Bioethicists Differ on Policies for Rationing COVID-19 Care

Half of hospitals in a nationwide survey have no policy to triage essential resources such as ventilators if they confront shortage, and the existing policies differ widely and often lack guidance on fair implementation, according to a new report in the Annals of Internal Medicine.

The survey was sent to 91 members of the Association of Bioethics Program Directors, with 73 distinct institutions which provide critical care that were eligible to respond. The researchers sought to characterize the development of ventilator triage policies and compare policy content.

"The severe threat posed by the current coronavirus disease 2019 (COVID-19) pandemic has resulted in resource shortages, requiring difficult decisions about the allocation of essential resources, such as critical care beds, ventilators, and medications," said Armand Matheny Antommaria, MD, PhD, of the Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, and colleagues from the Task Force of the Association of Bioethics Program Directors.

"In general, health care is provided according to a conventional, well established stand of care," Antommaria and colleagues explained. "When health care resources are severely strained, contingency standards of care, which modify usual practices but still aim at producing similar clinical outcomes, may be implemented."

Of the 73 eligible institutions, 67 program directors (91.8%) responded to the survey. Half of the institutions (36) did not have policies, or had policies that were under development. Seven of the institutions with policies would not share their contents with the surveyors. Most of those with policies had developed them through internal planning, with 5 (6.8%) utilizing policies that had been authored by either state health departments, regional bioethics committee networks, or a state bioethics advisory committee.

The 26 distinct policies that were identified differed in the criteria specified for triage, but commonly contained statements about benefit (96.2%), need (53.8%), age (50%), conservation of resources (38.5%) and lottery (34.6%). Only 6 institutions (23.1%) utilized a first-come, first-served allocation, and no policy utilized lottery or first-come, first-served as a sole criterion. Ten (38.4%) of the policies give preference to health care workers.

Most (80.8%) of the policies that specify need and benefit use a scoring system; commonly the Sequential Organ Failure Assessment (SOFA) score or the Modfied SOFA (MSOFA). Twelve of the policies (46.2%) utilize specific diagnoses in allocation criteria, such as excluding patients with cardiac arrest or severe burns. Of the 13 (50%) policies that have age criteria, only 2 (7.8%) specify age thresholds.

Most policies (65.4%) indicate that certain conditions and demographics cannot be used as criteria for allocation, with half of these specifically excluding criteria based on ability to pay, insurance status, and socioeconomic status. Only 7 (26.9%) specifically exclude use of disability as a criteria, and 4 (15.4%) exclude age as criteria for allocation.

Autommaria and colleagues find it notable that, although many institutions had begun contingency planning, including ventilator triage policies, in anticipation of an H1N1 influenza pandemic in 2009, many of those surveyed did not have triage policies ready at the outset of the COVID-19 pandemic.

"The rapidity with which these policies are being developed may unfortunately substantially limit stakeholder, including public, engagement," they observed.

In an "Ideas and Opinions" paper in the same issue of the Annals, Thomas Bledsoe, MD, Warren Alpert Medical School of Brown University, Providence, RI, and colleagues warn against policies that contain discriminatory approaches to allocation.

"Long standing principles of medical ethics should guide the profession, individual clinicians, health systems and our society," they wrote. "They must be reaffirmed in the circumstances of health system catastrophes, during which their application—but not the principles themselves—may change."

Bledsoe and colleagues advocate applying clinical criteria to assess an individual patient's chances of recovery, and not making assumptions that disfavor or favor a particular group. They emphasize that criteria for allocation should not be based on potential "life years."

"In a pandemic, the critical question is the ability to survive the acute event, not long-term survival," Bledsoe and colleagues asserted