Medical triage for Covid-19: if/when it comes to that, how should it be organized?

So far I haven't heard of any actual medical triage in the U.S. in which life-saving treatment for Covid-19 is rationed.  There has been a good deal of discussion of how to avoid this, and of the short supply of masks, gowns, sedatives for intubation, and health care personnel.  Much of that discussion  has focused on reallocating scarce resources to where they are needed (from where they are not so scarce (e.g. California Ventilators En Route to New York, Other States), so that rationing of e.g. ventilators doesn't become necessary.  But if the infection curve doesn't flatten enough, triage may well be coming, at least in some places. (Here's an up to date account of a hard hit rural hospital near New Orleans that hasn't yet had to triage, but might be getting close if nearby hospitals were to stop taking transfers of patients.)  

Already in Italy there was a period (maybe still) when patients over age 70 (and later over 65) were not being given ventilators because of an actual shortage of ventilators compared to the number of patients who needed them. So it makes sense that, along with the discussion of how to prevent the need for triage, there is an ongoing discussion of how to manage it, if  there comes a time and place where there aren't enough vents to go around. (I have already heard a somewhat related discussion in the U.S. about whether patients on vents should be resuscitated--given the small chance of recovery, and the exposure of health care workers to Covid-19 during a resuscitation attempt.)

As in discussions of repugnant transactions, discussing allocation of scarce resources provokes lots of debate about who should get what, and what kind of distinctions should and should not be made. 

Here are longish excerpts from several interesting contemporary accounts:

Here's an article in the March 23 New England Journal of Medicine:

Fair Allocation of Scarce Medical Resources in the Time of Covid-19

by Ezekiel J. Emanuel, M.D., Ph.D., Govind Persad, J.D., Ph.D., Ross Upshur, M.D., Beatriz Thome, M.D., M.P.H., Ph.D., Michael Parker, Ph.D., Aaron Glickman, B.A., Cathy Zhang, B.A., Connor Boyle, B.A., Maxwell Smith, Ph.D., and James P. Phillips, M.D.

"Rationing is already here. In the United States, perhaps the earliest example was the near-immediate recognition that there were not enough high-filtration N-95 masks for health care workers, prompting contingency guidance on how to reuse masks designed for single use.2 Physicians in Italy have proposed directing crucial resources such as intensive care beds and ventilators to patients who can benefit most from treatment.3,4 Daegu, South Korea — home to most of that country’s Covid-19 cases — faced a hospital bed shortage, with some patients dying at home while awaiting admission.5 In the United Kingdom, protective gear requirements for health workers have been downgraded, causing condemnation among providers.6 The rapidly growing imbalance between supply and demand for medical resources in many countries presents an inherently normative question: How can medical resources be allocated fairly during a Covid-19 pandemic?

...

"According to the American Hospital Association, there were 5198 community hospitals and 209 federal hospitals in the United States in 2018. In the community hospitals, there were 792,417 beds, with 3532 emergency departments and 96,500 ICU beds, of which 23,000 were neonatal and 5100 pediatric, leaving just under 68,400 ICU beds of all types for the adult population.12 Other estimates of ICU bed capacity, which try to account for purported undercounting in the American Hospital Association data, show a total of 85,000 adult ICU beds of all types.13

"There are approximately 62,000 full-featured ventilators (the type needed to adequately treat the most severe complications of Covid-19) available in the United States.14 Approximately 10,000 to 20,000 more are estimated to be on call in our Strategic National Stockpile,15 and 98,000 ventilators that are not full-featured but can provide basic function in an emergency during crisis standards of care also exist.14 Supply limitations constrain the rapid production of more ventilators; manufacturers are unsure of how many they can make in the next year.16 However, in the Covid-19 pandemic, the limiting factor for ventilator use will most likely not be ventilators but healthy respiratory therapists and trained critical care staff to operate them safely over three shifts every day. In 2018, community hospitals employed about 76,000 full-time respiratory therapists,12 and there are about 512,000 critical care nurses — of which ICU nurses are a subset.17 California law requires one respiratory therapist for every four ventilated patients; thus, this number of respiratory therapists could care for a maximum of 100,000 patients daily (25,000 respiratory therapists per shift).

...

"Previous proposals for allocation of resources in pandemics and other settings of absolute scarcity, including our own prior research and analysis, converge on four fundamental values: maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.24-29 Consensus exists that an individual person’s wealth should not determine who lives or dies.24-33 Although medical treatment in the United States outside pandemic contexts is often restricted to those able to pay, no proposal endorses ability-to-pay allocation in a pandemic.24-33

...

"These ethical values — maximizing benefits, treating equally, promoting and rewarding instrumental value, and giving priority to the worst off — yield six specific recommendations for allocating medical resources in the Covid-19 pandemic: maximize benefits; prioritize health workers; do not allocate on a first-come, first-served basis; be responsive to evidence; recognize research participation; and apply the same principles to all Covid-19 and non–Covid-19 patients."

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Here's a Washington Post story with a good summary of much of the discussion and disagreement about how different patients (and groups of patients) might be prioritized if ventilators have to be rationed:

Who gets a shot at life if hospitals run short of ventilators?

States, hospitals scramble to set guidelines that could prioritize pregnant women, health-care workers — and even some politicians

By Ariana Eunjung Cha and Laurie McGinley April 7, 2020 

"Pregnant women would get extra priority “points” in most if not all plans, U.S. hospital officials and ethicists say. This is not controversial. There also has been some discussion about whether high-ranking politicians, police and other leaders should be considered critical workers at a time when the country is facing an unprecedented threat.

...

"Catholic groups have called on hospitals to treat pregnant women as two lives instead of one. AARP, formerly the American Association of Retired Persons, has decried age cutoffs for ventilator access in some plans. Last month, the Arc, a disability rights group, filed multiple complaints with the Department of Health and Human Services objecting to plans that disadvantage those with “severe or profound mental retardation” or dementia.

...

"Bioethicist Brendan Parent, who served on a New York state task force that developed a highly regarded framework for rationing, sees hospitals and states following two paths.

"One group takes a utilitarian view of doing “the greatest good for the greatest number,” giving preference to those with the best chance of surviving the longest. Others are more focused on ensuring social justice and ensuring vulnerable groups have an equal chance.

...

"UCLA’s plan goes to great lengths to avoid possible discrimination, stating that medical teams may not consider a long list of criteria for ventilator allocation including gender, disability, race, immigration status, personal relationship with hospital staff or “VIP status” — an important reminder given the medical center’s proximity to Hollywood.

...

"In UCLA’s plan, front-line health-care workers and administrators may be given priority access to lifesaving treatment, when their return to work means more people are likely to survive the crisis. If all the allocation criteria are applied and there’s still a shortage of medical resources, then care should be allocated on the basis of a lottery, the document says.

...

"One of the most striking differences among plans is how they deal with the elderly and disabled. Some have strict age cutoffs, or explicit criteria that disadvantage those with certain conditions.

...

"Using life expectancy or remaining life years can also be problematic for those with disabilities, civil rights groups say. The typical life expectancy for a person with Down syndrome, for example, is 60 years, as compared to about 78 years for someone without the condition.

...

"Inova’s Motew said ethical principles allow for prioritizing “some individuals who provide more lifesaving opportunities if they could live” — and that this could include “government leaders.” He compared it to military medicine, in which those who are in a position to go back to help win the war are treated first."

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And here are some thoughts on what we might learn about medical triage from considerations that come up in allocating school places among different populations for whom some positions are reserved.  The idea is that different groups of patients would have places reserved for them, through the kind of political process that reserves places in schools for different demographic groups, with priorities within groups, and ordering of reservations among groups. Once those issues are settled by some political process, the problem starts to look like school choice with affirmative action, and in the model proposed by these authors (who are well acquainted with school choice), deferred acceptance algorithms emerge:

Triage Protocol Design for Ventilator Rationing in a Pandemic:
A Proposal to Integrate Multiple Ethical Values through Reserves
Parag A. Pathak, Tayfun Sonmez, M. Utku Unver, M. Bumin Yenmez
April 2020

Abstract: In the wake of the Covid-19 pandemic, the rationing of medical resources has become a critical issue. Nearly all existing triage protocols are based on a priority point system, in which an explicit formula specifies the order in which the total supply of a particular resource, such as a ventilator, is to be rationed for eligible patients. A priority point system generates the same priority ranking to ration all the units. Triage protocols in some states (e.g. Michigan) prioritize frontline health workers giving heavier weight to the ethical principle of instrumental valuation. Others (e.g. New York) do not, reasoning that if medical workers obtain high enough priority, there is a risk that they obtain all units and none remain for the general community. This debate is particularly pressing given substantial Covid-19 related health risks for frontline medical workers. In this paper, we propose that medical resources be rationed through a reserve system. In a reserve system, ventilators are placed into multiple categories. Priorities guiding allocation of units can reflect different ethical values between these categories. For example, while a reserve category for essential personnel can emphasize the reciprocity and instrumental value, a reserve category for general community can give higher weight to the values of utility and distributive justice. A reserve system provides additional flexibility over a priority point system because it does not dictate a single priority order for the allocation of all units. It offers a middle-ground approach that balances competing objectives. However, this flexibility requires careful attention to implementation, most notably the processing order of reserve categories, given that transparency is essential for triage protocol design. In this paper, we describe our mathematical model of a reserve system, characterize its potential outcomes, and examine distributional implications of particular reserve systems. We also discuss several practical considerations with triage protocol design.

And from the conclusion:

"In our formal analysis, we characterize the entire class of reservation policies that satisfy three minimal principles though implementation of the deferred-acceptance algorithm. As such, we also provide a full characterization of affirmative action policies."
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There are of course other models of triage than school choice. In transplantation, there's a shortage of both deceased and living donors, to the extent that many people who need transplants will never get them. The allocation of deceased donor organs is handled not entirely differently than generalized school choice of a particularly dynamic sort (potential recipients of a deceased donor kidney that suddenly becomes available are categorized into groups, not just by blood and tissue types which have immediate feasibility implications, but also by age and by how difficult it will be to find them a feasible match, and prioritized within groups mostly by waiting time and health status, differently for different organs).  Living donors (almost all are donating a kidney) are much less regulated, and through kidney exchange are mostly allocated through an exchange system that is fairly blind to group membership, although the statistics that are collected pay attention to people in a variety of categories.  The point of kidney exchange of course is not just to allocate scarce resources, but to make them less scarce.  That is a goal to think about whenever triage becomes necessary, or starts to look like it might.