James Tabery: How to prepare for the worst-case scenario

(Santi Palacios | AP file photo) Aid workers from the Spanish NGO Open Arms carry out coronavirus detection tests on the elderly at a nursing home in Barcelona, Spain, on Wednesday, April 1, 2020.

Hospitals in Utah and across the country are preparing for the worst-case scenario of the pandemic — deciding how to sort (or “triage”) patients in order to decide which patients get access to which scarce medical resources, like mechanical ventilators.

Most patients who are infected with the novel coronavirus, fortunately, recover on their own. But for some patients, things can take a worrisome turn. Difficulty breathing can turn into pneumonia, which can turn into acute respiratory distress syndrome — where the lungs fill up with fluid and deprive the body of oxygen. For those patients, a mechanical ventilator can provide breathing assistance while their bodies recover.

The problem is that mechanical ventilators are in limited supply, and epidemiological models that predict regional surges suggest some states across the U.S. may face a situation where there are more patients in need of mechanical ventilation than there are mechanical ventilators. As a result, hospitals are preparing to navigate that process should it arrive on their doorsteps.

Reports of these considerations of medical rationing have been met with moral outrage. A commentary in the Wall Street Journal decried hospitals that were “too comfortable with making excuses for killing.” When news of a Michigan hospital system’s planning was announced, critics charged the organization with “abandoning your patients.”

Triage protocols are routinely characterized as exercises in deciding “who lives and who dies.” Leaders, like Mayor Bill De Blasio of New York City and White House Coronavirus Task Force coordinator Dr. Deborah Brix, dismissed journalists’ questions about these efforts as sensationalist distractions.

Nothing could be further from the truth.

Triage works like this. Patients seeking medical care are assigned scores based on clinical measures such as lung, liver and cardiovascular function. The combined score is an indication of how medically stable a patient is. A patient with a very low score is likely to survive even without some particular treatment. On the other hand, a patient with a very high score is likely to die even with treatment.

The goal is to find those patients in the middle who are likely to survive but only with the treatment. Importantly, those patients who are ill-suited to receiving the particular treatment are not thrown to the proverbial curb. Rather, they are given alternative treatments (perhaps some other clinical support, perhaps comfort-oriented care). The ethical underpinning of this process is the idea that hospitals should try to save the most lives possible with the limited resources they have.

There are some genuinely thorny ethical questions about how to fairly triage patients. How, for example, do hospitals take into consideration the fact that the virus seems to be especially dangerous for the elderly without engaging in discriminatory ageism? Likewise, how should hospitals evaluate patients’ underlying medical conditions without discriminating against patients with disabilities?

But concerns about these questions should not distract from the fact that there is widespread ethical agreement on very basic elements of triage: There are no VIP patients. The successful CEO is no more entitled to a ventilator than the homeless person. Patients should be evaluated solely on their survivability, not on their purported quality of life. Triage decisions should be made by a small team of experts, not the health care workers at the bedside.

The wide areas of agreement about triage are designed to prevent the very concerns that critics have raised. No patients are killed. Rather, efforts are made to save the most lives. Patients aren’t abandoned. Rather, different patients are given access to different resources. No one explicitly decides who lives and who dies. Decisions are made about clinical profiles of survivability regardless of who the “who” actually is.

As hospitals across Utah release to the public their triage protocols (and they should), these plans will be subjected to public scrutiny (and they should). Utahns — who very well may be personally impacted by these plans — should assess how the hospitals are trying to save the most lives without engaging in problematic discrimination. But they should not question or dismiss the attempt to prepare for triage itself. To avoid that planning would be the one thing that truly is morally outrageous.

James Tabery, Ph.D., is an associate professor at the University of Utah, with appointments in the Department of Philosophy, the Department of Pediatrics, and the Department of Internal Medicine’s Program in Medical Ethics and Humanities.

James Tabery, Ph.D., is an associate professor at the University of Utah with appointments in the Department of Philosophy, the Department of Pediatrics, and the Department of Internal Medicine’s Program in Medical Ethics and Humanities. Opinions expressed here are his own and not necessarily representative of the University of Utah.