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US ventilator crisis brings patients and doctors face-to-face with life-or-death choices

BMJ 2020; 369 doi: (Published 05 May 2020) Cite this as: BMJ 2020;369:m1800

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Re: US ventilator crisis brings patients and doctors face-to-face with life-or-death choices

Dear Editor

Ethical challenges in the allocation of scarce resources during COVID-19 pandemic: Islamic View

The ethical implications of scarce resources allocation are very drastic in the current COVID-19 pandemic. The demand for critical care in several areas of the world like the northern region of Italy and New York were exceeding its supply. Intensive care doctors were facing overwhelming decisions about who should be provided with a ventilator, knowing the fact that those who are not admitted to the intensive care units will very likely die. Physicians have to consider the prioritization of patients who are most likely to survive over those with remote chances. This practice has triggered an immense debate about the right of everybody to access the healthcare. Many people found themselves personally affected by these implications and all of a sudden realized that the principle of “equals should be treated equally” may no longer be applicable. [1] Utilitarian principles should be the basis for such decision. The difficulty, however, arises when it is impossible to triage patients based solely on utilitarian considerations. [2]

On 20 March 2020, in response to the COVID-19 pandemic, the National Institute for Health and Care Excellence in the UK published the Guideline with clinical decision-making. The basis of the Guideline is to maximize patient safety and appropriate use of resources. Admission to an intensive care unit is based on some assessment of frailty, comorbidities and likeliness to recover from the intensive treatment. [2.3]
The Washington University in St Louis, the University of Pittsburgh, and the State of New York have all developed models for assigning scores to patients based on age and comorbidities which direct the allocation of these scarce resources to individual patients. [4]

The Islamic view

During the COVD-19 pandemic, three Fatwas (decrees) were issued by major Islamic Fiqh authorities. The European Council for Fatwa and Research (ECFR) issued a fatwa in Arabic on managing scarce resources during this pandemic. It states: “ Muslim physicians have a commitment to the medical systems and regulations in the hospitals they work in. If the matter is assigned to the physicians, they must utilize medical, ethical and humanitarian standards. Withdrawal of life-saving equipment in order to treat a patient arriving later is not permitted. If the physician has no choice but to choose between two patients, then the former is offered the ventillator, unless he is deemed futile; the one in need of urgent medical treatment over the one whose condition allows delay, and the patient whose successful treatment is more likely.” [5]

The second fatwa was issued by the Assembly of Muslim Jurists of America which stated that what is to be considered in prioritizing patients over others is the degree of need; so the one in greater need should be prioritized. If they have the same need the one with a greater likelihood of recovery, based on evidence-based clinical tools, should be given precedence. If such likelihood is equal, then those with the longer life expectancy should be given precedence. This is all consistent with the principle of “procuring the greater good by forsaking the lesser.” When applicable, service should be provided on a first come, first served basis. If all previous considerations do not give precedence to some over the others, resorting to lottery is a principle that is endorsed by the Islam. [6]

The International Islamic Fiqh Academy held a symposium on 16th April 2020 discussing the ethical and religious implications of COVID-19 and issued its recommendations stating that “Doctors must adhere to medical and ethical standards. In the case of too many patients and lack of adequate devices, it is left to the discretion of the physician who prioritizes the one who deserves prioritization, and when they are equal, he resorts to lottery between patients”. [7]

Hassan Chamsi-Pasha, FRCP, FACC. Cardiac department, King Fahd Armed Forces Hospital, Jeddah, Saudi-Arabia. (

Majed Chamsi-Pasha, MBBS, SBIM, Jeddah, Saudi-Arabia.

Mohammed Ali Albar, MD, FRCP. Medical Ethics department, International Medical Center, Jeddah, Saudi-Arabia.

1. Mannelli C. Whose Life to Save? Scarce Resources Allocation in the COVID-19 Outbreak. J Med Ethics. Epub ahead of print: doi:10.1136/medethics-2020-106227
2. Solnica A, Barski L, Jotkowitz A.Allocation of Scarce Resources During the COVID-19 Pandemic: A Jewish Ethical Perspective. J Med Ethics .2020 Apr 10. doi: 10.1136/medethics-2020-106242.
3. National Institute for Health Care Excellence. COVID-19 rapid guideline: critical care in adults. NICE guideline 2020;25.
4. Kramer JB, Brown DE, Kopar PK. Ethics in the Time of Coronavirus: Recommendations in the COVID-19 Pandemic [published online ahead of print, 2020 Apr 9]. J Am Coll Surg. 2020;S1072-7515(20)30309-4. doi:10.1016/j.jamcollsurg.2020.04.004

Competing interests: No competing interests

05 May 2020
Hassan Chamsi-Pasha
Consultant cardiologist
Majed Chamsi-Pasha, Mohammed Ali Albar
King Fahd Armed Forces Hospital, Jeddah, Saudi-arabia