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.