The Covid-19 pandemic has forced hospitals into a crisis standard of care that has required the allocation of limited resources and forced clinicians to make difficult decisions about who gets the ventilator, dialysis machine, or ICU bed. The crisis standard of care triage scoring guidelines in place today follow the utilitarian framework of maximization which allocates scarce resources to those deemed most likely to survive long-term, in order to save the maximum number of lives. At times this goal can supersede the principle of justice by placing those in marginalized groups at the lowest priority. Racial minorities, specifically Black and Hispanic populations, have been disproportionately harmed by utilitarian triage guidelines that seem neutral on paper, but this neutrality comes with negative consequences. As a result of systemic inequalities regarding access to care, jobs, adequate education, and housing, these populations are fundamentally disadvantaged in scoring systems because of their comorbidities, which result in reduced expectations for long-term survival.
If saving the maximum number of lives perpetuates health inequities for people of color, is it possible to maintain a utilitarian goal while simultaneously valuing justice and mitigating inequalities for these populations? When considering both the value of human life and acknowledging existing barriers to health, the decision of who gets the needed resource introduces many sides to the complex ethical dilemma of medical triages.
Background on Crisis Standards of Care
In public health crises like Covid-19, hospitals often find themselves with considerably more patients in the ICU than the number of resources to go around, constituting the need to switch to new standards of care in order to meet the high demand. The continuum in hospitals increases in intensity from conventional standards to contingency standards, and then finally crisis standards, where it reaches its highest intensity. Crisis standards are defined by the goal of maximizing lives saved using triage, i.e., maximization (Kirkpatrick). This change from conventional to crisis standards raises the stakes considerably, and with no guarantee that additional resources will be obtained, hospitals are left to prioritize some patients over others.
The most recognized scoring system for triage in the Covid-19 pandemic is the SOFA score, or the Sequential Organ Failure Assessment. The SOFA score was developed in 1994 to diagnose the acute morbidity of a critical illness at a population level in the ICU. The SOFA score assesses the six major systems of the body: respiratory, cardiovascular, neurological, renal, hepatic, and coagulation. Each system is given a score from 0 to 4, higher numbers reflecting a higher level of dysfunction (Lambden). Patients with the least amount of organ dysfunction are given the highest priority and those with the highest amount of organ dysfunction are given the lowest priority.
One important thing to consider is that SOFA scores were not designed to take into account racial injustices. Some might see this as a benefit, but in the framework of justice, it is an area of consideration, something I will discuss in detail later in this paper. It is important to consider the fact that scoring methods for crisis standards were not intended to be fair in every circumstance or exception, because crisis standards call for temporary solutions. This does not mean hospitals have to continue with the guidelines they established at the start of the crisis, but rather learn the flaws and conceive of a more ethical resolution.
Disparities in Prioritization
Comorbidities are a major criteria for the allocation of scarce resources, meaning patients with conditions that significantly lower their overall health will not be prioritized. Systemic injustices affect most significantly the development of comorbidities in Black and Hispanic communities like chronic kidney disease, diabetes, chronic obstructive pulmonary disease, and hypertension (Manchanda et al.). The combination of one of these conditions plus Covid-19 results in a substantial percentage of deaths (Stawicki et al.). The highest contributor to mortality is chronic kidney disease, something Black patients are four times more likely to develop than white patients. Additionally, Hispanics are just about two times as likely, in comparison to all non-Hispanics, to be diagnosed with chronic kidney disease. In African American adults over 20, a shocking 42% have hypertension compared to the percent of hypertension in Caucasion adults at 28.7% (Carratala and Maxwell)(Tartak et al.)(NIDDK). The SOFA score is solely meant to diagnose the severity of acute diseases, and with a systemic predisposition to developing these conditions, it begs the question: Is it fair to prioritize allocation of scarce resources to individuals based on the SOFA score (or similar assessments), when structural inequalities make it more likely that people of color will score lower on these scales?
When deciding who will benefit the most from treatment, hospitals generally weigh a patient's short-term survival. This encompases the time up until a patient’s discharge and up to a year after (White and Lo). Saved life-years is determined by a patient’s life expectancy, something that is impacted by one’s disabilities or conditions stemming from social injustices. Not to mention, long-term life expectancy is extremely difficult to predict and those predictions can be easily impacted by a physician’s biases. From 2019 to 2020, life expectancy for Black and Hispanic individuals has decreased disproportionally. The largest decline of life expectancy for individuals was for African Americans which dropped by 2.7 years in comparison to 2019. The second largest decline was by Hispanic individuals whose life expectancy dropped by 1.9 since 2019 (Rodriguez).
Triage From a Utilitarian Perspective
The theory of utilitarianism is defined by generating the greatest good for the greatest number of people. Under a utilitarian-centered triage approach the goal is simple: save the maximum number of lives. This maximization works alongside crisis standards to optimize the health of the greater public by prioritizing those with a greater chance of surviving beyond Covid-19 with the scarce resource.
Consider this simplified example, if you have two patients in need of a ventilator, one with a 90% chance of survival, and another with a 10% chance of survival, under utilitarianism you would give the ventilator to the patient with the higher chance of survival. If you are consistent in this approach, for every 10 people, 9 would be saved as opposed to just 1 person. This example, however, is a simplified model and does not accurately represent how someone’s predicted survival plays out because, as the name suggests, it is a prediction and is not guaranteed that one person will survive or another will die.
One might wonder how a framework that works to save the maximum number of lives can be unethical in its motives. It is in fact the very basis of the utilitarian ethical framework that leads to this objection. What the utilitarian approach fails to consider is how likely a patient is to develop score-raising comorbidities or what factors are contributing to their shortened prognosis
for long-term survival. If this approach does not address systemic inequalities, it will perpetuate those same inequalities.
Triage From a Justice Perspective
While one might consider a justice approach to hinge on equality, it instead focuses on equity, meaning social determinants of health are taken into account in order to give proportional care to individuals who are disadvantaged. There are no strictly justice-centered triage systems in place now, but if they were to be instituted they would be determined on the basis of health equity and maximizing justice outcomes.
Let's consider an example of two patients. One is 55 years old with an average life expectancy and who is in good health, can work from home, and lives in a spacious house in the suburbs. The second patient is 55 who works an essential worker job, shares a crowded home, and lives in the city where they must take public transportation. There is a greater chance the second person, who is at a greater risk for contracting the virus, is also a member of a racial minority. A justice triage would take these factors into account and give more priority to the individual facing greater systemic inequalities because their focus, unlike the utilitarian approach, would be on mitigating inequalities and maximizing justice outcomes, no matter the outcome of their health assessment (Tolchin et al.).
Many argue taking into account social justice concerns is not easily determinable for the limited timeframe in a public health crisis. In this approach, there are potentially fewer lives saved if scarce resource allocation is no longer (primarily) driven by projected survival, e.g., if a member of a disadvantaged population who has a lower projected chance for survival is given priority.
Comparison of Utilitarian vs. Justice Frameworks
The utilitarian approach of saving the most lives often conflicts with a justice framework, and it is difficult to determine where to draw the line between saving the most lives and mitigating existing inequalities. On the one hand, disregarding the save-the-most-lives goal of utilitarian triage results in an obvious outcome: more lives will be lost. But on the other hand, disregarding the framework of justice leads to an perpetuation of racial inequities and systemic injustices, creating an even larger divide in health equity.
In the words of bioethicists Ruth Faden and Madison Powers, from the Kennedy Institute of Ethics at Georgetown and the Berman Bioethics Institute of Johns Hopkins University, the goal of public health ethics is “to improve human well-being by improving health and related dimensions of well-being and to do so in particular by focusing on the needs of those who are most disadvantaged”(Faden and Powers)(White and Lo). In a crisis, hospitals must choose between many deserving candidates, and some will inevitably be neglected. However, it is the goal of public health to determine “who will benefit the most” in a fair and just way, which cannot exclude the most disadvantaged.
The pandemic has heightened racial inequities in the Black and Hispanic communities in particular, and in my opinion, this has made it clear there is no ‘best’ time to make efforts towards reducing the strain of inequities in healthcare. What the utilitarian approach fails to consider is how likely a patient is to develop score-raising comorbidities or what factors are contributing to their shortened long-term survival. This is why I believe more of a justice-centered lens needs to be adopted into the already existing utilitarian framework.
My Suggestion For An Ethical Triage
My suggestion for an ethical triage would keep aspects of the utilitarian approach while also increasing the priority of systematically disadvantaged individuals. I believe correction factors should be added to the existing SOFA score to take into account comorbidities that disproportionately affect Black and Hispanic individuals and significantly increase one’s mortality rate with the addition of a Covid-19 diagnosis (Galiatsatos et al.).
Another factor I would take into account is the area in which each patient lives and the degree of poverty, education, and environmental factors in that area. Dr. White and Dr. Lo from The University of Pittsburgh Department of Critical Care Medicine suggest using the Area Deprivation Index (ADI) because it ranks areas by socioeconomic disadvantage and takes little time to calculate. It has been proven that living in an area with a high ADI score correlates to developing certain health conditions like cardiovascular disease and diabetes (Neighborhood Atlas). Taking into account the environmental and socioeconomic considerations that impact a given area would make it less likely for individuals living in the same area to continue to be deprioritized.
Finally, I believe patients in disadvantaged populations should be granted more time with a life-saving resource if the race or ethnicity they identify with has been proven to need a longer recovery period. Evidence shows that to reach the same rate of mortality as white patients, Black patients need a longer recovery in the ICU (Galiatsatos et al.). This suggestion would reduce the times a life-saving resource was taken from a patient before they had enough time to use it, and most likely prevent their need to use the scarce resource again if they had too little time with it previously.
Carratala, Sofia, and Connor Maxwell. "Health Disparities by Race and Ethnicity." Center for
American Progress, 7 May 2020, www.americanprogress.org/issues/race/reports/2020/05/07/484742/health-disparities-race -ethnicity/.
Galiatsatos, Panagis, et al. Health Equity and Distributive Justice Considerations in Critical Care Resource Allocation.
Jöbges, Susanne, et al. "Recommendations on COVID-19 Triage: International Comparison and
Ethical Analysis." Bioethics, John Wiley and Sons Inc., Nov. 2020,
Kirkpatrick, James N, et al. "Scarce-Resource Allocation and Patient Triage During the
COVID-19 Pandemic: JACC Review Topic of the Week." Journal of the American College of Cardiology, The American College of Cardiology Foundation. Published by Elsevier., 7 July 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7213960/?report=classic.
Manchanda, Emily Cleveland, et al. "Inequity in Crisis Standards of Care: NEJM." New England Journal of Medicine, 17 Feb. 2021, www.nejm.org/doi/10.1056/NEJMp2011359?url_ver=Z39.88-2003&rfr_id=ori:rid:crossr ef.org&rfr_dat=cr_pub 0pubmed.
"Neighborhood Atlas®." Neighborhood Atlas - Home, www.neighborhoodatlas.medicine.wisc.edu/.
Nelson, Ryan H., and Leslie P. Francis. "Intellectual Disability and Justice in a Pandemic." Kennedy Institute of Ethics Journal, 17 June 2020, kiej.georgetown.edu/intellectual-disability-pandemic-special-issue/.
"Race, Ethnicity, & Kidney Disease." National Institute of Diabetes and Digestive and Kidney Diseases, U.S. Department of Health and Human Services, 1 Mar. 2014, www.niddk.nih.gov/health-information/kidney-disease/race-ethnicity.
"Risk for COVID-19 Infection, Hospitalization, and Death By Race/Ethnicity." Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization -death-by-race-ethnicity.html.
Rodriguez, Adrianna. "The U.S. lost a whole year of life expectancy – and for Black people, it's nearly 3 times worse." USA Today, 18 Feb. 2021, www.usatoday.com/story/news/health/2021/02/18/covid-us-life-expectancy-record-low-b lacks-latinos-most-affected/6778474002/.
Savulescu, J, Persson, I, Wilkinson, D. Utilitarianism and the pandemic. Bioethics. 2020; 34: 620– 632. https://doi.org/10.1111/bioe.12771
Tartak, Jossie Carreras, and Hazar Khidir. "Opinion: U.S. Must Avoid Building Racial Bias Into COVID-19 Emergency Guidance." NPR, NPR, 21 Apr. 2020, www.npr.org/sections/health-shots/2020/04/21/838763690/opinion-u-s-must-avoid-buildi ng-racial-bias-into-covid-19-emergency-guidance.
Tolchin, Benjamin, et al. "Triage and Justice in an Unjust Pandemic: Ethical Allocation of Scarce Medical Resources in the Setting of Racial and Socioeconomic Disparities." Journal of Medical Ethics, Institute of Medical Ethics, 1 Mar. 2021, jme.bmj.com/content/early/2020/10/16/medethics-2020-106457.
"'We Are Making Difficult Choices': Italian Doctor Tells of Struggle against Coronavirus." The Independent, Independent Digital News and Media, 13 Mar. 2020, www.independent.co.uk/news/health/coronavirus-italy-hospitals-doctor-lockdown-quaran tine-intensive-care-a9401186.html.
White, Douglas B., and Bernard Lo. "Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic." American Journal of Respiratory and Critical Care Medicine, vol. 203, no. 3, 2021, pp. 287–295., doi:10.1164/rccm.202010-3809cp.
White, Douglas B., et al. "Allocation of Scarce Critical Care Resources During a Public Health Emergency." University of Pittsburgh Department of Critical Care Medicine, ccm.pitt.edu/sites/default/files/UnivPittsburgh_ModelHospitalResourcePolicy_2020_04_ 15.pdf.