Bioethics Forum Essay
Prioritize Health Care Workers for Ventilators? Not So Fast
In places where Covid-19 is increasing – and in preparation for a possible second wave of the pandemic — hospitals are preparing to triage critical resources if necessary. Some are prioritizing health care workers for ventilators. We think this is a mistake.
Ventilator triage guidelines being developed for the Covid-19 crisis primarily aim to “save the most lives” using medical criteria to predict survival resulting from ventilator support, a broadly accepted goal in this context. Policies prioritizing health care workers, including a popular model policy, usually use this status as a tie-breaker, but sometimes to greater effect. Ventilator priority for health care workers has also received support in prominent medical journals such as the New England Journal of Medicine and JAMA, in the popular press, and here in Hastings Bioethics Forum.
While we agree that giving health care workers priority for ventilators has intuitive appeal, the idea is more controversial than it first appears. This is especially so because the workers being prioritized are members of the institutions (i.e., health care systems) in which these policies are drafted and the triage decisions will be implemented.
Ethical arguments for prioritizing workers for scarce resources generally appeal to their importance in keeping essential functions running or to reciprocity, each argument relying on a different form of narrow social utility. Neither is sufficient to justify ventilator priority for health care workers in the context of Covid-19. Further, prioritizing health care workers carries risks for other harms.
That health care workers keep essential functions running may justify prioritizing them for preventive efforts, such as personal protective equipment and vaccines, and potentially for early interventions, such as antivirals. But using this narrow social utility argument to justify prioritizing workers for ventilators presumes they will be able to recover and return to work quickly. This does not appear to be the case for those needing a ventilator as a result of SARS CoV-2 infection.
Some argue that Covid-19’s anticipated long-lasting presence alters this calculation, but expanded time also allows scarcities in both supplies and personnel to be anticipated, planned for, and potentially avoided. Worldwide and U.S. experience to date (even in the absence of much time for planning) has shown that clinicians and other health care workers can pivot to providing or supporting needed health care services outside their regular skill-set, and many are stepping up to be trained in preparation for the future.
Appeals to reciprocity also come up short in Covid-19. Under reciprocity, it is right or just for essential workers exposed to high risks to receive priority. But health care workers are not exceptional here. Many other people are also putting themselves at risk for contracting Covid-19 to help others or to keep society going – bus drivers, police officers, grocery clerks, and other food supply chain workers, to name just a few. These essential workers are also at high risk of infection but may be less likely to have the PPE to protect themselves or the work conditions to exercise other precautions against infection. Data are beginning to suggest they are dying at higher rates from Covid-19 than health care workers. Further, not all health care workers contract Covid-19 through their work.
Having health care workers come out on top risks other harms. Such prioritization can sow seeds of distrust within the communities that support and rely on hospitals and health care workers in times of need. To be trusted, they must be trustworthy. During a crisis, hospitals ethically may shift from “first come, first served” to “saving the most lives” to guide ventilator allocation decisions, but they should not abandon other core principles—respect for all persons, equity, duty to care, fidelity, and non-abandonment.
Those who have lived through a public health crisis recommend that institutions plan ahead. Decisions made in the middle of a crisis frequently are not as well considered as those made when things are calmer. But, when things calm down, life goes on and planning gets pushed off until tomorrow. And then, tomorrow comes. It is worth noting that some ventilator triage guidelines written prior to the Covid-19 pandemic included extensive public and community participation and involved months to years of deliberation, such as those drafted through statewide projects in Minnesota, New York, and Maryland. None of these ultimately recommend prioritizing health care workers for ventilators, though all considered it.
We absolutely owe a debt of gratitude to health care workers on the front lines of this crisis. We understand the inclination to prioritize them for ventilators. They are overworked, responding to a nightmare that evolves hour by hour, minute by minute, and worried about bringing the virus home to their loved ones or dying from it themselves. And we have seen their courage in service to others. But there are better means of recognizing their steadfastness and showing our collective gratitude than by granting them priority for a ventilator over another patient with an equal chance of clinical benefit.
Focusing on prioritizing health care workers for ventilators diverts attention from more urgent matters. Health care workers need sufficient PPE, adequate testing, and better preparation and support for times of crisis (especially in a pandemic, for which the reality, if not the timing, is clearly predictable). Our nation and health care systems have largely failed them in this regard.
Donna T. Chen, MD, MPH, is a core faculty member in the Center for Health Humanities and Ethics and an associate professor of public health sciences and of psychiatry and neurobehavioral sciences at the University of Virginia. Mary Faith Marshall, PhD, HEC-C, FCCM, is the Emily Davie and Joseph S. Kornfeld Professor of Biomedical Ethics, Director of the Center for Health Humanities and Ethics, and a professor of public health sciences and nursing at the University of Virginia. Lois Shepherd, JD, is the Peter A. Wallenborn, Jr. and Dolly F. Wallenborn Professor of Biomedical Ethics in the Center for Health Humanities and Ethics and a professor of public health sciences and of law at the University of Virginia, Twitter: @loislshepherd.
The ultimate reason not to prioritize “health care workers” is the difficulty drawing a line between patients with high instrumental value and those with insufficient instrumental value. ICU and ED nurses, physicians, respiratory therapists, etc. definitely have high instrumental value. What about elementary school nurses, health care educators, outpatient pharmacists, rheumatologists, radiology technicians, hospital board members, hospital dieticians, medical gas delivery personnel, etc.? Last month our ethics committee contemplated Chen et al’s arguments and, while the arguments above are compelling, they’re not the reason we chose not to prioritize health care workers. Practicality, not philosophy, won the day: we could not prospectively draw a bright line between which of the innumerable types of “health care workers” are above the “high instrumental value” threshold and which are not. Thus, in the brief moments available to decide which patients get vents and which do not, there will not be time to answer these important and compelling questions.
Respectfully, I wish to address what appears to be a misunderstanding in this blog post about the substance of the University of Pittsburgh Model Hospital Policy for Allocation of Scarce Critical Care Resources. The full policy can be found here: https://ccm.pitt.edu/sites/default/files/UnivPittsburgh_ModelHospitalResourcePolicy_2020_04_15.pdf
The authors suggest that the allocation framework we developed gives heightened priority only to health care workers, not a broader swath of essential workers. This is not the case.
In addition to health care workers, the Pitt model policy gives heightened priority to “individuals who perform tasks that are vital to the public health response” (page 7) and those who “play a critical role in maintaining societal order” (page 7). In practice, we operationalized this to include all essential workers employed by businesses identified in the state’s mandate to continue physical operations to accomplish COVID-19 mitigation. These essential workers include not only health care workers but also lower-paid workers who may be socially and economically vulnerable, such as grocery store clerks, bus drivers, agricultural workers, and custodial workers.
On reflection, I think we should have included more detailed, precise language in this section of the model policy to more clearly make these points. I apologize for the confusion this lack of clarity caused.
Giving heightened priority for treatment to these essential workers is justified by society’s reciprocal obligation to provide treatment to individuals who assume heightened risk in occupations vital to safeguard society during the pandemic. In addition, because there is significant racial diversity among essential workers, giving them heightened treatment priority may also mitigate the disproportionate impact of COVID-19 on disadvantaged communities.
Douglas B. White, MD, MAS
Vice Chair and Professor of Critical Care Medicine
UPMC Endowed Chair for Ethics in Critical Care Medicine
Director, Program on Ethics and Decision Making in Critical Illness
University of Pittsburgh School of Medicine
As co-authors of the initial essay, we thank Drs. Reynolds and White for their comments. We agree with Dr. Reynolds that the practicality of implementing a ventilator allocation scheme that aims to prioritize individuals based on narrow social utility criteria, like worker status, is daunting. We agree that this practical difficulty is likely one reason that many institutions have not chosen to prioritize health care or other essential workers. And, while practicability is important to consider, particularly given the limited time available when triaging ventilators, we were also interested in whether there was an important ethical reason to try to work out the practical issues associated with aiming to prioritize health care workers for ventilators. We did not find one.
We thank Dr. White for his clarification about the model policy (dated April 15, 2020) that he helped to develop. We agree that the paragraph on page 7 that he cites argues for prioritizing a broader group of workers. In his comment, he further notes that “we operationalized this to include all essential workers employed by businesses identified in the state’s mandate to continue physical operations to accomplish COVID-19 mitigation. These essential workers include not only health care workers but also lower-paid workers who may be socially and economically vulnerable, such as grocery store clerks, bus drivers, agricultural workers, and custodial workers.”
We did not see this in the model ventilator policy, though we do recognize this prioritization strategy from later policy documents providing an allocation framework for scarce emerging COVID-19 medications, such as remdesivir. (See the framework distributed jointly by the Pennsylvania Department of Health, Emergency Management Agency, and Department of Human Services, for which Dr. White provided input (https://cdn.ymaws.com/www.pshp.org/resource/resmgr/files/2020/6-4-2020/covid-19-ethical_allocation_.pdf), as well as a similar draft policy on allocating scarce medications from the University of Pittsburgh, which Dr. White co-authored (https://ccm.pitt.edu/sites/default/files/2020-05-28b%20Model%20hospital%20policy%20for%20allocating%20scarce%20COVID%20meds.pdf)).
In contrast to these later policy documents on emerging medical treatments, the widely disseminated model policy for ventilators states on page 9, within the section providing instructions on how to assign patients to priority groups, “We also recommend that individuals who are vital to the acute care response be given priority, which could be operationalized in the form of a tiebreaker.” (emphasis is ours). The sentence immediately following explains how to prioritize in the event ties remain “after applying tiebreakers based on life-cycle considerations and consideration of healthcare workers.” We interpreted these instructions to recommend prioritizing health care workers for ventilators. We appreciate, however, that the exigencies of the COVID-19 crisis have required quick drafting of policies and recommendations, and we were not intending to single out a specific institutional policy for criticism. Rather, we wished to address the ethical arguments surrounding the issue.
Donna Chen, Mary Faith Marshall, and Lois Shepherd