Bioethics Forum Essay

Should Covid Vaccination Status Be Used to Make Triage Decisions?

As the Covid-19 pandemic continues to strain health systems’ capacity to provide adequate care for critically ill patients, should patients’ vaccination status be considered in making triage decisions?

This question sparked debate recently after the leak of an internal memo of the North Texas Mass Critical Care Guideline Task Force, which provides triage guidelines for regional hospitals,  that proposed using patients’ Covid-19 vaccination status as a factor to assign intensive care beds. The task force has since clarified that it was not intended as policy but for internal discussion between the task force and physician representatives of the regional hospitals. They also hastened to note that a key purpose for raising the discussion was to ensure that if vaccination status were to be considered, it would only be one of several factors that might help predict patient survival and not a blanket exclusionary factor for receiving critical care resources.

Critical care triage during a public health emergency or an event involving mass casualties aims to optimize beneficial use of limited resources and depends primarily on medical criteria that can be objectively assessed or scored, with priority going to patients who are most likely to die or suffer without treatment and most likely to survive and derive other benefits with treatment. Most if not all guidelines and ethical frameworks for triaging intensive care resources during Covid-19 adopt these clinical criteria as “first-order” considerations. Other considerations may be used to assign “second-order” priority points, or for use as tiebreakers among patients with otherwise equivalent probability of survival. The second-order criteria, which are usually based on justice or equity considerations, have been considerably more contentious. These criteria sometimes include prioritizing those with the least opportunity to live through the stages of life (the life-stage or “fair innings” principle, which promotes intergenerational equity), those who have taken on additional risks and burdens while making relevant contributions to the pandemic response (principle of reciprocity), and those capable of saving others if they are saved. Second-order criteria also might give extra points to those from historically marginalized groups.

At first glance, the suggested use of vaccination status as a triage factor in the task force’s memo does not seem to deviate from using only first-order criteria–optimizing the efficient use of limited resources to save the most lives. Emphasizing that “triage must remain grounded upon likelihood of survival,” the memo suggests that physicians may use vaccination status as part of a multicomponent assessment of each patient’s likelihood of survival. Still, this proposal may be criticized within the logic of objective medical assessment.

While there is strong evidence that “Covid-19 vaccination decreases [the risks of] severe infection and death” (as the memo states), there is inadequate information at this time regarding the survival outcomes of matched vaccinated versus unvaccinated critically ill Covid-19 patients. Furthermore, not all vaccines are created equal. The relationships between each vaccine and the interactions of different patient demographics or pre-existing diseases with resultant survival outcomes are undoubtedly complex and currently unknown.

The relative lack of clarity on this matter is illustrated by a recent pre-print study, reporting on 2,080 patients admitted to a tertiary care center in India, that found that vaccination reduced the odds of death in the hospital by 30%, but did not report whether vaccination status matters once an individual becomes critically ill. Perhaps tellingly, the authors concluded, “vaccination has an impact on reducing odds of death. However, once the patient develops ARDS [acute respiratory distress syndrome] related to COVID-19 necessitating respiratory support, the prognosis is dismal.”

Given the lack of evidence on the matter, any application of vaccination status in assessing survival probability at present seems more likely to increase inconsistent and biased triage decisions than to improve predictive accuracy. But if it is ethically questionable to apply vaccination status as a first-order consideration for critical care triage, might it be ethically defensible to use it as a second-order tiebreaker consideration?

In fact, the task force’s suggested use of vaccination status was almost certainly not guided solely by medical utility considerations. The mixed motives underlying the discussion about using vaccination status in triage are highlighted by the following exception, reported by The Dallas Morning News: the draft policy states, “When vaccination status is considered, accommodations may be needed when the reason for non-vaccination is beyond the patient’s control, such as, but not limited to, caretaker refusal to have a disabled dependent vaccinated, recent COVID-19 infection, or medical contraindication.” This statement suggests that lowering a patient’s priority based on vaccination status should apply only to patients who are able, but unwilling, to be vaccinated. Since similar accommodations are not made for individuals with other medical risk factors, such as heart disease, kidney disease, or lung disease that might also have been within or outside the patient’s control, the proposed policy is treating vaccination status as different than other clinical risk factors.

This exception clause seems to reflect belief in a type of luck egalitarianism: inequalities in individual advantages are unjust and should be remedied when they reflect differences in brute luck or circumstances over which they have no control, while inequalities that reflect differences in individual choices are just and require no remedy. Such an approach, however, could well increase systemic inequities in the allocation of critical care resources. For example, members of particular communities in the U.S. face systemic disadvantages in health care access and generally lack trust in health or governmental authorities because of current and historical injustices perpetrated by these authorities. Thus, for some individuals a personal “choice” not to be vaccinated may be grounded in lack of access or fair opportunity to be vaccinated or in justifiable mistrust–and these choices follow predictable patterns.

In Texas, for example, Black people represent 12% of the population and 15% of all Covid cases, but they have received just 9% of the vaccine doses delivered. When individual choices add up to such clear systemic differences, more than individual choice is in play. And if vaccination status is given weight in triage decisions, it will predictably lead to a disproportionate number of patients from these already-disadvantaged communities being given low priority. In fact, seeming to recognize the potential for this strategy to exacerbate inequities, the co-chair of the task force has since added that accommodations might also be made for a “person from a disadvantaged community,” implicitly also reinforcing that the issue is not merely one of using medical resources most efficiently.

It is also debatable whether assigning priority based on vaccination status is a fair way to treat those making risky choices with regard to Covid. While highly significant, vaccination is one of many choices individuals make to reduce the risk of infection, severe disease, and death. A critically ill person who has not been vaccinated due to fear of vaccination might have taken other measures to reduce her risks of Covid. How should we decide between her and a critically ill vaccinated person who has not complied with other public health measures or who might even have engaged in high-risk behaviors such as nonessential travel to a place with high community transmission?

One possible ethical justification for prioritizing vaccinated patients in triage decisions is the principle of reciprocity. Vaccination reflects one’s opportunity, ability, and willingness to reduce Covid risks not just for oneself but also for others. And to the extent that an action presents a benefit to others (and especially if it comes at some risk to the individual), the others owe that person some consideration in return. Reciprocity was the major argument underlying prioritization of frontline health care workers to receive early access to the vaccines and it may be relevant in the context of a health system at risk of being overwhelmed, where any steps taken to prevent that outcome have societal benefits. Vaccination status as a tiebreaker might therefore be seen as a form of fair reward for those who choose to help protect their community by being vaccinated.

Two considerations militate against this approach. First, reward and punishment are two sides of the same coin. As such, vaccination status as a tiebreaker may be perceived as a disadvantage deliberately conferred on vaccine-hesitant persons to either incentivize them to be vaccinated or to punish them for not doing so. This may have the unintended consequence of increasing vaccine hesitancy overall by undermining the control of unvaccinated persons over their decision to vaccinate. Second, in order not to unfairly punish those who are unable to be vaccinated, it would be necessary to create a system to distinguish between 1) patients who lacked access to a vaccine, 2) those willing to be vaccinated but who couldn’t be for legitimate reasons, and 3) those who had access and were able to be vaccinated but chose not to for illegitimate reasons. Only patients in group 3 may justifiably be assigned lower priority, and presumably only if they are equal to others with respect to likelihood of short- and long-term survival. Operationalizing such a system in critical care facilities during an emergency situation would be difficult.

The controversy over the North Texas Mass Critical Care Guideline Task Force’s memo highlights the ethical complexity and operational difficulty of introducing new criteria into triage frameworks to ensure that decisions are scientifically and ethically justified during an evolving pandemic. With surges occurring across the U.S. and in many other countries, it is tempting to blame individuals who prefer not to be vaccinated despite vaccine access. But using vaccination status as a first-order triage consideration is not clinically justified at present, since it should not be assumed that vaccinated patients have a survival advantage once they require mechanical ventilation, at least until more information is available. While reciprocity might be used to justify vaccination status as a tiebreaker between patients with similar likelihoods of survival, such an approach raises questions about why vaccination is being treated differently than other behaviors that increase the risk of severe illness, and it will likely be couched as a narrative of punishment that further divides society at a time when cohesion is needed to combat a virus threat.

Voo Teck Chuan, PhD, is an assistant professor at the National University of Singapore, Yong Loo Lin School of Medicine, Centre for Biomedical Ethics. Abigail E. Lowe, MA, (@albobweey) is an assistant professor at the at the University of Nebraska Medical Center College of Allied Health Professions. Alva O. Ferdinand, DrPH, JD, is an associate professor at the Texas A&M University School of Public Health and director of the Southwest Rural Health Research Center. Tan Hon Liang, MD, (@HonLiangTan) is president of the Society of Intensive Care Medicine, chair of the Chapter of Intensivists, Academy of Medicine in Singapore, and a consultant anaesthesiologist and intensivist. Matthew K. Wynia, MD, MPH, (@MatthewWynia) is a professor of medicine and public health and director of the University of Colorado Center for Bioethics and Humanities and a Hastings Center fellow.

Views expressed by the authors are their own and do not represent views of their institutions. Teck Chuan, Abigail Lowe, Alva Ferdinand, and Matthew Wynia are members of the University of Nebraska Medical Center, Global Center for Health Security, Ethics Advisory Committee. They thank other members of the committee for thoughtful deliberations on this topic: David Brett-Major, Kelly K. Dineen, Lisa M. Lee, Rachel E. Lookadoo, Seema Mohapatra, Nneka Sederstrom, and Sarah Shannon.