In venues from medical labs to the Supreme Court, Americans deal increasingly with bioethical issues, as science brings developments in life and death cases.
Wayne Law Associate Professor Lance Gable leads a multi-disciplinary state ethics committee, that is creating guidelines for healthcare and public health systems in Michigan in the case of a public health emergency in which resources — such as vaccines, medicines, ventilators, even hospital beds — become scarce.
The proposed guidelines, which took three years to debate and draft, are available online at www.mimedicalethics.org. Gable, who teaches bioethics and public health law at Wayne Law, and officials at the Michigan Department of Community Health want public feedback on the ethical guidelines, which are meant to help healthcare providers and other public officials make hard decisions.
Suppose, for instance, a deadly pandemic erupts, and the medicine to treat the illness is in limited supply. How do public health officials decide who gets the medicine?
In that instance, the highest priority under the proposed guidelines would be the people most essential to “minimize morbidity and mortality” — a group likely to include health care workers and people working to make the medicine. Also given highest priority would be people with a high risk of dying who are likely to recover with treatment, people with a high risk of exposing others and people needed to “sustain a functioning society through actions to preserve the capacity to deliver health care, public health, public safety and other social services and critical infrastructure.” Those people likely would include some police officers and firefighters. And all of those higher priority people also should have a good chance of recovering with treatment to qualify.
“Who are essential personnel would depend on the situation,” Gable said.
Those initial proposed guidelines took months for the committee to establish. And then came the issue of who gets the medicine or scarce resource next. That’s still a dilemma.
“There were many disagreements over the positions we might take,” Gable said. “We had long conversations about almost every issue.”
What the 20 committee members, who included emergency preparedness experts, medical workers and government officials, agreed on is that a person’s social status and income could not play a role in the decision making.
Gable talked about the infamous Seattle “God Committee” from the early 1960s, when a group formally called the Admissions and Policies Committee of the Seattle Artificial Kidney Center at Swedish Hospital decided which patients would get hemodialysis, which then was a new treatment in limited supply. The group drew up a list of factors to weigh when they decided who would get the life-saving treatment. The factors included the patients’ income, net worth, educational background, occupation and past behavior.
“That’s horrible,” Gable said. “There’s no way we could allow those kinds of factors to be used to allocate scare resources during a public health emergency. We don’t want to go down that road at all.”
The ethics committee members established three additional categories of acceptable criteria for allocation of scant resources after the top priority categories of medical prognosis and essential personnel have been applied, and acknowledged that none of the categories are without controversy. Age — younger over older — might be one way to decide. So might a random lottery, or a first-come, first-served basis. But all of those criteria have problematic issues, Gable said.
The state guidelines, even when finalized, will not be laws, and no one will police them. But existing law could serve to help enforce the guidelines in many instances, if needed, Gable said.
He gave the example of a scarce flu vaccine situation in Florida a few years ago, when some people with access to vaccine started selling it to highest bidders on eBay. The state attorney general was able to stop such “rampant profiteering” using existing law, Gable said.
He hopes the guidelines he’s spent three years working on will never be needed. But it’s prudent to be prepared.
“We did not want to limit our guidelines to flu,” Gable said. “We wanted to cover any kind of public health emergency. We hope to provide guidelines to healthcare providers and other decision-makers in making ethical decisions about access to scare medical resources in the most effective and fair way possible.”
Bioethical issues have intrigued Gable for many years. He did his undergraduate work in areas of science and medicine as well as law and policy, and got a master’s degree in public health before becoming an attorney.
“All of these topics were interesting to me,” Gable said. “These are fields that are constantly changing and they’re very important.”