INTRODUCTION

COVID-19 has sickened more than one million people and outpaced the capacity of hospitals around the world to meet demand for vital medical resources, such as ventilators, intensive care unit (ICU) beds, and personal protective equipment (PPE). The best way to manage pandemics such as COVID-19 is with robust emergency preparedness prior to the disaster; yet in this regard, many regions have fallen sadly short (Sanger et al. 2020). In the absence of adequate preparedness, moral leadership at the federal level that sends a clear message and mandates private businesses to supply lifesaving resources is essential. Yet many nations, such as the United States, have not risen to the occasion (Science News Staff 2020). Finally, the last resort is rationing justly; in this realm many hospitals and regions have not done enough, leaving bedside providers to make difficult decisions (Goldstein et al. 2020) and employing strategies that, intentionally or not, disadvantage people based on age (Horowitz and Kirkpatrick 2020); co-morbidities (Goldstein et al. 2020); disability (Savin and Guidry-Grimes 2020); and race (Poston et al. 2020; Ray 2020). We can do better.

Pandemics differ from more typical mass casualty events, like mass shootings or earthquakes, where we implement well-established standard triage to manage scarce resources (Papadimos et al. 2018). Standard triage instructs healthcare workers to save the greatest number of lives by prioritizing those likely to die without a resource and most likely to survive with it. Considerations such as age, social worth, and disability are not supposed to factor into those decisions. With standard triage, emergency physicians and first responders implement distributive criteria established in advance. They are not themselves determining criteria for patient selection or “rationing at the bedside” (Lamas 2020). Instead, health professionals advocate for patients within the constraints set by a fair distributive scheme.

Yet standard triage is designed for short-term, self-limiting situations, not the global COVID-19 pandemic we are now in (Kaposy et al. 2010). One difference is that during a pandemic too many patients are equally likely to benefit from a resource after standard triage criteria are applied. This triggers the need for additional selection criteria applied to patients who share a similar prognosis. Without supplementary criteria, doctors are left to figure out on their own what to do, like the emergency physicians in New York being told to use their best judgment (Muoio and Eisenberg 2020) without crisis standards to guide them (Powell and Chuang 2020) or the abandoned physicians at Memorial Hospital when the floodwaters of Hurricane Katrina rose (Fink 2013). Aside from New York state doctors, who were given explicit legal immunity (Klitzman 2020), U.S. physicians in this situation face uncertain legal liability for the triage decisions they make.

To avoid this situation, criteria that meet previously selected standards of justice should be on hand. Yet what criteria are these? This paper argues that after standard triage is applied, the first priority should be healthcare providers on the frontlines and then non-medical personnel on the frontlines. The ethical arguments justifying this position appeal to narrow social utility, the social contract between healthcare workers and society, and reciprocity for vital services to society under conditions of high risk.

PRIORITY TO CERTAIN HEALTHCARE WORKERS

During the COVID-19 pandemic, many patients needing ICU care and ventilator support meet criteria for treatment set by standard triage, because they stand a reasonable chance of surviving with the resource and are unlikely to survive without it. This forces the question, what supplementary criteria should providers use to guide pandemic triage? We propose that after applying standard triage if a further selection is needed, the first priority should be frontline healthcare workers with workplace exposure to infected patients. This includes not only physicians and nurses but respiratory therapists and any other healthcare workers required to enter the room while an infected patient is present. During pandemics, providers with overlapping skills are often pressed into service when demand surges (Society of Critical Care Medicine 2020). For example, during COVID-19, hospitalists, anesthesiologists, certified registered nurse anesthetists, and operating room and post-anesthesia care unit nurses might be redeployed to ICUs since they possess overlapping skill sets and their availability may increase as elective surgeries are canceled to accommodate critically ill patients. To preserve PPE and minimize risks, there are stricter than usual limits on who may enter the room of an infected patient during a pandemic, thereby limiting the reach of this criterion. For example, during COVID-19, social workers might be asked to use telemedicine.

The ethical argument for priority to healthcare personnel on the frontlines is threefold. First, prioritizing frontline healthcare workers benefits not only these providers but the many other people they care for during a pandemic, producing a multiplier effect (Centers for Disease Control and Prevention 2011). This assumes that providers who fall ill recover and continue caring for patients during the pandemic. It could be argued, however, that in the case of COVID-19, those who suffer acute respiratory distress syndrome and require ventilators for an extended period are unlikely to return to the frontlines. Some will die soon after hospital discharge from heart damage, while others may take months or years to recover, experiencing difficulty walking, moving and even thinking as well as they did before (Dreger 2020). When this occurs, Patrone and Resnik doubt a multiplier effect can be achieved, claiming that “workers sick enough to require mechanical ventilation would be unlikely to return to work during a pandemic…and would do little to curb disruption to the infrastructure” (Patrone and Resnik 2011, 167). Yet it remains unclear how long the COVID-19 pandemic will last, and some healthcare workers who survive their illness may be of value during a later stage of the pandemic, especially if other healthcare workers fall ill or die, leaving a shortage of essential personnel.

The first argument reflects a limited appeal to social utility. Following Winsor, we distinguish broad from narrow social utility (Winsor et al. 2014). Broad social utility judges a person’s worth to society overall. It was reportedly used during the 1960s as a basis for allocating chronic kidney dialysis among people in Washington state (Alexander 1962). Patient selection among medically suitable candidates at that time was made by an anonymous committee, consisting of a lawyer, minister, labor leader, surgeon, banker, state government official and housewife (the sole female member). The committee adopted the advice of two nephrology consultants who recommended excluding candidates over forty-five and children (Warrick 1991). Among the criteria the committee considered were a candidate’s number of dependents, income, net worth, education, occupation, past contributions, and future potential. In the words of an anonymous committee member, “I believe that a man’s contribution to society should determine our ultimate decision” (Alexander 1962, 111). Analysis of committee decisions showed the presence of implicit bias and a tendency to select candidates who were disturbingly similar to members of the committee. Thus, those with the greatest chance of acceptance were middle-aged, middle-class white men. In subsequent years, the committee was roundly criticized as not accommodating people who were social outliers, most famously it was argued that “the Pacific Northwest is no place for a Henry David Thoreau with bad kidneys” (Sanders and Dukeminier 1968, 378).

Our argument appealing to a multiplier effect does not sanction the broad and indiscriminate use of social utility of the kind that the Seattle committee applied. Instead, we appeal to narrow social utility. Narrow social utility measures the short-term value an individual brings to a community during a public health crisis or other emergency. Short-term value is based on healthcare workers’ special knowledge and skills and their willingness to assume risk to carry out essential services. Narrow social utility applies specifically to crisis-related outcomes; for example, during the COVID-19 pandemic, healthcare workers on the front lines have tremendous social utility in the narrow sense of stemming the tide of the disease, which is a crisis-related benefit, even though others (e.g., a brilliant artist) might have higher social utility in the broad sense of benefitting society overall.

It might be objected, however, that preferring healthcare providers creates the appearance of favoritism. This is the worry expressed by the New York State Task for on Life and the Law, which rejects favoring physicians on the ground that “those who devised the clinical ventilator allocation protocol appeared to reserve special access for themselves” (New York State Task Force on Life and the Law 2015, 45). Yet we hold that consistently applying narrow social worth builds into selection criteria a broader rationale, one that extends beyond physicians to other healthcare workers and to non-medical personnel (discussed in the Section. “Priority to Non-Medical Personnel on the Frontlines Who Contribute Essential Services”). For this reason, we have dealt with this important concern adequately.

A second argument for prioritizing healthcare providers on the frontlines is that when they fall ill caring for infected patients, they are harmed in service to society. One way of spelling this out appeals to the metaphor of a social contract. According to this line of reasoning, society grants health professionals privileges and powers in exchange for their agreement to serve society by helping the sick, even at risk to themselves (Cruess and Cruess 2010). As part of this contract, society promises to care for healthcare workers if they fall ill. This rendering is not identical to the common construal of social contract theory, which envisions self-interested bargainers striking a deal that advantages both. Instead, it bears the mark of a broader exchange that engenders trust between committed participants (Silvers and Francis 2005). On our view, the health professions have the moral aim of service, not gain.

A third and related argument invokes the value of reciprocity and holds that society has a duty to give back to those who give to society (Becker 1990). A reciprocity-based duty implies obligations not just on the part of health professionals, but also on the part of governments and private citizens. For example, during the 2020 spring school break, throngs of party-going youth in the U.S. flocked to Florida beaches, ignoring public health warnings to physically distance to prevent the spread of COVID-19. Many contracted COVID-19 afterward and the disease’s toll mounted. Commenting on the situation, a physician reflected, “we shouldn’t have to pay for shortsighted government policies that have already eviscerated our public health infrastructure and may soon lead to the premature relaxation of social distancing rules” (Jauhar 2020).