LONDON, ENGLAND - JANUARY 08: A patient arrives by ambulance at the Royal London hospital on January ... [+] 8, 2021 in London, England. London Mayor Sadiq Khan has warned that "if we do not take immediate action now, our NHS could be overwhelmed and more people will die" as cases of Covid-19 in the capital skyrocket. There are currently 7,034 people in London hospitals with COVID-19, over a third higher than the first peak of the pandemic in spring 2020. (Photo by Leon Neal/Getty Images)

The second wave of Covid-19 is proving to be the deadliest. This week, the U.S. has had three days in succession of record numbers of Covid-19 deaths. The daily death tally swelled to more than 4,000, with numbers of hospitalizations also reaching record levels at more than 133,000. Daily increases in caseload have also been staggeringly high. While vaccines offer the prospect that better days lie ahead sometime later this year, the reality is that we are currently in the grimmest phase of the pandemic.

For a plethora of reasons the rate of vaccinations has been insufficient to this point in time to have a significant impact. And so, with hospitals running at or near capacity in many areas, hospital administrators and physicians in the U.S. - as in many other nations - are grappling with extremely difficult choices. They are determining who can be treated and who cant.

As Covid-19 continues to overwhelm California hospitals, Los Angeles County officials are doing what they previously deemed unthinkable: Explicit rationing of medical supplies, including oxygen and drug treatments, and ICU space.

The Los Angeles Emergency Medical Services Agency has also instructed emergency responders to limit the use of supplemental oxygen and not transport patients who cannot be revived.

In the event a crisis level of care is declared - which appears to be imminent - the Los Angeles countys four public hospitals are also preparing to designate specially appointed triage officers who would decide which patients are likely to benefit from continued treatment in hospital and which are not. As case numbers in Southern California continue their seemingly inexorable rise, the use of triage officers will surely be brought to bear.

In London, Mayor Sadiq Khan said today that one in 30 Londoners now has coronavirus. We will run out of beds for patients in the next couple of weeks unless the spread of the virus slows down drastically. The occupancy of hospital beds is nearing 100%. Indeed, as a whole the National Health Service (NHS) in Britain is under the most intense pressure it has experienced yet during this pandemic.

All this is happening as the new B.1.1.7 variant of the coronavirus is leading to exponential growth in cases in the U.K. The Imperial College in London has researched the B.1.1.7 variant and calculated that its as much as 70% more contagious than the previously dominant variant. This has caused the R0, or reproduction number, to rise by between 0.4 and 0.7. Accordingly, this explains the almost vertical ascent in cases in recent weeks in Britain. At the beginning of December, the number of daily new coronavirus cases was around 13,000. This week the average daily number exceeds 60,000.

In light of this, four days ago Prime Minister Boris Johnson declared the strictest lockdown yet deployed. It is an enforceable stay-at-home order, which bans people from mixing with other households, and prohibits people from leaving their homes for anything other than essential activities. Police will break up public gatherings and fine people found violating the rules. Universities, most schools, and all shops, gyms, and places of worship are closed until mid-February.

Rationing in the Context of Covid-19

In the 1930s, the British economist Lionel Robbins defined economics as the science which studies human behavior as a relationship between ends and scarce means which have alternative uses.

This definition encapsulates the essence of allocation decisions. For an economist the ends are different from a hospital decision-maker or physician. But, ultimately, no matter what the ends, decisions must be made about how to allocate scarce resources with alternate uses.

There are multiple such scarce resources for critically ill Covid-19 patients, including ventilators, oxygen, drug treatments, and ICU space. Invariably, the question is how to allocate such scarce resources. Should allocation go towards patients in the greatest need or those most likely to benefit? Or should age or disability be a factor? Alternatively, should a patients profession or status be taken into consideration? These are the kinds of questions triage officers in Los Angeles and London will be faced with.

Americans may not like the word rationing. But, like all other healthcare systems the U.S. rations, and not just in circumstances such as the Covid-19 pandemic. Most healthcare rationing in the U.S. is implicit rather than explicit. For example, access to private health insurance is rationed on availability of employer-sponsored coverage and price of premiums.

In addition, private health insurers ration, but do so implicitly. For example, they may, under cover of vaguely worded medical necessity clauses, deny coverage of treatments, remove drugs from formulary, raise out-of-pocket patient cost-sharing which could make certain medical therapies un-affordable for some, or impose onerous conditions of reimbursement, such as prior authorization, step edits, and indication restrictions.

By contrast, Britains NHS has always been quite explicit and transparent about rationing of healthcare services. In this regard, having to now explicitly make, implement, and justify hard choices regarding which critically ill Covid-19 patients to care for will not be entirely foreign to those involved in the decision-making.

In the context of Covid-19, it turns out, for instance, that from the outset of the pandemic the use of intensive care services for Covid-19 patients has consistently been limited in Britain to those reasonably certain to survive. Furthermore, ventilator treatment is not considered in many elderly patients best interests.

Until the vaccination rollout improves dramatically, stronger mitigation measures are adopted, and the effects of such policies are felt, the continued extremely elevated level of new caseload of infections will lead to situations like the ones being experienced in the Los Angeles area, as well as Greater London.

What this implies is that hospital administrators and clinicians will be placed in an especially uncomfortable role of being the ones rationing care, effectively granting death sentences to some. Not every patient can be helped, and this of course will also include non-Covid-19 patients as lack of ICU space applies to them as well.

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The Grimmest Days Of The Covid-19 Pandemic Coincide With The Most Severe Forms Of Rationing - Forbes