As the death toll from Ebola nears 900 in West Africa, medical ethicists warn that US medical facilities and states have few plans in place to allocate limited supplies of life-saving medications and equipment such as ventilators if such a deadly outbreak were to occur here.
Public health officials say it is unlikely the disease would spread widely in the United States because infection control procedures and protective gear are more advanced than in Africa. But the unprecedented number of cases in Africa and the ease of travel have ethicists and emergency preparedness experts pondering what-if scenarios.
With no vaccine or drugs to fend off Ebola, they say, an outbreak could overwhelm hospitals as patients compete for supplies of ventilators to help them breathe or beds in intensive care units. If an experimental vaccine becomes available, its supply would be limited at first — as were supplies of vaccine during the outbreak of the H1N1 “swine” flu in 2009 — and determining who would be the first to get it in a national epidemic could cause widespread panic.
Only a few state health departments have established ethical guidelines for rationing medical care in certain situations. Massachusetts is not one of them, offering no guidance for how hospitals should distribute immunizations or treatments in short supply, according to the Department of Public Health.
“Imagine we have a pandemic in Boston with proven treatments that are in limited supply,” said Dr. Robert Truog, director of Harvard Medical School’s Center for Bioethics. “We have not adequately thought through how to make the allocation decision of who will get it and who will not.”
The Centers for Disease Control and Prevention has issued a warning for Americans to avoid nonessential travel to Guinea, Liberia, and Sierra Leone, which have Ebola cases.
CDC director Dr. Tom Frieden said on the CBS Sunday talk show “Face the Nation” that it’s possible someone could travel to the United States with Ebola and spread the virus to family members through personal contact, but he doesn’t think “it’s in the cards that we would have widespread Ebola in this country.”
Officials said Monday an ailing man, who had recently traveled to West Africa, was being treated at Mount Sinai Hospital in Manhattan and kept in isolation while tests for Ebola and other illnesses were performed. New York City’s Health Department, however, issued a statement saying that after consulting with Mount Sinai and the Centers for Disease Control and Prevention, it concluded the patient is unlikely to have Ebola.
Ebola spreads through direct contact with an infected person’s blood and other bodily fluids and is not as contagious as airborne viruses such as the flu and the common cold.
Threats of supply shortages were real during the 2009 H1N1 outbreak and after last year’s Marathon bombing.
At Boston Children’s Hospital, physicians worried on the day of the bombing that they might not have enough ICU beds or staff if 50 injured children showed up at once. While that didn’t happen, “it was a little bit of a wake-up call,” said Truog, who practices critical care medicine at Children’s, “that we need more planning and to build consensus” among public health officials, hospital doctors, patients, and their families.
Hospitals did deal with a shortage of amputation kits in the days after the bombing, said Atyia Martin, director of the Office of Public Health Preparedness at the Boston Public Health Commission. While the city has a “skeleton” plan to locate, purchase, and ship supplies from other locations, it has “limitations,” she said, and can’t be used to solve every shortage crisis.
Bioterrorism fears following the 2001 anthrax attacks led to hoarding of the antibiotic Cipro, which is used to treat it, causing shortages in some states. And amid an avian flu outbreak five years later, concerns about a possible flu pandemic prompted then-Governor Mitt Romney to ask Massachusetts legislators to appropriate $36.5 million to stockpile thousands of hospital beds, breathing machines, and doses of medication, but his request was turned down.
New York is one of only a handful of states that has a guideline recommending how hospitals should allocate ventilators should a deadly flu pandemic strike this country, similar to the one in 1918 that killed 675,000 Americans. “We use a scoring system that predicts the likelihood of survival,” said Dr. Hassan Khouli, chief of the critical care section and chair of the ethics committee at Mount Sinai Roosevelt in New York City. Khouli serves on the state’s task force that is updating the guideline to include children. “The ethical principle driving this is to save the most lives.”
The CDC and Institute of Medicine have recommended ways to allocate scarce vaccines and ventilators, but these are voluntary. The CDC recommended, for example, that vaccines and anti-viral medications should first be distributed during a flu epidemic to those who preserve the “functioning of society” — vaccine makers, police officers, and hospital workers — over those who are more likely to experience serious complications, such as pregnant women.
Without a federal mandate, however, local health officials are more likely to follow recommendations issued by their municipality or state, said Arthur Caplan, head of the division of bioethics at New York University Langone Medical Center in New York City, preferring to, perhaps, distribute immunizations made by a local plant to pregnant women in their community rather than shipping it to the military.
Many hospitals have ethics committees that could set policies for patient triage if an outbreak results in dire shortages. “We’ve thought a lot about this,” said Dr. Paul Biddinger, medical director for emergency preparedness for Massachusetts General Hospital. “We’re unlikely to end up in a circumstance where we don’t have enough resources, but it’s not impossible.”
The hospital doesn’t have a specific policy for allocating ventilators or medications and would likely turn to federal recommendations, he added.
In practice, however, such guidelines may be tough to implement. “You can have rules about taking sick people off of ventilators to give them to someone else,” Caplan said. “But I don’t know that every doctor in a crisis will be willing to follow them.”