With medical experts and politicians now predicting that coronavirus cases will dramatically exceed the capacities of hospitals across America, doctors and nurses face the prospect of picking which patients to prioritize for treatment. Though the term “triage” may conjure images of rough battlefield medicine and crude estimates of patients’ survival odds, excruciating decisions on whom to treat already confront doctors in some places and will likely soon be necessary in America.
In Italy, infections have skyrocketed so quickly that its fatalities have surpassed China’s, where the outbreak started, and doctors are already weighing whom to treat as sick patients overwhelm the hospital system. The published guidelines for an Italian intensive care unit noted that it may become necessary to establish an age limit for access to intensive care. Doctors are reportedly weeping in the hallways as they decide which patients to save. “If you have a 99-year-old male or a female patient, that’s a patient with a lot of diseases. And you have [a] young kid that need[s] to be intubated and you only have one ventilator, I mean, you’re not going to ... toss the coin,” a surgeon and oncologist in Rome named Carlo Vitelli told NPR last week.
The United States is likely not far behind, with the confirmed case count already above Italy’s, and the country may soon experience an equally severe scarcity crisis. In New York City, health care workers are reporting that their resources are or will soon be overwhelmed. “These decisions run counter to everything that we stand for and are incredibly painful,” tweeted Meredith Case, an internal medicine resident at Columbia/New York-Presbyterian Hospital, on March 25. “Our ICU is completely full with intubated Covid patients. … We are rapidly moving to expand capacity. We are nearly out of PPE. I anticipate we will begin rationing today.”
Guidelines for rationing scarce resources differ by state, though many assign rankings based on a patient’s odds of both short-term and long-term survival. The federal government has not yet released official recommendations for the Covid-19 pandemic.
But difficult moral questions about how to allocate scarce medical resources have received extensive consideration from both philosophers and doctors, and it’s been the subject of rigorous academic study among bioethicists. After Hurricane Katrina, professors at Stanford University developed a widely used framework to guide medical decision-making in situations of resource scarcity, such as pandemics and natural disasters. In an influential 2009 article in The Lancet, Ezekiel Emanuel, chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, and two co-authors gave a systemic analysis of moral principles of allocation and how doctors can use them. Some researchers have even developed mathematical models to help decide whom to treat first.
As the coronavirus sweeps across America, these ethical principles will collide with the messy realities of limited medical resources in dramatic ways. Despite the best efforts of philosophers and physicians, the results will inevitably be imperfect compromises that invite a thousand more questions on how to judge whose life is worth saving.
Deciding whom to treat comes down to an ethical dilemma
There are three theories of how to make ethical triage decisions, according to David Magnus, director of the Stanford Center for Biomedical Ethics: egalitarianism, utilitarianism, and prioritarianism.
Doctors and nurses aren’t philosophizing about these approaches as they make long rounds and rush to treat patients. Rather, these frameworks allow health care professionals to streamline decisions and focus on medical tasks, not be mired in moral questions or burdened by guilt after making hard decisions. “As much as possible, we want to move away from forcing clinicians to make bedside decisions and to have broader decision-making about these issues in advance,” said Magnus.
Each theory has its own moral logic. Egalitarianism seeks to treat patients equally; using a lottery system to select vaccine recipients is one example. Utilitarianism aims to maximize total benefit, generally measured by the remaining life years — or expected remaining high-quality years — that decisions will save. If a 20-year-old and an 80-year-old both required a ventilator, treating the 20-year-old would likely maximize life years. In a choice between two people of the same age, the quality of life that each could expect upon recovery would become relevant. Prioritarianism, or the “rule of rescue,” treats the sickest people first; emergency rooms operate on this principle, for example, choosing to treat the gunshot wound victim before the person with a broken leg.
Though each of these appeals to certain moral intuitions, they all have serious problems. To treat patients equally, for example, is also to treat them indiscriminately — because egalitarianism does not distinguish between the age of patients or the severity of their conditions, it can easily seem like an arbitrary or wasteful use of resources.
Utilitarianism confronts the notorious difficulty of ranking quality of life and ignores the moral imperative of urgency. Imagine that the same medical resources could be used either to save one 75-year-old from coronavirus or perform a dozen hip replacements for 65-year-olds. While the latter might ultimately create more years of happy, healthy life, most would consider it the wrong choice, as the recent cancellations of elective surgeries around the country show.
Meanwhile, a rule to prioritize the sickest patients first can clash with the goal of helping the greatest number possible: Lavishing extensive resources on a single patient with only a small chance of surviving could mean refusing treatment to multiple patients who are less sick but more likely to live if treated.
While analyzing trade-offs among these principles is vexing in theory, making and implementing decisions in real time can be excruciatingly difficult. “If you have a patient on a ventilator and they have to be taken off — that is probably the most horrible of all decisions for a doctor or nurse,” said Emanuel. “Vaccines are not always life-and-death. But if someone who doesn’t have a ventilator is going to die, having to withdraw that person is incredibly psychologically traumatic, and this is likely to happen.”
And the nature of medicine makes some ambiguities inevitable. There’s space for individual judgment, for instance, about what constitutes an urgent versus elective surgery, or when respiratory failure is irreversible. If an older patient with coronavirus and a short life expectancy required CPR, it could be difficult to decide whether saving the patient justified exposing health care workers to significant risk.
In normal circumstances, many patients on ventilators in America have only a very small chance of survival, Magnus explained. Family members often insist on continued treatment even when loved ones will almost certainly not recover. “In our society, the ICU often becomes a place for grieving and prolonging the dying process. It’s not obvious that this is a good use of resources even in normal circumstances, but it’s just not going to be possible now,” he said.
What makes one life more worth saving than another?
The ethical dilemmas posed by the coronavirus are real-world examples of deep moral questions philosophers have studied for centuries. Princeton’s Peter Singer, probably the world’s most famous living utilitarian philosopher and a vocal proponent of effective altruism, told Vox, “There’s always a scarcity of resources in medicine, but situations like this make it particularly clear.”
Singer said he favors a utilitarian approach that considers multiple factors: the life expectancy of patients, some types of adjustment for quality of life, and perhaps the patient’s ability to help others. He gave the example of a patient with severe dementia or terminal cancer with a six-month life expectancy as cases where it might be reasonable to prioritize other patients. Attempts to rank quality of life are controversial, particularly in cases of disability, but they are also already widely used.
In the United Kingdom, quality-adjusted life year, or QALY, scores are a crucial factor in health care decision-making and are calculated by multiplying years of life by quality of life. If a given medical treatment would allow a patient one year with full quality of life, the patient would have a quality score of 1. If the same treatment would produce a year of life with only half of the normal quality of life, they would have a quality score of 0.5.
Numerical scores might give the illusion of objectivity, but the complexities of actual life inevitably complicate such decisions. Mental health, family size, income, temperament, pain tolerance, and professional, personal, and relationship satisfaction — a vast array of factors that escape quantification still influence the quality of one’s life but are not accounted for in current equations.
These are incredibly challenging and controversial decisions to make. In particular, people with disabilities have spoken up about their concerns that they will be left behind whenever triage decisions are made. “People with disabilities deserve to have equal access to scarce medical resources,” wrote the American Association of People With Disabilities in a letter to Congress, “and should not be subject to resource allocation discrimination when needs exceed supply...we believe that during this difficult period it is especially important to protect patients with disabilities from discrimination.”
The Office for Civil Rights at the US Department of Health and Human Services has also announced that it is investigating states rationing plans to ensure that they are compliant with civil rights law. As Alice Wong of the Disability Visibility Project told the New York Times, “I deserve the same treatments as any patient. As a disabled person, I’ve been clawing my way into existence ever since I was born. I will not apologize for my needs.”
For a utilitarian, prioritizing those who can benefit others is a defensible choice. “The classic case might be the Army doctor whose treatment is prioritized because he will be able to treat others,” Singer said. “I suppose in the current situation maybe it’s possible to make a case that certain doctors would be in a similar position, but of course you would want to be careful that you were not just prioritizing the health of your colleagues.” In fact, prioritizing medical workers is one of the suggestions made by Emanuel in an article recently published in the New England Journal of Medicine making recommendations for triage in the Covid-19 pandemic.
But defining what constitutes a benefit to others is also difficult and controversial. Elizabeth Anderson, a MacArthur “genius” grant winner and philosophy professor at the University of Michigan, cautioned against thinking in too “ruthlessly consequentialist” a manner. “In strictly consequentialist terms, you might ask who are the most valuable workers, but actually, that’s not the right way to think about it,” she told Vox. “In reality, if the CEO of a major corporation had a heart attack, they are actually more replaceable than the parent of young children, who need specific individuals to be there for them and have a very personal relationship with their parents. It’s an argument for prioritizing caretakers,” she said.
One factor that doctors and philosophers agree should not be relevant is the wealth of patients. But it’s also an undeniable reality of American health care that wealth improves quality of care. “It’s a huge flaw in the American system compared to any other affluent society,” Singer said. Emanuel imagined a scenario in which a scarce supply of coronavirus vaccines became available on the open market. “You don’t want a vaccine that only the rich can buy,” he said, adding that some form of random selection like a lottery would be preferable. “There is no moral framework in which wealth plays a role.”
As the number of cases continues to spike, American health care workers will likely face agonizing decisions on how to ration care — and soon. That’s why for now, self-quarantining and social distancing are themselves moral decisions we can all make that can have significant impacts. “How bad the triage will be depends enormously on the behavior of ordinary people now,” Anderson said. “The only way to solve this is through massive social collaboration.”
Taking collective action to decrease the scale of infections will ultimately reduce the suffering not only of patients but of nurses and doctors. “Triage is awful — it’s traumatizing,” said Anderson. “Doctors who have dedicated their careers to helping people now have to turn people away. It’s dreadful. It’s really on all of us to pull together so that we don’t force these horrible triage choices.”
Nick Romeo is an author and journalist whose work has also appeared in the New Yorker, the Washington Post, the Atlantic, National Geographic, and more.