By Dr Fadhlina Alias

The recent surge in COVID-19 infections has led to Malaysian medical practitioners voicing serious concerns on the ability of intensive care units in hospitals all over the country to cope with the increased number of patients who require ventilatory support in order to breathe. Our heroes are now confronted with difficult decisions on a daily basis, as to which patient should be given a ventilator, which is a limited medical resource.

The Duty of Beneficence vis-à-vis Distribution of Limited Resources

The duty to do good and promote a patient’s well-being, and not merely the avoidance of harm, is considered to be the primary aim and raison d’être of medicine. Beneficence entails that doctors place their patients’ interests before their own. This duty, however, does not impose an unqualified duty on doctors to adhere to the patient’s requests, and exceptions may occur in situations where the latter would not benefit or cause more harm to the patient itself.

An example of a contraindicative situation where beneficence is applied is cases of medical futility. When a course of treatment is futile, the doctor’s obligation to carry it out is negated due to the fact that it will not provide the intended benefit to the patient. Consequently, a beneficial treatment may need to be evaluated against the socio-economic reality of allocating health care resources, which entails the need for a balanced interplay between the principles of beneficence and justice. One of the central conceptualisations in health care policies is that the distribution of resources should not be concentrated towards a certain group of patients, but should be made available to realise the greater medical good for a wider segment of those on the receiving end of medical care. The duty of beneficence therefore cannot lead to unfair and unjust provision of health care resources.

Justifying Considerations of Medical Futility and Distributive Justice

From the bioethical perspective, when certain interventions are considered to be clinically futile and confer no benefit on the patient, there is no ethical obligation to administer or continue such treatment.

Although medical futility is a legitimate and viable justification for withholding or withdrawing life-sustaining therapy, it should not be perceived as sounding the death knell for terminally ill patients and denying them medical care. Whether a medical intervention is morally justified is contingent upon it being favourable towards the patient’s best interests.

A determination of futility does not in any way vitiate the doctor’s continuous duty to palliate and provide symptomatic relief to the patient, and ensure the patient’s comfort as he or she nears the end of life.

The principle of justice in the context of bioethics requires equity to be exercised in the allocation of health care resources and services. It necessitates fair adjudication in the delivery of health care at the individual level in ensuring that the patient receives fair treatment, and at the societal level in terms of just distribution of health care resources. Medical decisions in critical care, however, are relatively more challenging since they involve the allocation of scarce life-sustaining treatments that cannot be provided to every patient.

The rationing for patients in critical care, which is referred to as “microallocation”, involves creating a just balance between several criteria:

(1) the treatment’s likelihood of success, so that scarce resources are distributed to patients who can reasonably benefit from it;

(2) medical utility, which focuses on maximising a patient’s welfare and needs; and

(3) the avoidance of wastage and inappropriate utilisation of resources that can be applied towards treating and saving more people.

Therefore, it is ethically acceptable for doctors to not provide life-sustaining treatment such as ventilatory support to a patient, if there is cogent evidence that the treatment requested carries little or no benefit, or when it would result in an inefficient use of resources.

In other words, as difficult and harrowing as it may be, the decision of a doctor to give the ventilator to a patient who has a better prospect of recovery rather than to one whose death is unavoidable is ethically justified.

The least we can do now is to strictly abide by the directives meted out by the relevant governmental authorities relating to the COVID-19 pandemic so that we may help to relieve our heroes of this onerous burden.

#kitajagakita #lindungdirilindungsemua

-- BERNAMA

Dr Fadhlina Alias is Senior Lecturer at the Faculty of Syariah and Law of Universiti Sains Islam Malaysia.