Photo/Illutration A patient on a ventilator (Asahi Shimbun file photo)

Doctors and medical workers are distressed over a nightmare scenario that will soon become a reality if the novel coronavirus keeps spreading and the number of COVID-19 patients increases even further.

As resources come under strain, they may face situations where they must make the ultimate choice: Who should be on a life-support machine, namely a ventilator, and who should not?

The Japanese Society of Intensive Care Medicine and other groups issued recommendations on proceeding appropriately in those situations in November, advising doctors and staff to make a “team decision.”

However, the recommendations did not include concrete criteria for making judgments in those cases, leaving the tough decision making to those on the front lines.

Each health care facility has a limited number of ventilators and other life-support machines, and limited staff who can operate them.

In the worst-case scenario where medical resources run out, the groups’ recommendations said health care professionals are supposed to withhold or stop using life-support machines for certain patients and then redistribute them preferentially to patients with better potential health outcomes.

But those decisions must be made only after the medical and care teams discuss the matter, the recommendations said.

Each team has to discuss whether the decision is medically appropriate and valid and also consider fairness.

The decision also must be based on the patient’s will. If a patient lacks the capacity for judgment, the health care team will have to obtain consent from the patient’s family.

Tadashi Sawamura, who heads the intensive care unit at Saiseikai Kumamoto Hospital and drafted the recommendations, said the groups wanted to convey a message that “an individual decision can sometimes be self-righteous and dangerous.”

Satoshi Kodama, an associate professor of ethics at Kyoto University, said, “It is better to draw up certain standards, but leaving it solely in the hands of an academic society is difficult."

In their recommendations, the groups cited guidelines set up by the health ministry regarding the decision-making process for end-of-life medical care.

The most important general principle outlined in the guidelines is that medical and care workers need to have a thorough discussion with terminal cancer patients and those dying from old age and other factors, and then move forward with the plan based on the patient’s desire and decision.

“It is difficult to numerically explain the medical urgency and necessity,” said Norio Higuchi, a specially appointed professor at Musashino University, who heads the committee that drafted the ministry’s guidelines.

Higuchi added that he understands why the groups’ recommendations avoided setting out concrete criteria for making judgment calls. But he remains unconvinced whether such a decision can always be made based on a patient’s will and their family’s consent, as the recommendations suggest.

“In an emergency situation, where medical staff do not have enough leeway, they can’t grant a patient’s wish that asks for treatment no matter what their condition is,” Higuchi said.

“In medical ethics principles, it is required to prioritize people who need more urgent care and are more likely to be saved,” Higuchi added.

Sawamura said it is difficult to envision “when shortages of medical resources will become a real possibility” in the COVID-19 pandemic, because it depends on how effectively hospitals and regions use those resources.

“I hope we can stop infections from spreading further, then we can look back and say it was all worry about nothing,” he said.

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