00:01
Now that we've discussed the
topic of resource allocation,
let's move on to some case studies
to help bring this to light.
00:07
Case study number one, you are caring
for a 28-year-old male
who is admitted with bacterial endocarditis and needs replacement
of an already existing prosthetic heart valve.
00:17
After his first replacement, he continued
to abuse intravenous drugs.
00:21
The medical team feels it would be futile and a waste
of medical resources to replace his heart valve again.
00:27
Do you feel that this team's judgment
of futility is appropriate in this case?
What are the issues under consideration
in this difficult case?
The first is the one we discussed earlier
of utilitarianism versus deontology.
00:39
Some in fact might argue that the patient's
history of drug abuse excludes him
from consideration for another heart
valve which is a scarce resource.
00:47
Therefore, the "most useful" or utilitarian decision will be to allocate
this precious resource to a more deserving recipient.
00:56
Others would argue however that our fiduciary
duty, our duty to do good, is for each individual.
01:02
This is done without any regard for passing
moral judgment on any individual's character.
01:08
The other issue under consideration here is the
one of likelihood that we treated earlier.
01:12
How is likelihood applicable in this case?
Well, it would seem from the patient's past history that
there is a likelihood of relapse into further drug use
and a similar outcome that we saw previously and this would be
higher than that for someone without this particular history.
01:28
Although this is true, this is not an absolute
truth and this is not a guarantee.
01:34
Likelihood of relapse or failure can
be influenced by several things.
01:39
Number one, we may institute pre-surgical counseling
and addiction treatment to help this patient.
01:45
Secondly, we may have a support
or accountability system in place
which is designed to decrease the use
of relapse and procedural failure.
01:56
So, how do we tie this together in this case?
Well, it's plausible that this patient will in fact require additional
counseling and support services to improve his outcome.
02:06
However, replacing a heart valve is not as the word
was used by the team, futile in this case.
02:12
There is the chance that
there may be success here.
02:14
It may in fact, however, be possible that
the medical team is using bias to judge
what they might consider a wasted versus
a properly used medical resource.
02:24
Here, it's very important that we have thoughtful
discussion and this may provide an opportunity
which is very important for the team to voice
their concerns. They need to be heard.
02:33
However, we need to work through this in a
treatment plan that will provide maximal support
for this patient's recovery given his risk factors.
Let's take a look at a second case study.
02:44
During the COVID pandemic, one of the
feared anticipated situations
was the allocation of mechanical ventilators if the need
for ventilators would exceed the number that were available.
02:55
The following case will illustrate some
of the considerations necessary one must choose
between patients who are demonstrating
need for an existing scarce resource.
03:06
In this case, you are the attending ICU physician
during a pandemic and you have one ventilator to allocate.
03:14
The emergency department calls you
and they have three patients,
each of which is in need of a ventilator bed
for COVID respiratory failure.
03:23
The patients are as follows, a 76-year-old man
with a history of COPD who is requiring home oxygen.
03:30
The second patient is a 34-year-old man who has dialysis-dependent
renal failure as well as alcoholic liver cirrhosis.
03:39
And then, finally, we have a 26-year-old
woman with a history of myasthenia gravis.
03:44
Which patient should get this very scarce ventilator?
This is a difficult decision.
03:48
Let's look at the issues under consideration
for each of these three patients.
03:52
With regard to the first patient,
the 76-year-old man
with a history of chronic obstructive pulmonary
disease who is requiring home oxygen therapy.
04:00
Well, the patient's COPD suggests
that he may have difficulty weaning
from this ventilator should you choose
to allocate it to him.
04:08
His age also suggests that his life expectancy
should he survive all of this
would be less than that of
the other patient's in need.
04:16
So, but we don't discriminate
specifically on the case of age,
we do need to consider this as part of his comorbidities in this case.
Let's look at the second patient.
04:26
This is the 34-year-old man with a history of dialysis
dependent renal failure and alcoholic cirrhosis.
04:32
Well, this patient possess two significant comorbidities
which negatively impact his overall survival rate.
04:39
Furthermore, there is the factor that his liver
disease was at least partially self-imposed
and this raises the issue of value judgements
entering into the discussion, much like our first case.
04:51
The third patient is our 26-year-old woman
with a history of myasthenia gravis.
04:56
Her myasthenia and respiratory muscle weakness clearly
represent an impediment to eventual ventilator weaning.
05:03
This must be taken into consideration.
05:05
However, we also know that she could be treated
with drugs to help alleviate this symptomatology
and perhaps, increase her likelihood of weaning
from the ventilator should she receive it.
05:16
In addition, her absence of other comorbidities
portends more favorably for her survival.
05:22
So, in a difficult case like this
where you must make a choice,
choosing the third patient might be considered
a defensible choice under these circumstances.
05:31
If we were to summarize these two cases,
we would say in the first case,
we had one existing patient who had
some sort of what would be considered
a moral or ethical impediment
to getting a scarce resource.
05:41
We worked through how we have to overcome biases to overcome
questions of futility that may not in fact really exist.
05:49
The second case was a more challenging
case where we had one existing resource
and we had to look at three patients and make a very difficult
decision of which patient would obtain that resource.
06:00
These cases are important because
they put these philosophical concepts
into practice in our clinical work
of ethics and medicine.