Ventilators: Even Equal Access Leaves Vital Questions

As the bodies in New York City, the world's media and financial capital, accumulate it is understandable that physicians, nurses, and medical technicians would strive to do all in their power to close the wound. Nonetheless these very pressures can lead healers to take dangerous risks and--worse yet--deceive even themselves. Hippocrates had good reason to issue his famous command: primum non nocere--first do no harm.

There are trends in modern medical practice and in the culture at large that should lead patients and policy makers to ask some penetrating questions. In many clinical settings today the patient is regarded as an ensemble of numerical indicators culminating in a specific diagnosis. How this diagnosis fits with or is expressed in the context of family and friends is seldom explored. This is especially the case in a health care system that directs the bulk of compensation to interventionist procedures and technologies and consequently trains too few primary care physicians. In a recent New England Journal of Medicine perspective piece, Louise Aronson, MD cites the case of an elderly woman with multiple comorbidities who nonetheless was still enjoying a rewarding social and family life. At the recommendation of a specialist surgeon she had what was touted as an elective outpatient surgery only to end up with the need for multiple costly follow-ups and the loss of her quality of life.

Right now in much of the world there is an intense quest both to increase the overall supply of ventilators and to assure fair distribution of them. I agree with David Lay, who recently wrote about his experience fighting Covid-19 for the Washington Post, that "it is an outrage and an embarrassment that a nation as wealthy as ours is even discussing possible ventilator shortages... We need to make sure that every patient who needs a ventilator can get one so that as many of them as possible can survive."

But the very urgency and justified anger in this quest may distract us from some uncomfortable questions. How affective are ventilators? Can they be a cause of needless suffering? Are these risks being adequately traced and conveyed to the patients when they can still make informed choices. In an article for The Spectator, Dr. Matt Strauss posed these questions to Dr. Paul Mayo, perhaps New York City's most illustrious critical care doctor.

[Mayo] expressed the risks pithily: "putting a person on a ventilator creates a disease known as being on a ventilator."

When we mechanically blow air into your damaged lungs faster and harder than humanly possible, ventilator-induced lung injury may result. Generally, for a person to tolerate the undertaking, we have to sedate them, leading to immobility and severe weakness.

What Mayo describes some may call a side effect. I would say it is an intrinsic feature not merely a bug. In his recent op-ed in the Post, Lat personalizes Mayo's critique, writing:

For those of us lucky enough to get off ventilators, our lives are not the same. Many patients who come off ventilators suffer lasting physical, mental and emotional issues, including cognitive deficits, lost jobs and psychological issues, such as depression and post-traumatic stress disorder.

For me, my lungs must rebuild their capacity. I experience breathlessness from even mild exertion. I used to run marathons; now I can't walk across a room or up a flight of stairs without getting winded. I can't go around the block for fresh air unless my husband pushes me in a wheelchair. When I shower, I can't stand the entire time; I take breaks from standing to sit down on a plastic stool I have placed inside my bathtub...

These concerns should lead us to redouble all patients' access to those prophylactic steps that would allow us all to avoid the necessity of making such harrowing choices. As James Adams and James Barker, two retired primary care physicians correctly put it in a Common Dreamsop-ed last month, the lack of access to health care "is an incubator for the preexisting conditions and comorbidities that are making this disease more fatal than it should be... Our lack of paid family and medical leave forced many people who were exhibiting symptoms to stay at work, thereby spreading this coronavirus quicker."

Unfortunately once a pandemic initially surfaces, politics and partisansan considerations rather than science often govern the response. Failure to adopt basic containment and social distancing measures--long recognized by epidemiologists as effective--turns a problem into a catastrophe.

Political economy often plays an important role in undermining our capacity to respond to crisis. In this deregulatory, profit-maximizing era hospitals have no incentive to stockpile extra ventilators. At the same time, manufacturers have no incentives to catalogue or report any harms associated with the deployment of this technology..

None of this is to argue against use of ventilators. But full and easy access to and even participation in the development of a technology does not guarantee its safety. Patients and their advocates should demand a full accounting of their success ratios and associated pains, including information about the rehab process as well. Exaggeration of the benefits of this or any technology eventually redounds to the detriment of its public health advocates.

In her perspective piece in the NEJM, Aronson persuasively advocates a further step: "As a geriatrician and an octogenarian's daughter, I know many happy, engaged elders in their 70s, 80s, 90s, and 100s--including Sally--who would not want to be put on a respirator if they become critically ill" Lay and Adams and Barker in fact come to different personal choices, with the latter pair declining hospitalization at all while Lay provocatively comments: "I'm not complaining. I am incredibly grateful to be alive. And for that, I have the ventilator to thank."

Aronson adds: "Patients and our health system would be better served if all adults and elders use some of the spare time created by our new, home-confined lives to discuss and document their care preferences, whether their goal is aggressive, supportive, or palliative care. The absence of such planning increases suffering at the end of life, and its presence helps people with serious or life-limiting illness to live and die according to their personal priorities."

I would add that such a conversation might well include open discussion of religious and secular perspectives on death itself and ways to acknowledge and mitigate our fears. For me, part of this conversation would include a more measured appraisal of the technological optimism that has long gripped our culture and perhaps serves as compensation for those fears. As Yves Smith, editor of Naked Capitalismputs it: "lots of normally capable policy wonks seem not able to come to grips with the fact that the coronavirus has the upper hand."

The history of medicine has its dark side. Just as "Atoms for Peace" in the 1950s promised us electricity too cheap to meter but gave us ubiquitous nuclear pollution, medicine in the same era saw such disasters as the use of ionizing radiation from x-rays to treat teenage acne and even to fit shoes. Covid-19 is dangerous enough. In our fear or our hubris let us not add to the tragedy.