Cruel but inevitable

As doctors we commit to decisions that mean life or death. I suppose, given the variety and severity of cases we—internists-in-training—see every day, this is inevitable. How must we wrestle with the daunting task of taking care of several critically ill patients and deal with the fact that we only have one or two vacancies in the Medical ICU? Who should we prioritize?

Dr. Flàvia R. Machado’s piece[1] illustrates this peculiar dilemma. It’s a worthwhile read.

We begin another day at 7:00 a.m., and once again we need to decide who will get an intensive care unit (ICU) bed after an elective surgical procedure. A 55-year-old grandmother with colon cancer? An elderly man with liver metastases? A young woman suffering from pain who needs an arthrodesis to keep working so she can continue to feed her family? Should we choose or deny patients because they have cancer? Should we choose on the basis of age? On patients’ previous quality of life? Or on social impact, if, for instance, one patient has four children to raise? Should we give the bed to a patient whom we’ve already had to refuse once? Or should we perhaps just stop playing God and give it to whoever asked first? 

Every day, all around the world, intensivists face such cruel choices. And deciding which patients will have elective surgery is not even our most hideous task; emergency admissions are far worse. Death is probably not imminent for a patient who is denied the chance to have a tumor removed, but some patients will die without immediate intensive care to sustain their lives. 

Poverty is shocking, but social inequality may be even worse. Social inequality is the hallmark of middle-income countries, which usually have two distinct health care systems, one public and one private. How can we advocate for equality in health care, treating all patients the same, if not everyone is starting from the same place?

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[1] N Engl J Med 2016; 375:2420-2421