疫情版电车难题：医护人员该优先救谁？

疫情笼罩，全球无数患者在经受病毒的折磨。然而，许多国家面临着医疗资源的极度短缺，呼吸机更是少之又少。救谁？不救谁？如何分配有限资源？重重选择正摆在人们的面前......

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Harrowing scenarios already are unfolding in country after country hard-hit by the COVID-19 pandemic, including Spain, where one nursing home official said sick residents are dying after being unable to get into overflowing hospitals.

Like much of the rest of the world, ventilators that help people breathe are in particular demand across the U.S., given the respiratory problems common among people severely ill with COVID-19.

As many as 900,000 coronavirus patients in the U.S. could need the machines during the outbreak, according to the Society for Critical Care Medicine. Yet the group estimates the country has only 200,000, many of which already are being used by other patients.

In New York, the U.S. epicenter of the outbreak, one city hospital has already logged 13 coronavirus deaths in a single day and officials are setting up hundreds of hospital beds in a sprawling convention center as cases climbed past 30,000 in the city.

A lot of thought has been given to just such a predicament, well before critical shortages from the coronavirus pandemic. “It would be irresponsible at this point not to get ready to make tragic decisions about who lives and who dies,” said Dr. Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado.

Facing this dilemma recently — who gets a ventilator or a hospital bed — Italian doctors sought ethical counsel and were told to consider an approach that draws on utilitarian principles.

In layman’s terms, a utilitarian approach would maximize overall health by directing care toward those most likely to benefit the most from it. If you had only one ventilator, it would go to someone more likely to survive instead of someone deemed unlikely to do so. It would not go to whichever patient was first admitted, and it would not be assigned via a lottery system. 

The crushing emotional burden of carrying out potentially life-and-death decisions is why the guidelines typically designate separate triage teams to make the call, rather than leaving it to the doctors and nurses providing bedside care.

History offers examples of competing values. During World War II, soldiers received penicillin before civilians. In Seattle in the 1960s, social worth was among the criteria used to ration dialysis machines.

In a paper in The New England Journal of Medicine published Monday, Dr. Ezekiel Emanuel, vice provost for global initiatives and chairman of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, and colleagues offer ways to apply ethical principles to rationing in the coronavirus pandemic. These too are utilitarian, favoring those with the best prospects for the longest remaining life.

In addition, they say prioritizing the health of front-line health care workers is necessary to maximize the number of lives saved. 

Guidelines previously developed by New York state’s health department exclude some seriously ill people from receiving limited ventilators in major emergencies, but note that making old age an automatic disqualifier would be discriminatory. The plans go on to add, however, that given the “strong societal preference for saving children,” age could be considered in a tie-breaker when a child’s life is at stake.

Recommendations published this week by German medical associations in response to COVID-19 also say age alone shouldn’t be a deciding factor. Among the situations where they said intensive care should not be provided if availability is in short supply: if the patient would need permanent intensive care to survive.

Either way, experts have to make the choice as soon as possible since the disease is still in epidemic phase, and the most important thing is to give a clear explanation of each of the guidelines.

“Key is to be transparent about the principles, save as many lives as possible, and ensure that there are no considerations such as money, race, ethnicity or political pull that go into allocation of lifesaving resources such as ventilators,” said Dr. Tom Frieden, president and C.E.O. of Resolve to Save Lives and former director of the Centers for Disease Control and Prevention.

Recommendations published this week by German medical associations in response to COVID-19 also say age alone shouldn’t be a deciding factor. Among the situations where they said intensive care should not be provided if availability is in short supply: if the patient would need permanent intensive care to survive.

And elected U.S. politicians entrusted with public welfare are making calculations centered around the question: How many possibly preventable deaths are acceptable, as weighed against millions of jobs lost and trillions of dollars of economic output foregone?

Coronavirus shut-downs could lop 25% or more from U.S. output, some economists forecast, throwing tens of millions of Americans out of work. The U.S. government and the Fed are mounting what could be a $6 trillion economic rescue.

Paul Winfree, director of economic policy studies at the conservative Heritage Foundation, said allowing the downturn to deepen into a depression would ultimately negatively impact health.Economically, Minnesota Governor Tim Walz said, the state can't afford to stay shut for a year or more until a vaccine is developed.

The question remains if the American consumer, who is responsible for about two-thirds of U.S. GDP, will be confident enough to go to crowded malls and cozy restaurants if the death toll is still rising.

For a growing chorus of economists, however, the notion of weighing deaths against the economy is fundamentally flawed.

MIT economist Emil Verner last week co-authored a paper about the response to the 1918 flu epidemic and found that cities that restricted public gatherings sooner and longer had fewer deaths - and ultimately emerged from the pandemic with stronger economic growth.

“Saving lives and saving the economy are not in conflict right now,” former Fed Chair Janet Yellen and more than 30 other current and former policymakers and economists wrote in a joint statement published earlier this week.

“We will not put a dollar figure on human lives,” New York Governor Andrew Cuomo said. Almost half of the 130,000 U.S. cases to date have appeared in New York, where some hospitals are overwhelmed with critically-ill patients.