Through a mixture of systemic and individual failures, front-line health care workers are in an impossible position: They are, or may be, asked to make the ethically and emotionally fraught decision of who lives and who dies because of Covid-19 — and many Americans have little or no understanding of how that process works or why. This lack of understanding can lead to disagreements, exacerbate tensions between patients and care providers and even intensify feelings of grief or loss.
When hospitals are overwhelmed — whether by Covid-19 cases or other crises — decisions must be made as to how to distribute scarce medical resources. Early in this pandemic, as uncontrolled surges sprouted in Italy, Spain, New York and elsewhere, medical-resource rationing was at the forefront of ethical and policy debates. Experts agreed then and agree now that overwhelmed hospitals have a duty to steward scarce resources by using them to save the most lives but must balance that duty without devolving into ruthless utilitarianism.
It appears this debate may not stay academic much longer.
The latest surge of Covid-19 cases has arrived at America’s hospitals, with hospitalizations and positivity rates increasing at alarming rates across the Midwest. Cases per capita in North Dakota and South Dakota since the beginning of the pandemic are among the highest in the world. Health officials warn that intensive care units in El Paso, Texas, and parts of Wisconsin and Utah could exceed capacity within weeks; plans for rationing ICU beds, ventilators and even staff are being discussed in the latter.
We are in uncharted territory.
Although ethicists and health policy experts have had many discussions about how U.S. hospitals should handle a mounting wave of Covid-19 cases if capacity does become overwhelmed, we are only just beginning to learn about how the average American thinks about triage decisions in this pandemic. Understanding public attitudes toward triage, and reacting appropriately to those attitudes, could help provide legitimacy to a process that is often obscured by bureaucracy and that, without proper oversight, could have discriminatory consequences.
We set out to provide that legitimacy — and offer hospitals and health policy experts a path forward. Our study, which was published this week in the scientific journal PLOS ONE, surveyed over 1,800 Americans about triage decisions during the Covid-19 pandemic, and we came to the following conclusions.
Understanding how Americans may react to the ethically fraught decision of who lives and who dies can assist hospitals when disagreements arise.
First, even while hospitals are being overrun by Covid-19 cases, Americans generally support allocating scarce medical resources in ways that will both save the most lives and save the patients who are the worst off. By contrast, Americans broadly do not support allocating scarce resources solely on a first-come-first-serve basis, or to patients based on their potential value to society.
This result supports the model triage framework used across the United States.
Second, although Americans support the goal of saving the most lives, most were ambivalent about the forcible withdrawal of resources already allocated to patients with poor prognoses for reallocation to patients with better prognoses.
Experts have argued that, if resource constraints become dire, this practice is morally acceptable; some even speculated early in the pandemic that raiding nursing homes for ventilators might be warranted. However, our results suggest that, even if ventilator or ICU bed reallocation might be justified in philosophical theory, Americans may not be as quick to agree with the theorists. Americans tend to think that medical resources should be taken away from patients to whom they were allocated if they recover or die, not forcibly withdrawn.
Finally, we found that Americans favor revising a hospital's existing allocation plan if it is discovered that people of color are automatically disadvantaged in receiving scarce resources under that plan, even if it might lead to less lives saved overall. These results likely reflect growing concerns about health equity in America as well as the disproportionate impact of Covid-19 on Black and brown Americans. During the pandemic, 1 in 1,000 Black Americans have died, often due to racist social determinants of health, and our results suggest a palpable desire among Americans to correct this injustice.
(Notably, we conducted our study just before George Floyd's death — and before much of the data were available on the disproportionate impact of the pandemic on communities of color. If we repeated the study now, the attitudes in favor of revising hospitals' allocation plans that disadvantage people of color might be more pronounced.)
In many ways, our findings validate a core principle of the triage frameworks used across the United States: Steward scarce resources by saving as many lives as possible. But our research also hints at a deep desire among Americans to address issues of racial justice in the fight against Covid-19, as well as issues of access to quality health care as a whole.
These findings only give us partial insight into how to address the growing surge of Covid-19 cases in ways that will make ethical and emotional sense to most Americans. Policy makers, hospital administrators and clinicians will need to balance this information with evidence-based approaches to triage decisions. Still, understanding how Americans may react to the ethically fraught decision of who lives and who dies can assist hospitals in anticipating when disagreements could arise over such decisions, or how to prepare for the moral and emotional trauma that patients' families may experience or to which health care workers may be subjected as they care for dying Covid-19 patients day after day.
We are in uncharted territory.
The U.S. logged over 100,000 Covid-19 cases in one day for the first time this week (and then repeated it), and the vacuum in U.S. leadership has forced our health care workers to persist in the fight despite physical, emotional and moral exhaustion. We have faith in the wisdom of our front-line health care workers to make the best decisions if they are confronted with difficult triage dilemmas.
But understanding how Americans will react to those decisions may help our health care workers navigate these coming, even more difficult times.