Rebuttal From Drs Hick and Hanfling

We agree with White, Lo, and Peek on the need to address the deep inequities exposed during COVID-19. However, adjusting triage processes by using social indexes is not the way to do so.

Translating ethical values into ethical operational frameworks is a difficult proposition. For example, despite general community consensus to prioritize younger individuals for access to scarce resources (“fair innings” principle),^{1 , 2} a legally and operationally defensible mechanism to include age has been elusive, because of the preference of some populations—including Native Americans—to prioritize their elders. Furthermore, equal protection issues surrounding age-based allocation have been legally contested.³ Issues are multiplied and consequences magnified when we try to address broader and less binary social constructs such as race and economics in allocation.

When we harm one individual by awarding treatment to another, we must match our values directly to our procedures and not “miss the target.” Even assuring essential worker reciprocity (rewarding service) and instrumentality (maintaining society) can be challenging. Who is an essential worker? Which jobs can avoid direct contact with the public? Many essential workers contracted COVID-19 outside the job setting, and sometimes in defiance of community precautions.^{4 , 5}

The authors say that they do not intend to address historical inequity but they essentially propose to, because their correction is not aimed at the equivalent critical care outcomes but adjusts for undiagnosed and complex medical problems associated with social determinants of health such as socioeconomic deprivation and distrust of medical providers and treatments. Who exactly they intend to prioritize is unclear. Is it the poor in general? Is there differential priority between Black, Latinx, and Native American individuals? Do they intend to offer direct benefit to rural communities that score highly on Area Deprivation Index (ADI) but not Social Vulnerability Index indicators, knowing that these populations may be distrustful of medical care? Their table on outcomes relies on a series of nesting assumptions that we do not believe have validity. Assuming that all patients that do not receive an ICU bed will die is at odds with the successful higher-acuity care provided in non-critical care units in addition to telemedicine and “care-in-place” support for critical care extension.

Even though race was specified as a factor to consider in the Emergency Use Authorization for monoclonal antibody treatments, several states are facing legal challenges for including race as a consideration.^{6 , 7} For example, Minnesota withdrew race as a factor in its allocation framework because of equal protection issues, despite clear evidence that race independently predicted increased hospitalization risk.⁸

Although we agree with the authors’ goals, their proposal insufficiently identifies the beneficiaries, corrections, and correlation to the ADI as a solution. The ADI and other nonspecific population measures should not be used in critical care resource allocation. We must improve clinical prognostic tools, refine processes for determining nonbeneficial care, eliminate inappropriate decision schemes such as those reliant on SOFA scores, ensure implementation of load-balancing mechanisms to promote consistency of care,⁹ and work toward improving trust in, and access to, medical care.