New publications from Dr. Fleck

leonard fleck photoThe work of Center Professor Dr. Leonard Fleck appears in the new book Prioritization in Medicine: An International Dialogue, published by Springer. Dr. Fleck’s chapter is titled “Just Caring: Fair Innings and Priority Setting.”

Dr. Fleck also has an article in the current APA Newsletter on Philosophy and Medicine (Volume 15 Number 2) titled “Just Rationing in the ICU: What Benefits Count?” The current issue can be accessed on the American Philosophical Association website, or you can go directly to the PDF.

Is it ever morally justifiable to remove a patient from the ICU?

fleck-crop-facEarlier this month, Center Professor Dr. Len Fleck attended the American Philosophical Association’s Eastern Division meeting in Washington D.C. Dr. Fleck organized and chaired a session for the Philosophy and Medicine Committee, titled “Removing Patients from the ICU: Is It Ever Morally Justifiable?”

The very real problem that precipitated this session is that on any given day in the United States most ICUs are at 100% capacity. There are no empty beds, and there are patients coming in from surgery or serious accidents who have a real need for that ICU bed, who can clearly benefit from that bed, while a patient already in the ICU may be near death but may “need” that bed for two extra days of life. Dr. Fleck and team’s key ethical question was this: Does that patient already in the ICU have a compelling moral right to remain there just by virtue of the fact that they were there first?

Of the session’s four panelists, Marion Danis, MD, from National Institutes of Health took the position that ICUs have a specific medical and moral purpose, and when a patient can no longer benefit from that level of care, they no longer have a right to occupy that bed. That is, step-down care is more appropriate, medically and morally. Tim Murphy, PhD, of University of Illinois-Chicago critically assessed different possible moral bases for admission to an ICU. He asked: Is admission to an ICU a gift, a promise, a covenant, a contract or a duty? Each of these conceptions would have different implications with respect to removal from an ICU. Rosamond Rhodes, PhD, of Mt. Sinai Medical Center (New York) argued that admission to or discharge from an ICU should be governed by the moral norm of “avoiding the worst outcome,” ethically speaking. She added that following that rule might not be possible in the real world, given legal and regulatory outcomes. Finally, Luke Gelinas, PhD, Harvard University Fellow, argued that clinical uncertainty with regard to prognosis ought to be given serious weight, especially with respect to the decision to remove someone from the ICU in favor of someone judged likely to have a better prognosis “waiting at the door of the ICU.”

Dr. Fleck asks: What do you think are the appropriate ethical considerations that should govern such decisions, given that you might be a future possible patient in the ICU or “at the door” of a full ICU?