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Abstract

e104 www.ccmjournal.org January 2021 • Volume 49 • Number 1 DOI: 10.1097/CCM.0000000000004720 Copyright © 2020 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Life years saved is unrelated to survivability in a patient afflicted with coronavirus disease 2019 (COVID-19). It may be objective, but it adds arbitrary factors to the admission decision. Consider the Gideon parable (Judges 7:5). This also was an objective but an arbitrary method to reduce the group size to a desired number. The exclusion criteria from joining Gideon’s army, which was their style of drinking water, have nothing to do with successful soldiering, but those excluded at least very likely gained a longer life expectancy. The selection process was arbitrary and no obvious harm was done to those excluded. The rationing device by Sprung et al (1) is also arbitrary with respect to predicting COVID-19 treatment survival, but unlike in Gideon, it will generate a shorter life expectancy for those not selected. Eight months of caring for COVID-19 patients has taught us that we still cannot accurately determine who will live and who will die, even in the absence of a resource shortage. In a recent article by Garcia et al (2), ICU survivors and nonsurvivors had the same Sequential Organ Failure Assessment score. In addition, in this series, 67% of patients received off-label treatments likely reflecting the international uncertainty around effective treatment and prognosis. The group excluded in the model by Sprung et al (1) is not excluded for medical reasons related to the chance to survive COVID-19 treatment. Hidden within the life years saved concept is a set of subjective choices and biases on the part of the authors as to what constitutes a better life. This is medically unethical, because it is unrelated to the beneficence of the treatment. This also makes it legally untenable: a reasonable ICU doctor is required not to exclude a patient for medically arbitrary reasons such as projected life years. All scoring systems reflect only the aggregate and never the individual. Scoring systems are not made for the individual when the use becomes the withholding of treatment from the one to give it to another. In the average ICU week, I will on average have two patients die. One death I can predict, the other is a surprise. Such a large probability of being wrong on matters of life and death is not a place of strength to argue for arbitrarily restricting what might be as much as a 50% chance of life-saving ICU admission for COVID-19.