The Atlantic, March 12 2020 The Extraordinary Decisions Facing Italian Doctors There are now simply too many patients for each one of them to receive adequate care. ByYascha Mounk Two weeks ago, Italy had 322 confirmed cases of the coronavirus. At that point, doctors in the countrys hospitals could lavish significant attention on each stricken patient. One week ago, Italy had 2,502 cases of the virus, which causes the disease known as COVID-19. At that point, doctors in the countrys hospitals could still perform the most lifesaving functions by artificially ventilating patients who experienced acute breathing difficulties. Today, Italy has 10,149 cases of the coronavirus. There are now simply too many patients for each one of them to receive adequate care. Doctors and nurses areunable to tend to everybody. They lack machines to ventilate all those gasping for air. Now the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) haspublished guidelinesfor the criteria that doctors and nurses should follow as these already extraordinary circumstances worsen. The document begins by likening the moral choices Italian doctors may face to the forms of wartime triage that are required in the field of catastrophe medicine. Instead of providing intensive care to all patients who need it, the authors suggest, it may become necessary to follow the most widely shared criteria regarding distributive justice and the appropriate allocation of limited health resources. The principle they settle upon is utilitarian. Informed by the principle of maximizing benefits for the largest number, they suggest that the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care. The authors, who are medical doctors, then deduce a set of concrete recommendations for how to manage these impossible choices, including this: It may become necessary to establish an age limit for access to intensive care. Those who are too old to have a high likelihood of recovery, or who have too low a number of life-years left even if they should survive, would be left to die. This sounds cruel, but the alternative, the document argues, is no better. In case of a total saturation of resources, maintaining the criterion of first come, first served would amount to a decision to exclude late-arriving patients from access to intensive care. In addition to age, doctors and nurses are also advised to take a patients overall state of health into account: The presence of comorbidities needs to be carefully evaluated. This is in part because early studies of the virus seem to suggest that patients with serious pre-existing health conditions are significantly more likely to die. But it is also because patients in a worse state of overall health could require a greater share of scarce resources to survive: What might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients. These guidelines apply even to patients who require intensive care for reasons other than the coronavirus, because they too make demands on the same scarce medical resources. As the document clarifies, These criteria apply to all patients in intensive care, not just those infected with CoVid-19. My academic trainingis in political and moral philosophy. I have spent countless hours in fancy seminar rooms discussing abstract moral dilemmas like the so-called trolley problem. If a train is barreling toward five innocent people who are tied to the tracks, and I could divert it by pulling the lever, but at the cost of killing an innocent bystander, should I do it? Part of the point of all those discussions was, supposedly, to help professionals make difficult moral choices in real-world circumstances. If you are an overworked nurse battling a novel disease under the most desperate circumstances, and you simply cannot treat everyone, however hard you try, whose life should you save? Despite those years of theory, I must admit that I have no moral judgment to make about the extraordinary document published by those brave Italian doctors. I have not the first clue whether they are recommending the right or the wrong thing. But if Italy is in an impossible position, the obligation facing the United States is very clear: To arrest the crisis before the impossible becomes necessary. This means that our political leaders, the heads of business and private associations, and every one of us need to work together to accomplish two things: Radically expand the capacity of the countrys intensive-care units. And start engaging in extreme forms of social distancing.

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