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José Luis Pinto Prades, Full Professor of Economics de la Salud
The Coronavirus pandemic has generated situations that were unthinkable until now. One of many has been the need to ration resources that patients needed in extreme situations such as ICU beds or ventilators.
Different scientific associations and national and international publications have generated proposals to solve this problem. In Spain, for example, the Spanish Society of Intensive Care Medicine, Critical Care and Coronary Units (SEMICYUC) presented a document with some recommendations for the use of these resources in case of shortage.
Among the suggestions, SEMICYUC advised that "when faced with two similar patients, priority should be given to the person with more quality-adjusted years of life". That is, between two people, with the same probability of being cured, who require intensive care or a ventilator, priority should be given to the one who was in better health before being infected by coronavirus. Thus, if one of them has a disability or chronic disease, he/she would be in second place. With this criterion, the system maximizes quality-adjusted life years.
However, the dictates of the Spanish agency do not coincide with those of other guidelines, which do not include quality of future life among their recommendations. Moreover, this criterion is explicitly excluded from the parameters established by prestigious academic journals such as, for example, the New England Journal of Medicine. This publication makes its rejection clear, stating: "we advise against the incorporation of future quality of life and quality-adjusted life years when establishing the maximization of benefit". The journal also reminds us that taking into account future quality of life to prioritize among patients would entail ethical and legal problems.
Certainly, most medical protocols mention the benefit patients will receive from treatment in deciding who gets priority. Now, there is a big difference between, for example, the protocol developed by the New York State Health department in 2015 on the use of ventilators in the event of a pandemic and the SEMICYUC's protocol . In the case of New York, patients are prioritized according to the probability of survival in the short term deadline, that is, according to the probability that they will leave the hospital alive; without mentioning what will happen afterwards; that is, whether they will live more or fewer years, or their quality of life.
In other cases, the guidelines include life expectancy in one form or another. For example, if patients have a life expectancy of less than one year, they have a lower priority. In other words, there is a minimal advantage, but from that point on, we are all equal.
In conclusion, although most guidelines take into account the benefit for the patient, I have not found any that consider the quality of life that the patient will have on leaving the hospital, as SEMICYUC does. Therefore, it is worth asking whether the quality-adjusted life years proposed by this state organization is a lawful criterion for prioritizing patients, since it discriminates, among others, against people with chronic problems and disabilities. To what extent can Spanish physicians decide whether the quality of life of their patients after COVID will be sufficient to give priority to some over others?