Allocating Medical Resources in the Time of Covid-19

TO THE EDITOR:

The Covid-19 pandemic has caused severe shortages and threatens to overwhelm health care infrastructure; thus, guidance on allocation like that offered by Emanuel et al. (now published in the Journal) is much needed.¹ However, their failure to discuss bias, discrimination, or disability is a glaring omission. Their primary recommendation is to maximize benefits by shifting resources to patients with a better prognosis and to focus on life-years saved — a recommendation that builds on earlier arguments for prioritizing the life of a younger patient over that of an older patient with a similar prognosis, since this benefits the person with the most to lose.² But maximizing longevity, as opposed to merely maximizing lives saved, demands judgment calls that are subject to discriminatory, often implicit, social biases to which health care providers are not immune.³ This could result in morally and legally unacceptable discrimination against disabled, poor, and minority patients.⁴ Therefore, these recommendations must be supplemented with explicit guidance against such discrimination. This guidance should be realized in antidiscriminatory criteria that limit the factors that can be considered or by development of triage committees⁵ that are focused on antidiscrimination, to whom factors such as disability (unrelated to prognosis), socioeconomic status, race, and insurance status are not disclosed. Alternatively, these criteria or committees might explicitly attempt to balance the concern for maximizing prognosis with concerns about social justice.