Proportionality, Pandemics, and Medical Ethics

Much has been written about allocating scarce resources during the COVID-19 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) pandemic. Less attention has been devoted to whether there is a limit to practitioners’ obligations with respect to the care of individual patients. Instead of adequate scrutiny of this question, the tendency has been to hail practitioners who have placed themselves at selfless risk as heroes and laud them with nightly applause.

Although the conduct of health care practitioners has been admirable, approaching medical ethics from the perspective of heroism is neither sustainable nor robust enough to meet the complexity of emergency conditions during a pandemic. And it is unfair because an expectation of heroism presumes that clinicians will assume a disproportionate share of burden that should be distributed more widely.

When medical ethicists assess clinical practice in terms of the proportion of burdens and benefits, they invoke the doctrine of proportionality. A choice is proportionate when the benefits outweigh the burdens. Alternately framed, the relationship between ends and means should be proportionate, that is, adequate or appropriate.

Such formulations inform decisions about all clinical decisions: For example, what is the net risk-to-benefit ratio for a patient being assessed for surgery? Will more benefit than harm accrue from the procedure? In routine clinical practice when we think about proportionality we remain focused on how burdens and benefits play out for an individual patient. We determine what is in the patient’s best interest while respecting the patient’s autonomy and the interests of families if the patient has lost decision-making capacity.

In the context of the current pandemic, the standard formulation of proportionality is limited. When narrowly cast as an assessment for individual patients, proportionality fails to account for the burdens imposed on others. Consider the quandary of a cardiac arrest in a patient positive for COVID-19 with acute respiratory distress syndrome who is on maximal ventilatory support, 2 pressors with refractory metabolic acidosis. The family has been approached for a do-not-resuscitate (DNR) order but wants everything done; they insist on chest compressions should the patient arrest. There is no provision for unilateral DNR orders in their jurisdiction. The health care team is frustrated and believes that chest compressions would be pointless and expose them to needless risk of contagion. They maintain that the patient is already maximally resuscitated. In their view, restoring and maintaining a viable cardiac rhythm would be impossible. Yet the family persists in demanding resuscitation, leading to what is euphemistically labeled a “futility dispute.”

Invoking a more expansive conception of proportionality can factor in the consequences of an attempted resuscitation for practitioners on the scene as well as the availability of resources for other patients whose care might be compromised by this action. Viewed as a balance of burdens and benefits in light of all the interests at stake, the extremely low likelihood of patient benefit from attempted resuscitation can be assessed against the risk of aerosolized contagion to staff that occurs during resuscitation. Judged this way, resuscitation is not only futile, but it is also dangerous. Risk would be compounded if there were limited availability of negative pressure rooms or the staff were ill-provisioned with adequate personal protective equipment (PPE), as has been reported during the pandemic surge.

Understood against this broader context, proportionality also casts the narrow clinical question of resuscitation into a public health frame. It asks us to consider how actions on behalf of an individual patient affect outcomes for other patients and the well-being and safety of staff during a period of scarcity. Not only would a futile resuscitation consume scarce resources like PPE, which might be deployed elsewhere in a more salubrious manner, but it also might expose the precious resource of health care workers to needless risk. This would unnecessarily compromise their welfare and ability to help other patients. With high infection rates of health care workers, some resulting in mortality, there is little justification for exposing practitioners to needless risks for essentially symbolic resuscitations.

Hermeren, in an essay explicating proportionality, suggests that proportionate actions seek to realize an important goal using relevant means that will help achieve the desired goal. The most favorable approach associated with the least risky alternative should be employed so that the means are “not excessive in relation to the intended goal.”

Although saving a life is an important goal, additional resuscitative efforts in the case vignette become disproportionate because they will not achieve that end. In the aggregate, resuscitation becomes disproportionate because of 3 interrelated factors: low benefit to the patient; risk to staff; and consumption of scarce resources that might benefit others. Given this analysis, resuscitation can be deemed excessive in relation to the desired goal.