A judge, jury and execution: Being a doctor in the COVID-19 pandemic
Dr. RK is the duty doctor at a hospital in the outskirts of Mumbai on the 15th of April, 2020. She has been working in the isolation ward of the hospital since the beginning of the COVID-19 epidemic. It is late at night and her shift has been extended because of the shortage of medical personnel and due to a high influx of patients. She has spent the last nine hours monitoring the patients and evaluating the treatment protocol. Finally, she arrives in her cabin and sits for the first time in what seems like forever, especially without the heavy personal protective equipment.
Just as she sits down to give her worn soles some rest, a nurse rushes in and informs her in a hushed whisper that the cheerful 77-year-old lady in the general ward has started to show symptoms of the disease and that her condition is rapidly worsening. Dr. RK’s mind begins to race and she tries to remember the patient’s case history. The 77-year-old was suffering from diabetes and her kidneys were failing; she was teetering on the brink of a renal failure. Medical facts aside, Riya remembers the old woman in her residential complex, someone who inquired of her every time they ran into each other. Dr. RK rushes to examine the patient’s condition, and then decides that a ventilator support is imperative. Just as she calls the ICU to inform her decision to shift the patient, she is called-in for a VIP case.
The district medical officer runs up to her and informs her that a prominent 36-year-old businessman, who was under self-quarantine has tested positive for COVID-19. He said that the patient had a history of recent travel to Italy. He was asymptomatic at first but his condition has worsened over the days presenting currently with severe breathlessness. The medical officer said that the businessman must be immediately shifted to the ICU when his ambulance arrives. The businessman employs around 15000 people in his four business ventures and carries his own political clout.
Faced with these three challenging cases in the span of less than five minutes, Dr. RK tells her trusty team of nurses to ready three ventilators in the ICU. Within minutes, however, a senior nurse informs her that three of the four remaining ventilators are malfunctioning and cannot be used. This leaves Dr. RK in an extremely difficult position. She has to decide who among the following will get to use the only functioning ventilator: the 77-year-old woman in whom she sees her grandmother or the 36-year-old influential businessman who can cost her job or the 19-year-old girl who is just beginning to live her adult life. No matter the decision she takes, she will also have to figure out a course of action for the remaining two patients but she could have as well consigned them to permanent damage if not their deaths. As this is a remote area, the next nearest hospital is about 200 miles away. Also, there is a shortage of drivers because of the lockdown and at this late hour, thus it is highly likely that the remaining patients will be shifted only the next day.
The doctor tells the nurses to attend to the patients, take some preliminary readings and then starts reflecting on a decision that could change three lives and families forever. While frazzled and tired physically, Dr. RK’s mind is in overdrive. She recalls WHO material that indicates fatalities to be very high (about 20%) for people aged over 80 and significantly lower (about 0.2%) for people in their 30s and below. However, complications like asthma, COPD or diabetes can significantly increase the probability of a fatality. Further, all of these patients were suffering from severe breathing difficulty, and unless urgent care is administered, they may not survive the night.
With complications likely to rise with every passing minute, the doctor decides to recall her classes of medical ethics and recount if any of the established principles could help her arrive at a decision. The Hippocratic oath that she took just before passing out from college is the first one, she thinks of. She remembers snippets of it like ‘I will not let considerations of age or disability affect my judgement’. The principle of patient autonomy is the next one that comes to her mind. She wonders if it would be appropriate for her to go and ask any of the patients if they are willing to forsake the ventilator for the benefit of a more ‘deserving’ patient. “Who is more deserving?”, she asked herself. Is it the youngest person of the lot? Or is it the person with the highest likelihood of survival? She wonders if it is acceptable for her to override patient autonomy in testing times like this to avoid a greater damage to society. Though she wondered who made her- a, judge, jury and executioner. The principles of beneficence and nonmal efficiency were the next she considered. Like any other doctor she must not willfully hurt any individual and also try her best to facilitate the best treatment available for all of her patients.
Attempting to save all three lives by giving all of them a ventilator was out-of-the-question. She then thinks about the patients and tries to assess who deserves the ventilator. The young woman has the greatest number of years left, arguably. However, she suffers from a pre-existing lung disease, which may decrease her prospect of surviving COVID-19. The girl is the only child of her parents and it would be impossible for them to forsake their child’s treatment for anybody else. The older woman is the one with the lowest number of years left, arguably. She also suffers from complications like diabetes and other ailments that can have a negative impact on the chance of survival. The businessman, though in a comfortable age bracket and expected to have a fairly high immunity. It is unclear if the infection has passed to a stage where his lungs were damaged to such an extent that the probability of survival decreases. He is also the owner of many businesses and his death can cause economic fallout beyond his immediate family. The doctor wants to impart the greatest happiness to the greatest number, but the cost of that decision was an increasingly steep one. She can base her decision on a set of predefined rules or try to make a decision based on ground realities. She even tries calling the senior-most doctors for advice but the poor network has put them off the grid. The clock is ticking as she has to decide or risk being accused of medical negligence. She decides to give herself a couple more minutes to arrive at the decision.
She comes back to the fundamental nature of the problem and a few ethical perspectives come to her mind. She thinks of universalism, an approach which mandates her thought to have universal applicability. In this situation, it would mean that her decision must be purely objective and devoid of any sort of personal bias. She would need to be satisfied with her decision even if in a hypothetical situation, she was one of the patients. With a heavy heart, she makes a firm decision to not consider her emotional ties with the old woman or the young girl as part of her decision-making process. Similarly, even the political connections of the businessman should not affect her decision. What then, should her decision be based on?
She then thinks of utilitarianism, which leads her to question which individual would impart the greatest contribution to society post recovery. It is clear that the businessman would be the one to save then, as he provides employment to a huge number of workers. The elderly woman arguably has a few years of life left. However, this theory becomes muddled when she comes to the 19-year-old girl. While she undoubtedly has a lot of potential to serve society in the long-run, how could one decide whether that potential was of higher value than what the businessman had already achieved? It seemed that, after all this thinking, the doctor had hit a roadblock, once again.
Suddenly, a nurse came running and informed her that the businessman had been brought in and his preliminary evaluation had been done. All three of the patients had fluctuating vitals and a decision had to be taken now. Then it struck her. The enormity of the decision she faced. After all, these were human lives at stake. She couldn’t help but feel uncomfortable, even ashamed of herself, for debating theories such as utilitarianism, when the subjects were innocent human beings. While her decision might save one life, she couldn’t help but imagine that it might also result in the other two possibly losing theirs. How could she ever justify such a decision? How could she live with it if one of the three patients died, and her decision could have saved them? She could not help but hold herself accountable. However, there are some things which have to be done. She did sign up for this, when she first registered as a doctor. Every second she spent pondering on this increased the risk of one of her patients deteriorating. So, putting on a brave face and holding back those tears, the doctor emerged, to face the situation head on. She moved towards one of the patients and asked the nurses to procure the ventilator.
Now, we leave it up to the reader to decide which patient did the doctor save. If faced with the same situation, whom would you save? While this tale might seem far-fetched, even fictitious to some, it portrays the reality of what front line healthcare workers often face and are increasingly facing today.
Based on the facts of this case, what decision would you take if you were in Dr.RK’s shoes?
About the authors:
Aniket Kar: Born and brought up in Rourkela, Odisha, Aniket is now a second-year student pursuing IPM at IIM Indore. He also works as a freelance writer and is interested in a myriad of topics ranging from philosophy and psychology to gaming and football
Jeevan Joseph. M: Born in Kerala and brought up in Dubai, Jeevan is now a second-year student of the IPM program at IIM Indore. He enjoys writing articles and short stories. His areas of interest include ethics, history, politics and public policy.