Back in 2009 I reported on a Hastings Center publication entitled When Endemic Disparities Catch the Pandemic Flu: Echoes of Kubler-Ross and Rawls in which the author recounts experiences of participating in panels considering the clinical and ethical challenges posed by pandemic flu. Within the context of this series on COVID-19 the report makes interesting reading. In it, several different scenarios are addressed, as different strains of flu (and by extension also non-flu pandemics) provoke different levels of hospital entry and resource consumption. The author poses the question of how to distribute limited resources amongst the population in times of acute crisis using data about the number of ventilating machines that are currently available in the different districts of the city of New York, an issue that the pandemic we are experiencing today also raises.
On 20 March this year, as we battle the COVID-19 pandemic here in the Netherlands and across the world, the national news organization NOS published an article Why Does the Netherlands Have So Few Intensive Care Beds in Comparison to Other Countries? (in Dutch, my translation) that addresses the scarce resources problem (and its possible causes) today.
The article opens with a bar graph that shows the pre-crisis number of IC beds per country across Europe. The Netherlands sits fifth from bottom, with 6.4 beds per 100,000 citizens. Our cousins in Germany have the highest, with almost 30 beds per 100,000, with the average in Europe 11.5. Italy sits just above the centre point with 12.
The article responds to the title question in the opening paragraph: ‘the reduced capacity in the Netherlands is largely due to the reduced intake of older and weaker patients. In the Netherlands, quality of life is given precedence, and not the prolonging of life for each individual patient’. This explanation is accredited to Marianne Brackel from the patient organization IC-Connect.
An explanation follows: As a rule, Dutch doctors try to avoid what Brackel calls ‘senseless medical treatment’. ‘If the chance of recovery is low then we prefer to choose palliative care…’. Doctors explain to patients that IC treatment puts an immense strain on the body and is far from pleasant before they are asked if they would like to try to proceed, rather reflecting the line that I described in my last post in this series.
The article continues with a counter argument taken from the Emeritus Professor in Geriatrics Paolo Falaschi (Rome, Italy) who states that he is ‘totally against age discrimination in medicine’, and that any patient who is 100 years old and requires medical care should receive the best possible.
The article continues with an explanation of the situation in Germany, the country with by far the highest IC capacity. Geriatrics Doctor Hans Jürgen Heppner explains that anyone who has the chance of survival must have access to IC regardless of their age, and in order to guarantee this possibility the infrastructure has to have enough capacity. He adds however that this philosophy also brings problems in the case of a pandemic, because the system does not have the provisions for making decisions about who should have access and who not. In the Netherlands such problems have been discussed in parliament and legislated for, some form of clarity and procedure exists, but this is not the case in Germany. Such an emergency situation would require large scale reorganization.
Both the Dutch position and the German-Italian positions are inadequate at the moment however, as the Dutch find themselves with barely enough capacity to cope (it is not just old or weak people in IC due to COVID-19, but a broader swathe of age-groups) a problem they aim to resolve by expanding (triple) the number of posts in the coming days. This expansion, alongside the related need for other necessary materials is not a problem-free proposition however, as the recent withdrawal of 600,000 facemasks recently purchased in China and subsequently found to be faulty demonstrates, not to mention the potential holding of (flagship Dutch technology company) Phillips ventilators manufactured in the US, by the Trump administration.
Italy seems to have managed to maintain capacity in the North where the outbreak is most extreme, but it remains to be seen if they can continue to do that as the virus spreads in the South of the country where such resources are scarcer. Germany has enough capacity at the moment, but nobody can guarantee that it will suffice over time, meaning that they will possibly be faced with making decisions that will be difficult to take (by medical staff) and to justify and accept (for medical staff, patients, family members and politicians), particularly as they are currently treating patients flown in from other EU countries.
On a more critical note, this article once again (see my previous post) instrumentalizes the current Italian situation. The article closes with a quote from the Dutch doctor cited throughout the article in response to an unsubstantiated statement made by the journalist: In Northern Italy, where health care is heavily overloaded, people are said to have been removed from ventilation due to severe equipment shortages. The Doctor argues that this is caused by the Italians themselves as ‘these are deficiencies that they have created themselves by putting patients on a ventilator, including all the very elderly’.
I have followed the Italian situation very closely both through the media and personal connections, and I have never seen any evidence of this alleged removal of treatment. What I have seen however, is an incredible expansion of facilities, with assistance from several countries from both inside and outside the EU, and that reflects the Italian state’s recent diplomatic role as peacemaker and upholder of social justice.