With reports of shortages of protective equipment and tests—and concerns about future ventilator shortages—growing in the midst of the COVID-19 pandemic, what's the fairest way to allocate those scarce resources?
With the question becoming increasingly pertinent, experts offered six recommendations to help guide providers in an analysis published in The New England Journal of Medicine on Monday. They include Ezekiel Emanuel, M.D., often referred to as the architect of the Affordable Care Act, and other bioethics experts.
In short: Providers need to look for ways to maximize benefits for as many patients as possible.
This may be necessary to address, bioethics experts said in a separate analysis also published in the NEJM in an examination of the particularly "problematic" issue of ventilator shortages.
"In the weeks ahead, physicians in the United States may be asked to make decisions that they have never before had to face, and for which many of them will not be prepared," wrote the authors, led by Harvard Medical School Center for Bioethics Director Robert Truog, M.D.
"Though some people may denounce triage committees as 'death panels,' in fact they would be just the opposite—their goal would be to save the most lives possible in a time of unprecedented crisis," they wrote.
Here's a look at some of their recommendations offered by the experts Monday.
1. Maximize benefits: "Operationalizing the value of maximizing benefits means that people who are sick but could recover if treated are given priority over those who are unlikely to recover even if treated and those who are likely to recover without treatment," the authors wrote. "Because young, severely ill patients will often comprise many of those who are sick but could recover with treatment, this operationalization also has the effect of giving priority to those who are worst off in the sense of being at risk of dying young and not having a full life."
2. Give front-line healthcare workers priority: "Testing, [personal protective equipment, or PPE], ICU beds, ventilators, therapeutics, and vaccines—should go first to frontline health care workers and others who care for ill patients and who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace," the authors said.
3. Don't follow "first come, first served" for equity: The authors recommend a lottery system for patients with similar prognoses in the scenario of a pandemic. "Treatments for coronavirus address urgent need, meaning that a first-come, first-served approach would unfairly benefit patients living nearer to health facilities. And first-come, first-served medication or vaccine distribution would encourage crowding and even violence during a period when social distancing is paramount," the authors wrote. "Finally, first-come, first-served approaches mean that people who happen to get sick later on, perhaps because of their strict adherence to recommended public health measures, are excluded from treatment, worsening outcomes without improving fairness."
4. Change up your priorities based on the intervention: While lifesaving measures should be aimed at maximizing overall benefit, which could likely end up being younger patients, interventions like vaccines should be prioritized for older people or those with chronic conditions which have had significantly worse outcomes—but only after healthcare workers and first responders, the authors wrote.
5. Prioritize care of trial participants: Those patients who "participate in research to prove the safety and effectiveness of vaccines and therapeutics should receive some priority for Covid-19 intervention," the authors wrote.
6. Don't differentiate between COVID-19 patients and those with other conditions: "Fair allocation of resources that prioritizes the value of maximizing benefits applies across all patients who need resources," the authors wrote. "For example, a doctor with an allergy who goes into anaphylactic shock and needs life-saving intubation and ventilator support should receive priority over Covid-19 patients who are not frontline health care workers."