Il Sistema Sanitario Nazionale e la pandemia da SARS-CoV-2: un disastro annunciato? Riflessioni per un cambiamento

Almost two years after the first official report from World Health Organization (WHO), the SARS-CoV-2 pandemic (covid-19) outreached 200 mln of cases around the world with an overall mortality equal to 2% (more than 4.5 mln of cases). In many countries, when the surge in cases of severe covid-19 respiratory failure has exceeded the availability of intensive healthcare resources (intensive care beds, respirators, human resources) clinicians were forced to triage intensive care unit (ICU) admissions. In order to support these difficult decisions, many scientific societies and national regulatory bodies developed guidelines to prioritize patients entitled to receive mechanical ventilation and other life support treatments. From an ethical point of view two main theoretical approaches – the egalitarian and the utilitarian one – have been suggested to identify the criteria to be adopted for triaging the ICU patients. In regard, there is a limited consensus until now and in many cases these different theoretical approaches gave rise to a clash of opinions contributing to additional difficulties for doctors. In Italy, the National Committee for Bioethics is the only public institution that, through an official document, has expressly taken a position on the issue of triage and rationing of resources, admitting its lawfulness in particular conditions as long as it is based on common clinical criteria of clinical appropriateness and ethical proportionality, underlining however the fundamental role of “preparedness”. As the covid-19 crisis seems slowing down, the need to debate the triage criteria and the allocation of the scarce ICU resources it seems less pressing. Instead, it seems more useful to dwell on two aspects with respect to the choice of regulatory criteria for allocating resources: 1) the necessary interconnection between macro- and micro-allocation choices which ends up conditioning the decision-making processes relating to individual patients; 2) the opportunity for decision-makers and healthcare professionals to maintain a right level of “honesty” towards citizens and patients regarding the causes of the lack of resources and the decision-making processes that involve the need to make “tragic choices” at both levels.