The weight of resource allocation in a New York hospital during the pandemic felt immense. Initially, the guidelines were still being formulated, and the anxiety of deciding who would receive escalated care was palpable among the medical staff. Like many hospitals in the city, ours was rapidly developing its own protocols, entrusting in-house teams to make these agonizing choices. Being involved in these decisions firsthand shifted my perspective. The worry about abstract criteria faded as the reality of immediate needs took over. Hope emerged with the promise of external aid. Having previously been the one to travel and offer humanitarian assistance, it was a profound shift to witness aid flowing into our city. Makeshift hospitals were being erected across New York, a welcome expansion to our strained capacity. The announcement that the Javits Center and the Navy hospital ship Comfort would initially only accept non-Covid patients was met with disbelief among my colleagues. We knew then, as reality quickly confirmed, that the virus was ubiquitous. It wasn’t long before policies shifted, and these facilities began to admit Covid patients, acknowledging the pandemic’s pervasive reach.
The influx of healthcare workers and equipment from across the country brought a renewed sense of optimism. For those patients with a genuine chance of survival, we felt empowered to provide comprehensive care. Yet, the inherent difficulty of withholding care remained a constant. These were never easy decisions, but there was a consensus among doctors that the choices being made were rational and ethically sound. We weren’t acting as arbiters of fate, as critics had accused those who developed early triage guidelines, but rather drawing upon our collective experience to discern which patients had a realistic path to recovery and which were likely to endure prolonged suffering without meaningful benefit. Even in Italy, as I heard from Dr. Vergano, initial criticisms of similar approaches had subsided as the harsh realities of the pandemic became undeniable.
Despite the reasoned approach to resource allocation, concerns about the potential for moral injury among healthcare professionals, particularly those with experience treating combat veterans, were valid. When treatment is rationed, the decisions are almost always grounded in medical necessity and are made with careful consideration, often involving family in these difficult conversations. I recall several phone calls with family members, guiding them through the grim realities of their loved ones’ conditions, the aggressive interventions required, and the low probability of success. Assuring them that choosing not to pursue maximal intervention was an act of compassion, not abandonment, was crucial. I conveyed that I would advocate the same course for my own family. While absolute certainty is elusive, there was a strong conviction that further aggressive measures would not have altered the outcome, and in fact, would have prolonged suffering. There is a measure of peace in that understanding.
Reflecting on the early days of the pandemic, I recall intubating an elderly man. With the benefit of hindsight, knowing what we now know about the virus’s trajectory and the strain on resources, I would make a different choice. I would preserve that ventilator for someone with a higher likelihood of recovery. I would prioritize the greater good, even if it meant overriding immediate family wishes, trusting that understanding would follow. It has become increasingly clear that in many situations where aggressive interventions are not pursued, the outcome would have been unchanged.
However, a different kind of moral injury emerges – the kind that stems from witnessing death even after deploying every advanced medical intervention available. These are patients who arrive still communicative, with lives and stories to share. They receive the full spectrum of modern critical care – ventilators, life-sustaining medications, and the unwavering dedication of the medical team. We invest our expertise and compassion into their fight for life. And yet, we watch their bodies fail. They are often alone, separated from family by necessity. The repeated exposure to this cycle of intensive care followed by death becomes emotionally numbing. The true moral injury, I fear, is the erosion of individual memory. Patients begin to blur together, losing the distinct details that separate one person from the next. They become a collective of breathless bodies, united by similar symptoms and histories. The profound realization that I am often the last person they see, not their loved ones, and that their individual identities will fade into a sea of faces, replaced by the next wave of patients – that is a heavy burden. The fear is that this profound human experience will devolve into routine.
