.

Consideration: If not the age, then what?

The cabinet does not want doctors to make a choice based on age, as Martin van Rijn has already expressed. But what is the alternative? The doctors also indicate in this document which choices they did NOT want to make. For example, based on personal relationships. Doctors therefore do not want to have to choose the patient with children, who would have priority over the patient without children. Or that someone with a lot of money or a high-ranking job takes precedence. Whether that ethnicity, nationality or gender would play a role. Or that someone with a disability has less chance.

An interesting point: the doctors also do not want to look at the guilt of the patients. They do not want to deny care for the patient who needs IC care through ‘own fault’, for example because he contracted the infection after a forbidden dance party. This seems to go against your gut feeling, the doctors admit, but ethically it is better: ‘Even ‘own fault’, although it may be intuitively attractive, does not play a role, because the limits of one’s own responsibility are intrinsically difficult to determine and certainly not in the hectic hectic mentioned above’. The script refers to the example of the young drunk driver who needs an IC bed. Is it his own fault that he had an accident? The question of guilt is so complex that you cannot judge it so quickly.