In the heart of New York City, hospitals are facing unprecedented challenges, compelling them to develop critical resource-allocation guidelines. As a Doctor From New York deeply involved in this process, I’ve gained a firsthand understanding of the agonizing decisions that must be made when healthcare resources are stretched to their limits. Initially, the prospect of implementing these guidelines was daunting, but now, actively participating in these difficult choices, my anxieties have shifted.
The outpouring of support has been a source of profound hope. Having previously traveled to offer humanitarian aid in other regions, it is now deeply moving to witness the world turning its attention and resources towards our city. Makeshift hospitals are rapidly being established throughout New York, poised to alleviate some of the immense pressure on existing facilities. There was initial optimism, perhaps naively, that facilities like the Javits Center and the Navy hospital ship Comfort would cater to non-Covid cases. Amongst colleagues, the sentiment was wry – “everyone has the virus.” It became clear quickly that the reality of the situation would necessitate a change in approach, and indeed, policies were adjusted to accommodate the influx of Covid patients.
The arrival of healthcare professionals and essential medical equipment from across the nation is a significant boost. For those patients with a genuine chance of survival, I am increasingly confident in our capacity to provide comprehensive care. Undoubtedly, profoundly difficult choices remain. No doctor ever wants to withhold necessary treatment, but I believe that the decisions being made are grounded in rational medical judgment, reflecting a consensus among experienced physicians. We are not driven by hubris, as was unjustly alleged against those who developed earlier guidelines, but by the extensive experience that allows us to discern which patients have a realistic path to recovery and which are likely to experience prolonged and ultimately futile suffering. Even in the face of past criticisms leveled against similar approaches, the necessity and ethical grounding of these difficult decisions are becoming increasingly clear, even to previous detractors.
However, the psychological toll on healthcare providers is a serious concern, particularly for those with experience in treating combat veterans. The ethical strain of allocating scarce resources and, at times, withholding treatment can lead to significant moral injury. It is important to emphasize that when treatment must be rationed, or withheld, these decisions are almost invariably made with careful consideration and with the hope of involving families in these painful conversations. I have already had several heart-wrenching discussions with family members, carefully explaining the likely course of their loved one’s illness, the invasive nature of potential medical interventions, and the unfortunately low probability of survival. In these moments, it is crucial to offer reassurance that their feelings of guilt are unwarranted, emphasizing that I would advocate for the same course of action were it my own family member. While absolute certainty is impossible, the aim is to avoid prolonging suffering when recovery is unlikely. There is a small measure of solace in knowing that decisions are made with the intention of minimizing unnecessary pain and distress.
Reflecting on an earlier case, an elderly man intubated at the outset of this crisis, a moment before the full weight of the pandemic had descended, I find myself questioning past actions. Knowing what I know now, with the benefit of hindsight, I would have made a different choice. That ventilator could have been preserved for someone with a greater chance of recovery. I would have felt compelled to override the family’s wishes, trusting that in time, they might come to understand the agonizing context of such decisions. It is becoming increasingly evident that in many situations where aggressive medical interventions are not pursued, the reality is that these patients were unlikely to survive regardless of the measures taken.
Paradoxically, it is not these situations of withholding care, but rather witnessing death despite providing maximal treatment, that I anticipate will inflict the deepest moral wounds. It is the patients who arrive capable of conversation, with personal histories and lives still vividly present, who receive the full force of modern medicine – ventilators, critical care drugs, every available intervention – and yet succumb, alone, despite our most dedicated efforts. Witnessing this repeatedly, the sheer volume of loss, threatens to become emotionally numbing. The most profound concern is the potential erosion of our capacity to see each patient as an individual. The fear is that they will begin to merge into a collective of “breathless bodies,” indistinguishable from one another, their unique stories fading into the overwhelming sameness of their symptoms and histories. The thought that I might become the last person they see, a stranger in their final moments, and then struggle to recall them as individuals amidst the sheer volume of cases, is deeply troubling. The risk is that this extraordinary situation becomes routine, that profound human experiences become reduced to a blur of medical procedures and tragic outcomes.
