Ethical Dilemma in Patients Selection during COVID-19 Pandemic in Indonesia: Choosing Who Shall Live or Die

Urfa Khairatun Hisan

doi:10.56741/hesmed.v2i02.336

Authors

Urfa Khairatun Hisan
urfa.hisan@med.uad.ac.id
Universitas Ahmad Dahlan https://orcid.org/0000-0003-4952-3542

DOI:

https://doi.org/10.56741/hesmed.v2i02.336

Keywords:

Ethical Dilemma, Patient Selection, Medical Resources, Rationing, COVID-19 Pandemic, Coronavirus, Medical Bioethics

Abstract

Debates surrounding the patient selection criteria for medical resources rationing have been sparked since decades ago. The arrival of COVID-19 has, once again, raised this debate. Due to its abrupt arrival, rapid infection rate, and unknown pathophysiology, COVID-19 has overwhelmed everyone, including healthcare stakeholders, causing a shortage of medical resources (e.g., beds, ventilators, oxygen supplies, drugs and medicines, and even personal protective equipment). Subsequently, resource rationing through patient selection is inevitable. This article comprehensively summarized the ethical dilemmas in patient selection during the COVID-19 pandemic, especially in Indonesia. We divide the dilemma into two major groups: the elderly and important people. We also present a scientific discussion covering the patients' selection approaches (first-come-first-served (FCFS)-based, severity-based, age-based, time-division/future prediction, equality-based, and random rationing). We reveal that there is no perfectly ideal approach for patient selection without sacrificing any factors. Since decades ago, patient selection policy has placed the elderly groups in an unfavorable position. The COVID-19 pandemic has, once more, showing us that elderly groups are still given lower priorities in the scarce medical resource setting. Lastly, until we are able to provide sufficient healthcare resources, this condition might be, and will always be, a bitter pill to swallow.

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Author Biography

Urfa Khairatun Hisan, Universitas Ahmad Dahlan

Urfa Khairatun Hisan is a lecturer at the Faculty of Medicine, Universitas Ahmad Dahlan, Yogyakarta, Indonesia, and a graduate student of the Department of Bioethics, Universitas Gadjah Mada, Indonesia. She received her B.Med. and M.D. degrees from the Faculty of Medicine, Universitas Gadjah Mada, Indonesia, in 2017 and 2019, respectively. Her research interests include public health and bioethics in medicine. She can be contacted at email: urfa.hisan@med.uad.ac.id.

References

Farrell, T. W., Francis, L., Brown, T., Ferrante, L. E., Widera, E., Rhodes, R., ... & Saliba, D. (2020). Rationing limited healthcare resources in the COVID‐19 era and beyond: ethical considerations regarding older adults. Journal of the American Geriatrics Society, 68(6), 1143-1149.

Jaziri, R., & Alnahdi, S. (2020). Choosing which COVID-19 patient to save? The ethical triage and rationing dilemma. Ethics, Medicine and Public Health, 15, 100570.

Savulescu, J., Vergano, M., Craxì, L., & Wilkinson, D. (2020). An ethical algorithm for rationing life-sustaining treatment during the COVID-19 pandemic. British Journal of Anaesthesia, 125(3), 253-258.

McGuire, A. L., Aulisio, M. P., Davis, F. D., Erwin, C., Harter, T. D., Jagsi, R., ... & COVID-19 Task Force of the Association of Bioethics Program Directors (ABPD). (2020). Ethical challenges arising in the COVID-19 pandemic: An overview from the Association of Bioethics Program Directors (ABPD) task force. The American Journal of Bioethics, 20(7), 15-27.

Craxì, L., Vergano, M., Savulescu, J., & Wilkinson, D. (2020). Rationing in a pandemic: lessons from Italy. Asian Bioethics Review, 12(3), 325-330.

Luyten, J., Tubeuf, S., & Kessels, R. (2022). Rationing of a scarce life‐saving resource: Public preferences for prioritizing COVID‐19 vaccination. Health Economics, 31(2), 342-362.

Pathak, P. A., Sönmez, T., Ünver, M. U., & Yenmez, M. B. (2021, July). Fair allocation of vaccines, ventilators and antiviral treatments: leaving no ethical value behind in health care rationing. In Proceedings of the 22nd ACM Conference on Economics and Computation (pp. 785-786).

Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., ... & Phillips, J. P. (2020). Fair allocation of scarce medical resources in the time of Covid-19. New England Journal of Medicine, 382(21), 2049-2055.

Kilner, J. F. (1990). Who lives? Who dies?: Ethical criteria in patient selection (pp. 77-94). New Haven, CT: Yale University Press.

Morris, T. (1992). Issues In Patient Selection.

Binstock, R. H., & Post, S. G. (1991). Too old for health care?: Controversies in medicine, law, economics, and ethics.

Worldometer. (2022). Worldometer: Coronavirus.

Mitchell, G. W. (2008). A brief history of triage. Disaster Medicine and Public Health Preparedness, 2(S1), S4-S7.

Rosenbaum, L. (2020). Facing Covid-19 in Italy—ethics, logistics, and therapeutics on the epidemic's front line. New England Journal of Medicine, 382(20), 1873-1875.

Jecker, N. S. (2022). Too old to save? COVID‐19 and age‐based allocation of lifesaving medical care. Bioethics.

Scire, E., Jeong, K. Y., Gaurke, M., Prusak, B., & Sulmasy, D. P. (2022). Rationing with respect to age during a pandemic: a comparative analysis of state pandemic preparedness plans. Chest, 161(2), 504-513.

Callahan, D. (1995). Setting limits: medical goals in an aging society with" a response to my critics". Georgetown University Press.

Antiel, R. M., Curlin, F. A., Persad, G., White, D. B., Zhang, C., Glickman, A., ... & Lantos, J. D. (2020). Should pediatric patients be prioritized when rationing life-saving treatments during COVID-19 pandemic. Pediatrics, 146(3).

Worldometer. (2022). Worldometer: Age, Sex, Existing Conditions of COVID-19 Cases and Deaths.

New York City Health. (2020). COVID-19: Daily Data, Summary Deaths.

Lavazza, A., & Garasic, M. D. (2022). What if some patients are more "important" than others? A possible framework for Covid-19 and other emergency care situations. BMC Medical Ethics, 23(1), 1-11.

Jessop, Z. M., Dobbs, T. D., Ali, S. R., Combellack, E., Clancy, R., Ibrahim, N., ... & Whitaker, I. S. (2020). Personal protective equipment for surgeons during COVID-19 pandemic: systematic review of availability, usage and rationing. Journal of British Surgery, 107(10), 1262-1280.

COVID, N. (2020). 19: Rapid Guidance for Critical Care. London: National Institute for Health and Care Excellence.

Marckmann, G., Neitzke, G., Schildmann, J., Michalsen, A., Dutzmann, J., Hartog, C., ... & Janssens, U. (2020). Decisions on the allocation of intensive care resources in the context of the COVID-19 pandemic. Medizinische Klinik-Intensivmedizin und Notfallmedizin, 115(3), 115-122.

Boreskie, K. F., Boreskie, P. E., & Melady, D. (2020). Age is just a number–and so is frailty: Strategies to inform resource allocation during the COVID-19 pandemic. Canadian Journal of Emergency Medicine, 22(4), 411-413.

Tempo.co. (2021, October 27). Harga TES PCR dari rp 2.500.000 di awal pandemi Kini Turun Jadi RP 300.000. Tempo. Retrieved December 1, 2022, from https://bisnis.tempo.co/read/1521706/harga-tes-pcr-dari-rp-2-500-000-di-awal-pandemi-kini-turun-jadi-rp-300-000

BPS provinsi D.I. Yogyakarta. (n.d.). Retrieved December 1, 2022, from https://yogyakarta.bps.go.id/indicator/6/272/1/upah-minimum-kabupaten-upah-minimum-provinsi-di-di-yogyakarta.html

Farrant, A. (2009). The fair innings argument and increasing life spans. Journal of Medical Ethics, 35(1), 53-56.

Bognar, G. (2015). Fair innings. Bioethics, 29(4), 251-261.

Rivlin, M. M. (2000). Why the fair innings argument is not persuasive. BMC Medical Ethics, 1(1), 1-6.

Miller, F. G. (2020). Why I support age-related rationing of ventilators for COVID-19 patients. Hastings Center Bioethics Forum.

Syukur, M. (2022, November 30). Mengintip Lapas terpadat kedua di Indonesia, Narapidana Penuh Sesak Seperti 'sarden'. liputan6.com. Retrieved December 1, 2022, from https://www.liputan6.com/regional/read/5139911/mengintip-lapas-terpadat-kedua-di-indonesia-narapidana-penuh-sesak-seperti-sarden

Sulhin, I. (2020). Covid-19, Pemenjaraan Berlebihan, Dan Potensi Katastrofe Kemanusiaan. Jurnal Hukum & Pembangunan, 50(2), 400-422.

Agustiwi, A., & Nurviana, R. (2020). Kajian Kritis Terhadap Pembebasan Narapidana Dimasa Pandemi Covid-19. RECHTSTAAT NIEUW, 5(1).

Riccioni, L., Bertolini, G., Giannini, A., Vergano, M., Gristina, G., Livigni, S., & Mistraletti, G. (2020). Clinical ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances. Recenti progressi in medicina, 111(4), 207-211.

Hodge, J. G., & Piatt, J. L. (2022, January). Legal Decision-making and Crisis Standards of Care: Tiebreaking During the COVID-19 Pandemic and in Other Public Health Emergencies. In JAMA Health Forum (Vol. 3, No. 1, pp. e214799-e214799). American Medical Association.

Dhama, K., Patel, S. K., Natesan, S., Vora, K. S., Iqbal Yatoo, M., Tiwari, R., ... & Malik, Y. S. (2020). COVID-19 in the elderly people and advances in vaccination approaches. Human vaccines & immunotherapeutics, 16(12), 2938-2943.

Rhodes, R. (2020). Justice and guidance for the COVID-19 pandemic. The American Journal of Bioethics, 20(7), 163-166.

Stevis-Gridneff, M., Apuzzo, M., Pronczuk, M., & Lima, M. (2020). When COVID-19 hit, many elderly were left to die. New York Times, 8.

Daniels, N. (1988). Am I my parents' keeper?: an essay on justice between the young and the old.