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Germany weighs controversial triage issue

April 27, 2020

Who should get treatment — and who shouldn't? The COVID-19 pandemic has sparked debate in Germany about which patients should be admitted to intensive care units if there is a shortage of beds.

Members of the medical staff in protective suits treat a patient suffering from the coronavirus disease in an intensive care unit at Havelhoehe community hospital in Berlin
Image: Reuters/F. Bensch

There's an ongoing debate in Germany about whether a law should be introduced to decide which patients are admitted to intensive care units if the COVID-19 outbreak worsens.

Writer Peter Schneider, one of the leading intellectuals of the 1968 student protest movement, recently made a controversial contribution to the national discourse about medical ethics with regard to the pandemic. In an article for the daily Berlin newspaper Der Tagesspiegel, he wrote that if it came down to him needing a bed in the intensive care unit (ICU), he would not accept it.

Read more: German man 3D prints face shields for senior homes

That's unless, he continued, the death rate among COVID-19 patients in the intensive care unit was lower than in the US state of New York.

According to New York Governor Andrew Cuomo, roughly 50% of all coronavirus patients who enter intensive care units in the state end up dying, German daily Tagesspiegel reported. In Germany it's 30%, according to DIVI, a German association for intensive care and emergency medicine that has been tracking COVID-19 cases requiring intensive-care treatment.

Jens Spahn visits a hospital wearing a mask
Health Minister Jens Spahn (far right) has been urged to weigh in on the debateImage: Reuters/F. Rumpenhorst

Confronting ethical decisions 

So far, there has not been a shortage of ICU beds and there has been no need for any triage in Germany. According to figures from the Robert Koch Institute (RKI), just under two-thirds of Germany's 30,000 ICU beds are currently in use.

Read more: Load lifts on German city hardest by COVID-19 pandemic

However, the debate about how to prioritize medical services and supplies is intensifying, as Germans look to other European states where doctors have been faced with these ethical issues. In Spain, Italy and France, Europe's hardest-hit countries, some COVID-19 patients have been left to die in hospital corridors because ICUs were overwhelmed. Doctors were effectively forced to choose who should have a chance of survival on a ventilator, and who should not. 

No decision is not an option

Uwe Janssens, chief ICU physician at the St. Antonius Hospital in Eschweiler near Cologne, said such decisions are difficult but crucial.

"A decision has to be made in a critical situation when there are not enough ventilators," he said. "A decision has to be made because if it isn't, everyone dies."

Janssens is also president of the German Interdisciplinary Association of Intensive Care Medicine and Emergency Medicine, which published a revised version of its clinical ethics recommendations on April 23.

He insists the recommendations underline the fact that when faced with such difficult decisions, the guiding principle of medics treating patients with severe COVID-19 must be the perceived chances of artificial respiration being successful. Underlying conditions, age, social background and disabilities should absolutely not play a role when making triage-related decisions.

Read more: Coronavirus crisis rekindles hospital debate in Germany

"This is not about life expectancy in the medium or long term but about as many people as possible surviving," he told DW. "And by that we mean everyone: disabled people, old people, young people, those with dementia — all those who have a real chance of surviving."

But Green party lawmaker Corinna Rüffer is skeptical. "If doctors follow the guidelines of professional societies, many disabled people won't have a chance of treatment that keeps them alive," she said. Speaking recently in the German parliament, she said patients would be "sorted" on a "scale of infirmity," meaning young disabled people who needed full-time assistance would be at a disadvantage.

Parliament has a 'duty'

Jürgen Dusel, the federal government's commissioner for matters relating to persons with disabilities, has also called on parliament to act, saying it was its "duty to draft regulations that were in accordance with constitutional law."

Janssens said the legal issue was problematic, because Germany's "Basic Law does not have any provisions for such a situation." He added that such a law would be "the worst of all options."

Though Janssens said he understood disabled people's fears that they would be at a disadvantage, he insisted they had nothing to worry about and pointed out that a person with Down syndrome would receive the same treatment as anyone else.

"It's important that this debate leads to us being trusted."

State cannot put a value on human life

The German Ethics Council has highlighted another concern, saying that a triage-related law would be limited.

"The state cannot put a value on a human life and cannot decide whose life should be saved in a difficult situation," it said in a statement released in March, pointing instead to the recommendations of professional associations.

German Health Minister Jens Spahn underlined this view in his short response to Rüffer in parliament, saying there was no need to draft laws on "this question of medical ethics."

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