How do we decide which patients with COVID-19 should get priority for lifesaving ventilators and ICU beds? Writing in the July issue of Medical Care, a prominent bioethicist argues that COVID-19 triage strategies should focus on saving lives, rather than prioritizing life-years saved. Medical Care is published in the Lippincott portfolio by Wolters Kluwer.
"Justice supports triage priority for those with better initial survival prognosis but opposes considering subsequent life-years saved," according to a special editorial by John R. Stone, MD, Ph.D., Professor of Bioethics and Co-Founder and Co-Executive Director of the Center for Promoting Health and Health Equity at Creighton University, Omaha.
He adds: "Groups experiencing historical and current inequities must have significant voices in determining triage policy."
'Justice-respect-worth' framework calls for rethinking COVID-19 triage
Recent articles have proposed frameworks for making the "terrible choices" posed by COVID-19 - focused on maximizing the benefits of treatment based on life-years saved. In one approach, patients with lower "prognosis scores" get lower priority for critical care.
But the focus on counting life-years violates "the foundational moral framework of social justice, respect for persons, and people's equal and substantial moral worth," Dr. Stone writes.
In particular, prioritizing treatment for patients with a better prognosis will give lower priority, on average, "to individuals for whom social/structural inequities are significant causes of worse health" - with racial/ethnic minorities being a key example.
"Historical and present inequities have reduced expected life-years in populations experiencing chronic disadvantage," according to the author.
"Justice requires avoiding policies that further increase inequities...greater priority for more predicted life-years saved will exacerbate those inequities."
A more just approach would be to consider the individual's likelihood of initial survival while ignoring subsequent life-years saved.
Triage policies can reasonably give priority to people more likely to survive hospitalization and a brief time after."
John R. Stone, MD, Ph.D, Professor of Bioethics and Co-Founder,Center for Promoting Health and Health Equity, Creighton University
By this approach, a younger and older patient would have a similar priority for lifesaving care- as long as they had a similar chance of surviving for more than a few months after leaving the hospital. (Dr. Stone adds that bias against the elderly is another reason not to prioritize life-years gained.)
While guidance for triage decisions tries to ensure objectivity, assessments may still be affected by implicit and unconscious negative bias.
For that reason, specific diversity in triage teams is essential. Policy decision-makers must include representatives of "populations historically oppressed and disadvantaged," according to the author.
Dr. Stone highlights the importance of the "justice-worth-respect" framework in making difficult decisions about which patients should be prioritized for scare healthcare resources.
He concludes: "Triage policies focused on life-years saved will perpetuate social injustice and generally should be rejected."
Stone, J. R., (2020) Social Justice, Triage, and COVID-19
Ignore Life-years Saved. Medical Care. doi.org/10.1097/MLR.0000000000001355.