Then there are the specifics of this particular virus. The data gleaned from places like China and Italy—and it is sparse—suggests some traditional triage methods might do harm in the pursuit of fairness. Much of the existing guidance relies in some form on a sequential organ-failure assessment score, or SOFA, a common metric that tries to predict patient outcomes. If a person suffers from poor liver or heart function, for example, they might be less likely to come off a ventilator alive. It’s one stab at fairness—a way to decide who is most likely to benefit.
But earlier this month, a group of emergency preparedness specialists wrote a paper for the National Academy of Medicine, warning against relying upon SOFA scores too much for rationing decisions. They pointed to research conducted during the H1N1 outbreak that suggested the scores did little to predict outcomes for lung damage due to pneumonia. (SOFA scores were originally developed for sepsis, a different condition.)
Another hotly debated issue on the listserv: whether health care workers would be first in line for treatment. Much of the disaster guidance developed for other kinds of emergencies holds that they shouldn’t be, for practical reasons: The disaster would be over before they were able to get better and save more people. In a pandemic, however, they might have enough time to recover. “But it’s also a matter of justice,” Malek says. “That we treat everybody the same and we don’t prioritize or show favoritism to our own people.”
And finally, disability rights advocates have pushed for a first-come, first-served model. Ari Ne’eman, a health researcher at Harvard, argued recently in The New York Times that rationing plans would discriminate against the disabled and force some people—especially those for whom ventilators are an essential part of daily life—to avoid seeking treatment for risk of losing their life-saving equipment. “Equity would have been sacrificed in the name of efficiency,” he wrote.
Ethicists drawing up rationing plans say they must balance disability rights with a call to save as many lives as possible. Cunningham would like to see health systems move away from so-called “exclusion criteria,” found in many rationing plans—rules that, as a last resort, would result in automatic denial of life-saving support on the basis of particular characteristics such as age or disability.
Cunningham’s model guidance would use a composite score developed by Doug White, a critical care researcher at University of Pittsburgh. It includes SOFA scores, but only as a contributing factor. It also takes into account other data such as a surviving patient’s anticipated life span once they’re outside the hospital. While conditions that affect those scores may correlate strongly with age, Cunningham says, there would be no particular cutoff or disqualifying medical condition. Ideally, the decisions would be made by a diverse triage team that has no relationship with the patient, and would contain an appeals process and opportunities to reevaluate individual cases.
Cunningham’s research is contributing to draft guidelines for Kaiser hospitals, but those plans are still under review. The Kaiser system’s guidance would be deeply influential, because it sprawls across eight states and Washington, DC.
At the very least, Cunningham says, some kind of regional cooperation among hospital systems is “paramount,” so that patients don’t simply move from place to place seeking care. “If we had dramatically different guidelines, you can see how people would start hospital shopping,” agrees Malek. She says Houston Methodist is in discussions with other area hospitals to make sure standards are at least complementary.
But it remains to be seen how that will work in practice. For Caplan, whose hospitals in New York are on the precipice of having to ration equipment, implementation of any new set of guidelines is at the top of his mind. “The hardest thing is not to write a policy,” Caplan says. “It’s emotional support and psychological support for the people who are going to do it and for the families of people who won’t get on the lifeboat.”