As the number of patients sickened by the coronavirus surged worldwide, hospital officials considered a gut-wrenching question: If doctors can’t care for everyone, which patients should get lifesaving treatment?
Triage policies are intended for worst-case scenarios, when resources are scarce and a hospital is too overwhelmed to save every patient.
But rationing treatment presents a serious moral dilemma, says St. Louis University bioethicist Jason Eberl. He spoke with St. Louis Public Radio’s Shahla Farzan about the ethical challenges of deciding who to treat — and planning for the next pandemic.
On triage as a battlefield tactic:
Historically, the notion of triage goes back to battlefield medicine, to a physician during the Napoleonic era who was basically looking at who is most likely to benefit from treatment, who can get back on the battlefield and so on. Of course, we're not in battlefield conditions, but under crisis conditions where you have a surge of patients coming into the hospital, all who need access to specific forms of care — perhaps using certain specialized types of equipment like ventilators in the case of COVID-19 — that's where the need comes in to determine who should be prioritized to get care.
On his research, showing more than half of 67 U.S. hospitals had no policy for determining which patients get a ventilator in a shortage:
Under normal conditions, triaging doesn't really happen. So, on the one hand, it wasn't that surprising, although I was more surprised by the lack of state-level policies. Back when SARS was a concern and H1N1, a number of states devised potential pandemic policies. A lot of those seem to have gone by the wayside. It was surprising to me that there wasn't more forethought in this, and honestly, I would say that's kind of an ethical failure on state health departments and hospitals to not have been better prepared. We've never seen anything like this pandemic, but we've seen other precursors that forewarned us something like this would eventually happen.
On the patchwork of triage plans:
In terms of triage policies, there are no national-level guidelines from any governmental agency or the American Medical Association. There are several influential policies out there, though. New York's policies, the state of Maryland's policies, all of those have served as models that other state agencies or individual hospitals have adopted. But they still have to choose which ones, whether they need to adapt them at all or write their own policy from scratch. So that does leave open the possibility that someone who goes to SLU hospital might be triaged under a different set of criteria than if they went to Barnes-Jewish Hospital.
The amount of difference among the policies was really interesting to see. Where we saw a lot of differences was with what are referred to as secondary criteria — where you have two patients who are at the same level in terms of need and potential likelihood to benefit. What do you use as a tiebreaker? About half the policies we looked at mentioned age as a potential tiebreaker. There's an idea out there, at least in the minds of some ethicists, that everyone deserves a fair shot at passing through the various stages of life. The idea being that if you have a teenager and someone who is in the elder phase of life, that teenager has not had a fair shot at living through life stages, and so there's some reason to prioritize them. Of course, one could imagine, there are a lot of ethical issues with using age as a tiebreaker.
Another consideration is conservation of resources. In addition to a ventilator, what else is this patient going to need? Do they have other health conditions that may require a lot of investment of limited health care resources in order to save them? Generally, ethicists pretty much all agree that this should be a blind process, that the triage committee should not be aware of anything about the patient other than the medical information in their chart. Only two policies of the 26 we surveyed required that that triage committee do a blind process.
On the ethical issues of rationing care:
One of the concerns — especially if it's not a completely blind process — might be whether certain forms of bias creep in, even inadvertently. Pretty much every policy we looked at explicitly excludes discrimination based on socioeconomic status, race, gender, sexual identity. But disability is a tough one, because on one hand, policies are very explicit about not discriminating against someone, for example, if they have Down syndrome. But there are other disabilities that may involve negative health conditions and that may affect the likelihood of one's survival.
Putting aside disabilities, socioeconomic status, even though there's no explicit bias against persons who are economically disadvantaged, being economically disadvantaged is correlated with higher rates of diseases like diabetes, coronary artery disease and so on. That might lead to their being in a poor health condition, which if they get COVID-19 infection, may make them a deprioritized candidate for getting aid.
On lessons from the pandemic:
To me, the more immediate ethical concern is the availability of personal protective equipment for health care workers. I think the first long-term lesson would be for hospital administrators and also for government agencies to really look at how we're allocating funds and making sure we're purchasing sufficient equipment and having it on hand and available. I think what's been exposed in our health care system, and our society as a whole, is really just where we choose to invest our financial resources as a country, or as a health care institution or as a university or whatever. You know, what are we prioritizing?
Triage policies shouldn't be COVID-specific. In general, how you account for disparities and persons with disabilities and making sure that they won’t be discriminated against, those are general ethical concerns that should be part of any triage policy. Hopefully, we can at least get to some general ethical consensus on that across policies. All of this needs to be rethought carefully and over time once we get over the hump of this current crisis. Because I think it's inevitable that there will be another similar type of crisis. It's not a matter of if, but when.
Follow Shahla on Twitter: @shahlafarzan
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