Intensive care – and trolley cars

Dr Eric Crampton
26 October, 2021

Trolley problems are fun thought experiments in the philosophy and economics classroom. A trolley is hurtling down the track and will run over 10 people, unless you pull the lever. If you pull the lever, the trolley will shunt to a side-track. There, it will kill 2 people.

Every choice is terrible. Fail to act, and 10 will die. But you can pretend not to be responsible for their deaths. No one will blame you. The train was already on that track. Act, and two will die – and you will know that you pulled the lever that killed them. So will their families and friends.

On a utilitarian calculus, the case for pulling the lever is obvious. Eight fewer people die. But would you do it?

New Zealand hospital system is staring down a similar trolley problem. There simply will not be sufficient hospital capacity to deal with the Covid cases that will come through. Elective surgeries have already been deferred to deal with Level 4 restrictions. But it will get worse.

Under normal medical triaging procedures, when space in hospital or ICU is limited, the first patients to miss out are those who are not in immediate danger. As Covid cases fill beds, surgeries for chronic, debilitating illnesses will be cancelled or postponed – because they are not immediately life threatening.

Alberta, Canada, shows us what lies down this track.

The Canadian province of 4.4 million people has had more than 200 Covid patients in ICU every day since mid-September.

When the ICUs filled up, surgeries were postponed. Infants needing treatment for congenital conditions that will only worsen with time are pushed out of hospital because of Covid’s burden. Their treatments will be less successful the longer they are made to wait, but their cases are not directly life-threatening. Cancer patients miss out on treatment, shortening and worsening their lives. But there will always be more pressing and urgent need from the Covid patient arriving by ambulance, unable to breathe.

The default track is terrible. All rationing options when space in hospital is scare are terrible. Every single option you might choose means that someone misses out on care. And the greater the shortage, the more critical the care that is missed.

The default track has one distinct advantage. Nobody has to pull a lever to change course. Nobody has to take on that responsibility, or bear that horrible burden. The next bed always goes to the person in most desperate need, and that has a logic to it. But it does come at a horrible cost to those whose conditions are debilitating and painful, but not immediately life-threatening.

There is another option.

It is also terrible. But is it less terrible than what happens if we choose not to decide?

In New Zealand, as in Alberta, 14% of those aged twelve and up had not received their first vaccine dose as of late last week. Alberta was somewhat ahead of New Zealand on second-doses: 78% of their population is fully vaccinated, to New Zealand’s 69%.

The 14% of unvaccinated Albertans over the age of twelve make up the vast majority of hospitalised Covid cases, and an even greater fraction of cases in intensive care units. Over the past 120 days, the unvaccinated 14% have made up 75% of all hospitalised Covid cases over the age of 12, and 87% of those in ICU.

The numbers are perhaps starker when expressed another way.

For every 10,000 fully vaccinated Albertans over the age of 12, over the past 120 days, 3 wound up in hospital with Covid and 0.3 wound up in ICU with it. For every 10,000 unvaccinated Albertans, 69 wound up in hospital and 17 in ICU.

The province of 4.4 million people currently has 218 people in ICU with Covid. Vaccinating 600 people there would prevent 1 ICU admission and 4 hospitalisations. As a rough estimate.

New Zealand, with 5.1 million people, had 186 staffed ICU beds on the most recent count – though surge capacity will become available thanks to nursing staff provided a very short training course.

Every option for rationing scarce hospital capacity is horrible. Every way you might do it means someone will miss out, bringing misery at best, shortened lives, or death.

But one option has a chance of shortening the queue for ICU – of reducing the overall burden, rather than just shifting that burden around.

If the Covid outbreak reaches the point where space in hospital must be triaged, priority could be given to those who are vaccinated, and spaces provided to the unvaccinated only if there were room.

It is a horrible option.

But the status quo is also horrible.

If a cancer patient is told there will be no room because the hospital is full of Covid patients, there is nothing the cancer patient can do to not have cancer. Children with congenital conditions cannot choose to no longer have that condition and to have a far smaller risk of needing surgery.

But if the government were to announce that, in two weeks’ time, a first dose of vaccine were the entrance requirement for Covid treatment at hospital – and that a second-dose requirement would apply in eight weeks, there is something that people could do.

They could get vaccinated.

In a large outbreak, like Alberta’s, 600 people deciding to be vaccinated means about 4 fewer people need to be pushed out of hospital over a 120-day period. Because 4 fewer people need hospital care for Covid, because vaccination meant that they did either not catch it or were protected against serious illness. And one fewer person needs a space in ICU.

A vaccination requirement may be the only way of rationing scarce hospital capacity that has the benefit of reducing need for hospital spaces in the first place. If everyone is vaccinated, we are far less likely to have to ration at all. There would be far fewer cases, and what cases we have would be far less serious.

It could only be done if accompanied by a very serious push to get vaccines out everywhere, so no person would be denied care because they were denied access to vaccination. That push should happen regardless of how scarce spaces in hospital might be rationed.

The objections to this form of rationing are obvious.

Denying care because someone has chosen not to be vaccinated is horrible. But failing to do so will deny care to someone else. Is that less horrible? And if more people become vaccinated because of this change, fewer will be denied care because less care will be needed.

Currently, Māori have lower vaccination rates; this form of rationing could have terrible disparities. Regardless of how care might be rationed come the crunch, more has to be done now to improve equity in access to vaccination and in support to encourage vaccination. But the status quo rationing option has its own terrible disparities. Who bears the largest burden when hospitals cannot function normally and elective surgeries are pushed out? It is not the communities who, on average, are healthier and who have less need for hospital care.

We may worry about precedents: a public health system that allocates care by someone’s notion of deservingness, rather than by medical need, would be truly awful.

But the point here is not deservingness, or to punish the unvaccinated. A large outbreak, if vaccination rates were not substantially higher, would require doubling the size of the relevant parts of the health system. It cannot be done. The only precedent that should be taken here would apply to future pandemics where a readily-available vaccine reduced the risk of needing ICU to a tiny fraction of the baseline risk, and where it is impossible for the health system to otherwise cope.

Every rationing option is awful. The option here presented is not good. I do not like it. But if it is worse than that status quo rationing option, that is something that should be decided on deliberately. Simply taking the status quo option because it is the status quo, and because nobody would blame the government for failing to pull this trolley-track lever, could too easily be even worse.

And we may worry too that, where the entire traffic light alert system is based around whether the hospital system can cope with demand, the status quo option does not just mean patients with non-critical conditions miss out. It also means that traffic lights would be red for longer, and that there is more risk of returning to harder lockdowns.

Hopefully, vaccination rates quickly increase to levels where the hospital system will not be under threat. But if they do not, how scarce spaces are rationed will matter. Which trolley track is really worse bears thinking about well before that point is reached. Doing so early enough would give more people time to get off of the track.

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