By Barry Newman
Barry is a retired NHS intensive care consultant. He volunteers for Dorset Humanists, both on the committee and as a school speaker. The subject of this article is the allocation of life-saving resources in a society. It is written from the perspective of intensive care medicine, which necessarily requires practitioners to exercise discretion in deciding who to treat and for how long, in an environment where the cost of this treatment can be in excess of £3,000 a day.
Attitudes to the value of life, and therefore the public resources that are directed towards prolonging life, have varied throughout history and between societies. Those responsible for allocating public resources are inevitably faced with hard choices. Resources are never infinite, so decisions must be made, and such decisions are made regularly throughout all healthcare systems.
In the UK, patients are presented to intensive care for consideration when there is perceived risk to their lives without the close attention of many nurses and doctors and the availability of complex techniques and equipment available only in these facilities. It can be assumed that a significant number of these people would not survive without these services. Denying admission would not take a life, but would significantly reduce the chances of survival. Challenging decisions about who to admit occur on a regular basis (often several times a day) and depend largely on whether a patient has a realistic prospect of survival and so warrants access to the resource. Not only must survival be considered, but the quality and quantity (duration) of that survival.
So how do ICU clinicians decide who to treat, and who to leave to their fate? And what do they feel about making these decisions? But firstly, who are these clinicians? The process and authority to make such decisions varies from country to country. In the UK, by law, when a patient lacks full mental capacity (as is the case for most critically-ill patients being considered for intensive care) the responsible senior doctor is charged with making decisions in the patient's best interests. These must be holistic interests rather than a narrowly-defined interest like surviving another hour or another day. However, the best interests of any one person are hard to define and a degree of subjective judgement is always present. The doctor is required to 'take into account' the views of close family, but not obliged to follow their wishes. This can create real difficulties.
There is no specific training for, or defined process by which, the responsible clinician makes these decisions. The knowledge and skills are usually learned by example and acquired during the very long apprenticeship that trainees undertake. The decisions are invariably made by an individual – not collectively – and this burden usually falls on the senior consultant on duty who acts as gatekeeper to the resource.
What criteria would this gatekeeper use? The overall consideration is whether putting somebody through a potentially extremely unpleasant experience would provide them with both quantity and quality of life that would be of value to them. Not to anyone else. In the NHS, cost is an indirect factor in the decision due to the unavoidably limited capacity of intensive care.
The senior clinician will use all information available, but particularly the state of physical health enjoyed (or suffered) by the patient prior to the sudden deterioration that brought him or her to the attention of intensive care. Longstanding progressive, debilitating, chronic illness is usually a strong negative influence on such decisions. Age is also a factor, as age is usually a reliable indicator of a person’s reserve or capacity to recover well. There are scoring systems and other aids to such decision-making, but it is finally a judgement call by an experienced and senior doctor who will take personal responsibility for most of the treatment decisions for that patient. And it must be appreciated that the time available to make these decisions is often as short as minutes.
How do clinicians feel when making these decisions? Certainly a great burden of responsibility tempered by experience, and an understanding that this is the job that they have chosen! However, where decisions are finely-balanced, patients are usually given the benefit of the doubt, admitted and treated in the hope of a good outcome. If this does not occur, the clinical team faces the further challenge of treatment withdrawal. In this sense, intensive care clinicians may be 'killing' a patient, but even superficial consideration of the situation will reveal that this is in fact withdrawal of burdensome and futile intervention – not active killing.
How can the decision-making process described above be defended? How can such crucial decisions be made by one person against a backdrop of such uncertainty? Critical to the process, I believe, is the ethics of virtue, which requires the virtuous clinician always to seek the best decision, and to hope that their human frailty will not seriously impede this goal. Where relevant information is scarce and outcome is very uncertain, I suggest that intention to do no harm and always to do as much good as possible is the essential prerequisite for the decision-maker.
The general issue of allocation of public resources is often subject to harsh criticism where decisions do not accord with our own views or when outcomes are poor. These decisions are frequently subject to media manipulation and political interference. However, for such decision-making in uncertainty, perhaps all we can hope for and expect is consistently virtuous behaviour from those charged with making the decisions. Virtue in that they constantly try their best to do the right thing for all. We often conflate retrospective analysis with foresight (the 'I told you so' lobby) and make accusations of poor decision-making when outcomes are imperfect. Perhaps we should recognise our own imperfections and weaknesses when making decisions in uncertainty, and appreciate the difficulties faced by those making resource allocation decisions that affect us all.