“Place age limit for access to intensive care, [that is]

based on greatest possibilities of survival.”

Early last month, the Italian Society of Anaesthesia was forced to publish the above guideline (1) for the country’s hospitals. Besides the rising cases of infection, the doctors realised that patients required up to 15-20 days of intensive care as the disease progressed (2). In the face of medical resource scarcities, the guideline established that everyone could not be saved from the coronavirus. And a massive death toll ensued. Yet, the challenge of taking on the coronavirus appears to be greater for the developing world. In comparison to the developed countries, resource scarcities in the developing countries are far more glaring. Due to a weaker state apparatus, the family’s dependence on its providers is greater. Overall, the stakes are high. In this context of an absent social, economic and psychological safety net, this letter argues that rationing decisions should include other non-medical concerns and be made explicit in situations where all else is equal in terms of the ability to benefit from the treatment.

Rationing in healthcare

Broadly speaking, rationing in medicine refers to the denial of treatment to someone who can benefit from it (3). When the demand for healthcare exceeds its supply, rationing decisions are unavoidable. Traditionally, rationing has been implemented based on the ability to benefit from treatment. However, the present surge in demand for healthcare will mean a greater denial of treatment to potential patients. The following challenges highlight why both medical and non-medical reasons could play an important role in healthcare rationing.

Although the Indian government has moved fast to curb its spread, there are, as on April 17, 13000+ cases of the coronavirus in the country. It is also likely that community transmission of the virus already exists in certain areas. Due to India’s high population density and the prevalent community-based lifestyle, it is feared that social distancing measures are unlikely to be as effective. In the absence of large scale testing, it is possible that the true number of cases will remain unknown, and even multiply.

From a healthcare delivery perspective, there is a critical shortage of resources. Roughly, there is one bed for every 1000 people in the country. The highest positive estimate is that there are about 57,000 ventilators in the entire country in total (4). On top of that, social and economic challenges underlie healthcare utilisation and access. As in other developing countries, the medical system favours those who are rich and well connected. In addition, social stigma with regard to infectious diseases prevents the sick from seeking care.

Besides its health system related issues, India lacks the resources for the provision of social security mechanisms. Families excessively rely on income earners for financial support. If the sole breadwinner fails to receive treatment, the entire household could collapse.

Rationing decisions

Given these challenges, rationing decisions in the country need to be well thought out. Especially because a number of hospitalised patients are young, and even children. To those affected, immense emotional and financial losses are caused because of these decisions. Besides medical reasons, age-based and financial factors could help decide whose lives matters most in the face of these rationing decisions. This is especially important in the absence of a social, economic and psychological safety net. In this context, the following rationing scenarios are presented below:

• A fair innings: Williams (5) developed the “fair innings approach” in which he argues for placing a higher value to the lives of the young. Using a sports analogy, he argued that those who have already lived a long life (had a fair innings) need to be given less value than someone who has not yet lived his life. Other than the potential to benefit from the treatment, age-related weightage guides the triage of patients so that young patients can have a fair innings.

• Providers of the family: World Bank policies argue for a higher weightage for the lives of those who are in the 30-40 age range as they work and sustain their families (6). They provide for both the young as well as the old. In this way, the entire family is dependent on them. Loss of their lives would put their entire families in financial distress.

• The less well off: Since the poor and less well-off are in poor health, and as it is possible that they are more likely to be infected, leading to potential death from the virus, it makes sense to prioritise their treatment. In the Indian context, the less well-off also live in conditions where it is possible for them to spread the virus to others in the area who are also in poor health. Treating them could mean potentially saving the lives of others who would come in contact with them. From both a utilitarian and social justice perspective, it is essential to treat the less well-off to stop the virus.

In conclusion, it is possible that some hard rationing decisions would be made to treat coronavirus patients in the coming times. From an ethical perspective, one needs to look at these considerations to make sound rationing decisions. Whatever those decisions may be, decision makers would need to explain the trade-offs in an explicit and rational way in order to prevent worsening the impact of the virus. In doing so, a wider public debate needs to be carried out to help guide such important decisions.