Map of life expectancy at birth from Global Education Project.

Monday, May 05, 2008

Tough luck

A couple of recent reports in the popular press on academic exercises offer considerable food for thought. First, I'll offer my own well-fed cogitations on this effort by a task force of physicians in various powerful positions to decide who gets triaged to the scrap heap in the event of an influenza pandemic or a comparable mass casualty event. Unfortunately, the issue of Chest in which this report appears hasn't made it onto my library's on-line subscription service yet, so I can only go by the news report. Hence I don't know the full composition of the task force. It includes representation from the military and the Department for the Impregnable Defense of the Glorious FatherlandHomeland Security, among other federal agencies, as well as medical societies and prominent academic physicians. I'm sure many will see this as vaguely sinister but I'll give them the benefit of the doubt as to motive.

I've railed against the pathological state of denial in this country often enough that I am obliged to welcome an exercise that seriously contemplates the possibility of bad stuff happening. The idea here is that the need for such resources as mechanical ventilators and intensive nursing care exceeds the supply. The task force members have created guidelines for who gets to breathe and who gets to drown in their own sputum. Those who get shitcanned include those with advanced dementia, people with severe trauma, people with serious chronic diseases such as heart disease and, oh yeah, everybody over age 85.

The news report doesn't spell it out, but my reading is that they have mixed a couple of criteria here, with life expectancy being the most important, but quality of life and the resources required to take care of the person also figuring in the formula. Now, you might just say that this is dirty work, but somebody has to do it. When the people are stacked up like firewood in the ED, you've got to choose somehow and you're better off having a plan.

My first objection ought to be obvious. Who appointed these people God? It's fine to raise the issue but they seem to assume that it stops here. They've pronounced, we're done. In fact, acting on these guidelines would be illegal. You aren't allowed to discriminate in the provision of services -- and particularly publicly funded services such as health care -- on the basis of age or disability. Furthermore, there is a strong correlation between socioeconomic status and the likelihood of having poorly controlled diabetes or heart disease, for example -- among the markers for death in the task force report. That includes education, income, and oh, by the way, race. So these guidelines actually use the consequences of prior lack of access and inferior health care, among other factors, as reasons to deny care to people at the point where they need it the most, while moving the privileged people who enjoy better health thanks to your previous discrmiination to the front of the line.

And yet, and yet. Here you are, overwhelmed by a catastrophe, confronted with hundreds of desperately sick people, and you can't save them all. Doesn't it make sense to try to save the people who have the most life left, and the most left to live for, first?

Well, maybe so, but the 86 list isn't necessarily going to help you very much. You aren't going to have a list of all the people who need care, ordered from top to bottom on the basis of their shitcan score, so you can just work down until you run out of drugs or IV bottles or whatever it may be. Instead, the people are going to come in continually, in more or less random order. They will not be accompanied by detailed information about their cognitive or medical condition. You will not know in advance exactly how much of what resource each person will need -- whether they will need a ventilator, for example, or for how long. If you decide, "I'm not going to bother with this diabetic," and she dies, you may find out later that you did, in fact, have enough resources to take care of her, and they're still sitting on the shelf.

Conversely, in the case of pandemic influenza, it is likely to be the robust young people who are most severely sick and who need the most resources for their care. This was the experience in 1918. The explanation may be that it is an overactive immune response called a "cytokine storm" that caused death in that epidemic. (Here is an attempt to make that concept intelligble to lay people.) So it might well be that a much larger number of people could be saved by concentrating on the older folks.

So I would say this needs much more discussion, and probably legislation of some sort -- which would be almost impossible to pass.

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