Allocation of Scarce Medical Resources Amidst Corona Pandemic

Cases are coming to light where people in need of urgent medical help are being turned back by hospitals that are overstretched with the COVID-19 pandemic. There is no mal-intent in this, but life is dear to all of us, in particular, those with serious ailments.

A few days back, a patient living with HIV and suffering from mouth ulcers for some years, which over the passage of time developed into oral cancer had approached the Delhi High Court seeking a direction to the All India Institute of Medical Sciences (AIIMS, Delhi) to provide her necessary medical treatment amidst lockdown.

Before the lockdown set in, she had been visiting Centre for Dental Education and Research, AIIMS, Delhi seeking appropriate medical intervention. Here she was prescribed a biopsy which showed that her mouth ulcers were cancerous. During her consultations at AIIMS, Delhi she was informed that it was difficult to get a date for surgery before mid-July at AIIMS, Delhi, and therefore she could seek the surgical intervention at AIIMS, Jhajjar.

At AIIMS, Jhajjar, the patient was prescribed certain test including CT Scan, viral load testing and MRI depending on the results of which she was to undergo surgical intervention to manage the cancerous growth. She was given appointments for these tests at AIIMS, Jhajjar. However, before she could visit AIIMS, Jhajjar again to undergo the tests, in view of the lockdown due to COVID-19 and the fact that AIIMS, Jhajjar had been notified as an exclusive hospital for treatment of patients for COVID-19, the patient received a message as to cancellation of her appointment. Given that her condition was not improving and to ensure that the surgical intervention does not get delayed, she got her tests done from private labs.

Thereafter, her condition worsened, and suffering from copious bleeding from the tongue, she made repeated visits to the emergency ward of AIIMS, Delhi. However, she was only provided interventions that temporarily stopped the bleeding of the tongue and was sent back home without appropriate treatment. So much so, that the patient was suffering from bleeding of the tongue on almost on a daily basis and was visiting AIIMS, Delhi for management of the same daily. The claim of the petitioner was that she was not being provided surgical intervention or other medical intervention to manage cancer and she had started bleeding from her mouth resulting in aggravation of her condition.

After the filing of the petition in the Delhi High Court, the petitioner had been admitted at Institute Rotary Cancer Hospital (IRCH), AIIMS on April 4, 2020, and her treatment had started. On April 6, 2020, when the petition was called for hearing, Justice Mukta Gupta of the High Court asked the AIIMS, Delhi to file a status report indicating the course of treatment being administered or likely to be administered to the petitioner.

A status report filed by the AIIMS, Delhi indicated that given petitioner’s condition she could not be immediately operated upon and that she was being prepped to be administered chemoradiation instead. The mask required for this purpose (orifit) had been prepared. Further, the status report indicated that that petitioner would also undergo tooth extraction post, which she would be kept under observation for stability. The status report also noted that the petitioner will be discharged only after she is cleared for receiving Radiotherapy. Afterwards, she is to receive definitive chemoradiation on an out-patient basis.

This case raises some very important ethical issues.  Can a critically ill patient be denied treatment on the ground that the medical facility has its hands full of COVID-19 patients? The obvious answer should be no, one life is as precious as the others; one emergency is as powerful as the other. The High Court recognizing the right to equal access to health facilities ensured that she got the best possible medical health, it is a different matter that she could not get the surgery she was earlier prescribed. The court deferred to medical opinion when it comes to what kind of treatment is needed by the patient.

While not yet in India, in Europe a form of triage is already being practiced, who gets access to medical facilities when all are equally entitled. Is there a law or ethical guidelines on who gets priority, the obvious inference being the person who does get priority, is likely to die?

The world today is facing such a situation, an acute shortage of ventilators, which are needed, for their respiratory ailment and yet there are too many patients and too few ventilators, some will be denied the ventilators, but who will that be?

Guidelines indicate that the young and those who have a better chance of surviving get preference over the elderly, sad but so it is. There are also stories of the elderly who have given up access to their medical facilities voluntarily in favour of the young and those more likely to survive.

As Abhinav Tiwari notes in his article, India has no explicit guidelines on this issue but hopefully, we won’t need them in the near future given that the number who need hospitalization as of now is low. Having followed a policy of national lockdown, hopefully, we will not get to that position. After all, we are making sacrifices during the lockdown so that our fellow human beings do not get infected, knowingly or unknowingly.

Justice Mukta Gupta’s intervention, for now, is a small step in messaging to the medical community that each life matters.

But we cannot forget that for every petitioner who can approach the High Court, there are hundreds who cannot for many reasons. The situation calls for national guidelines by the Medical Council of India and the Government of India under the MDMA and the EDA to the effect that anyone who needs life-saving treatment for ailments other than COVID 19 cannot be denied treatment on the ground only that the hospital is busy with COVID-19.

Anticipating a shortage of equipment, triage guidelines are also necessary.