LONDON – Denying vital care to conserve public resources is nothing new to Britain's National Health Service.
For costly treatments for cancer and other diseases, the health service officially limits what it will spend to postpone a death: £ 30,000, or about $ 37,000, for each full "quality,quot; year of life provided to a patient.
In the event of a pandemic, public guidance from health officials for more than a decade has been that physicians must prepare to retain the scarce resources of the weakest patients in order to save the strongest, especially with use of life support fans. .
However, now that a pandemic has finally arrived, health authorities this week refused to explain exactly how to make those dying decisions, evidently for fear of a public uproar.
Attacked by criticism from all sides for its slow response to the threat, the Prime Minister's government Boris Johnson has chosen to avoid the political pain of revealing his already written criteria for deciding which patients should die of the disease, even those with any chance of survival.
The absence of official guidance could effectively force front-line doctors to improvise their own criteria, lawyers and ethics specialists say, which could send poor, elderly or disabled patients to the end of the line.
Doctors in northern Italy have already reported withholding support from patients to prolong life in order to dedicate scarce fans to those most likely. Now other European governments and many American states are struggling to come up with similar classification policies in case their hospitals are overwhelmed.
However, the British government has much more experience and expertise in rationing treatments for medical problems than US states, making its inability to explain policy particularly striking.
"In the UK, these are decisions of public bodies for which they are publicly responsible," said David Lock, a lawyer who advises the British Medical Association on legal and ethical issues. "Therefore, there is an urgent need for a clear framework for physicians to make these decisions on behalf of the public agencies that employ them."
Without more careful guidelines, "really terrible decisions could be made," said Peter Todd, a lawyer who has represented autistic patients who were denied medical treatment by the National Health Service.
Senior health officials took initial steps last week to develop such a classification policy, quietly commissioning a small committee of doctors and other experts to help establish a specific protocol for access to Fans said three people familiar with the effort. The medical director's office was expected to release the guidelines late last week.
After considering whether the special panels in each hospital should make such decisions, the committee leaned toward establishing a numerical formula that would classify the chances of survival, much like the calculations British doctors currently use to classify patients who seeking liver transplants. Proponents argued that a numerical rating could lift the burdens of front-line physicians and reduce inconsistencies from one hospital to another.
However, on Monday, out of fear of spreading panic, health officials rebelled and decided to postpone the disclosure of the effort, people familiar with the project say. Officials argued that the recently imposed strict social distancing policy could reduce the infection rate enough to avoid the need for such triage.
When asked about the decisions to first draft and then withdraw the classification criteria, representatives from the Department of Health and Social Assistance emailed a statement: “As the public would expect, we worked hard to prepare for a number of scenarios different. we are as prepared as possible. "
However, despite official hopes of avoiding the darkest scenarios, doctors say Tensions in the British healthcare system continue to grow. Desperate efforts to produce more fans so far have failed to significantly expand the number available, currently less than 10,000, and the number of infected people continues to rise.
British health officials said on Friday that the number of hospital deaths in the past 24 hours had reached a new high of 684, bringing the total to 3,605. The full extent of the infection remained impossible to quantify, in part because the test materials were so scarce.
British authorities began issuing a vague pandemic guidance more than a decade ago, telling health care providers to give preference to those who are most likely to benefit from access to limited resources such as ventilators.
"Everyone matters equally, but this does not mean that everyone is treated in the same way," the ethics health department stated. guideline formulated after the 2009 H1N1 flu, or swine flu, pandemic.
"Even if the existing capacity of critical care beds can be maximized, during the peak of a pandemic, there may be 10 times more patients requiring mechanical ventilation than the number of beds available," the health department estimated at the Pandemic Flu Guide first issued in 2009.
"Additional safety measures,quot; may be needed, the same document warned, to protect doctors making classification decisions from the anger of people whose friends or family were denied respiratory support to sustain life.
But that general orientation failed to address many of the trickiest questions, including how to decide which patients have the best chance of survival.
Advocates for the elderly warn that older but physically healthy patients may suffer unfairly if doctors use age as a substitute for resilience, and that decision-making may vary from hospital to hospital. Diabetes, heart disease, obesity, or other health risks may be counted differently.
Ethics specialists warn that the poor would likely suffer disproportionately because they are more likely to have pre-existing health problems. Without specific guidelines, they say, doctors' decisions can be influenced by unconscious biases against ethnic minorities, people with mental disabilities, and other groups.
"This has been the most alarming concern for people with disabilities worldwide," said Catalina Devandas, United Nations Special Rapporteur on the rights of people with disabilities. "The highlight of this drama is that it appears to be the default reasoning of society at large: the lives of people with disabilities are not considered as valuable."
In the absence of guidance from Britain's top health officials, the same body that applies the £ 30,000 limit to new treatments, the Official National Institute for Health, Care and Excellence, generally referred to by the acronym NICE. – He sought to intervene. Last week N.I.C.E. He advised physicians to prioritize ventilator access in part by consulting a numerical score known as the Clinical Fragility Classification.
But the frailty rating is a measure of physical activity and overall self-sufficiency designed to assess only older people, not the general population. Lawyers representing people with autism and other disabilities quickly complained, and N.I.C.E. It modified its guideline to specifically rule out any application to people who are younger or with learning disabilities or long-term disabilities, although patient advocates argued that the changes were insufficient.
Then this week, the British Medical Association, the leading medical trade group, issued its own general guidelines, arguing that its members and other health care providers should be given special priority. That way they could return to caring for others, the association reasoned.
"Decisions about which groups will have to resort to scarce resources first may also take into account the need to maintain essential services," the medical association said. That should include, he said, "those people involved in addressing the immediate health and social aspects of the pandemic, and particularly those with poor and irreplaceable skills."
The association also said that healthcare providers must prepare not only to withhold life-sustaining treatment, but also to actively withdraw it to transfer it to others, even when the withdrawal could hasten the death of a patient who had been improving.
Even if the patient is "stable or even improving," the association said, a ventilator could be removed if "objective evaluation indicated a worse prognosis than another patient requiring the same remedy."
However, some legal experts argued that patients facing retention or withdrawal of respiratory assistance deserved at least a day in court. British courts should have an opportunity to decide on triage policies in a test case before they are more widely applied, he said. Kathleen Liddell, Director of the Cambridge Center for Law, Medicine and Life Sciences.
"This maxim that we should be saving the most lives is not complete," he said. "It has to be respecting the patient's human rights."
Some British doctors are already trying to reassure fragile patients that they won't be left for dead, even if efforts to save them can only go so far.
If treatment becomes useless, "we will change our approach to cure, but most importantly we will continue to care," wrote Dr. Matthew Morgan, an intensive care physician in Wales, in an open letter to vulnerable patients published last month in the BMJ, A British Medical Magazine. "We have not forgotten you."