Justice in Covid-19 Crisis Triage

Justice in Covid-19 Crisis Triage: Race Equity and Maximization

By Kate Lowry

This research paper explores crisis standards of care in the COVID pandemic and the issues of justice within scarce resource allocation in hospitals. When the demand exceeds the supply of critical care resources in the ICU, triage is implemented in an attempt to fairly distribute life-saving resources. This paper explores the criteria involved in this decision-making process and analyzes to what extent the hospital triage system in the U.S. today upholds the value of justice. By reviewing the scoring systems that hospitals use, it becomes apparent that people of color are at a significant disadvantage for life-saving resources. I will be comparing two key frameworks of triage, the utilitarian-based approach of maximization and the justice approach in order to find where disadvantaged populations have failed to receive priority. This analysis will help to define what the role of hospitals should be during crisis standards of care and to what extent the priority of populations of color should be valued.

Table of Contents:

• Abstract
• Introduction
• Background on Crisis Standards of Care
• Disparities in Prioritization
• Triage From a Utilitarian Perspective
• Triage From a Justice Perspective
• Comparison of Utilitarian vs. Justice Frameworks
• My Suggestion for An Ethical Triage
• Conclusion

The Covid-19 pandemic has forced hospitals into a crisis standard of care that has required the allocation of limited resources and forced clinicians to make difficult decisions about who gets a ventilator, dialysis machine, or ICU bed. The crisis standard of care triage scoring guidelines in place in the U.S. today follow the utilitarian framework of maximization which allocates scarce resources to those deemed most likely to survive long-term, in order to save the maximum number of lives. At times this goal can supersede the principle of justice by placing those in marginalized groups at the lowest priority. Racial minorities, and specifically Black and Hispanic populations, have been disproportionately harmed by utilitarian triage guidelines that seem neutral on paper, but this neutrality comes with negative consequences. As a result of systemic inequalities regarding access to care, jobs, adequate education, and housing, these populations are fundamentally disadvantaged in scoring systems because of their comorbidities, which result in reduced expectations for long-term survival.

If saving the maximum number of lives perpetuates health inequities for people of color, is it possible to maintain a utilitarian goal while simultaneously valuing justice and mitigating inequalities for these populations? Here is a case example of racial discrimination in a Covid-19 triage: two patients have the same Covid-19 symptoms and are in need of ICU care with a ventilator. One is a 40-year-old white man named John who has no comorbidities and is otherwise healthy. The other is a 40-year-old African American woman named Rosa who has diabetes and asthma. Rosa scores significantly worse on the SOFA (Sequential Organ Failure Assessment) score compared to John, meaning that her projected long-term survival is shorter. However, Rosa lives in a heavily-populated area where she has challenges accessing health care and affordable healthy food options. Additionally, Rosa, along with many other African Americans, has a lack of confidence and trust in the healthcare system because of the years of mistreatment towards African Americans like, for example, in the Tuskegee trials (Schmidt). The Tuskegee Trials, among many other experiments, represents the exploitation and abuse towards African Americans through the trial’s refusal to treat syphilis in African American men (Brandon et al.). Horrors like these have formed deep-rooted mistrust in the healthcare system, an important consideration when weighing the priority of discriminated against individuals in health crises today. 

If you had to make a decision between giving the ventilator to Rosa or John, which patient should be prioritized? John’s life expectancy is greater and he is expected to spend less time in the ICU than Rosa, so he will end up being prioritized. Due to Rosa’s preexisting conditions, which could be attributed (at least in part) to the structural injustices that she has faced in her lifetime, Rosa would not be given the ventilator, or at least not right away (Schmidt). There is a chance that when another ventilator becomes available she would receive it, but when receiving priority is a matter of life and death, this decision is a critical one. When considering both the value of human life and acknowledging existing barriers to health as shown through this case study, the decision of who gets the needed resource introduces many sides to the complex ethical dilemma of medical triages. 

In public health crises like Covid-19, hospitals often find themselves with considerably more patients in the ICU than the number of resources to go around, constituting the need to switch to new standards of care in order to meet the high demand. The continuum for normal to emergency standards for hospitals increases in intensity from conventional standards to contingency standards, and then finally crisis standards, where it reaches its highest intensity. Conventional standards are defined as the normal standards of care in hospitals with no use of triage or resource rationing. When intensity increases, hospitals move into contingency standards in which the conventional standards remain, but with a shift to the conservation of resources. This standard is usually in preparation to move into crisis standards, so a limited rationing of resources takes place. An important thing to note in these standards is that both prize patient autonomy, meaning that these stages follow a patient-centered care model. The largest shift takes place between contingency and crisis standards of care. In the standards of highest intensity, the demand exceeds supply of resources and rationing criteria are applied. Crisis standards are defined by the goal of maximizing lives saved using triage, i.e., maximization. In this threshold, the burden of distributing scarce resources is taken on by triage teams as opposed to a single physician at the bedside. The prioritization of patient autonomy is replaced by public-health objectives in order to ensure a maximization of survival (Kirkpatrick). This change from conventional to crisis standards raises the stakes considerably, and with no guarantee that they will be able to get additional resources in the near future, hospitals are left to prioritize some patients over others. 

In the U.S., The University of Pittsburgh Department of Critical Care Medicine is a proponent of one of the leading frameworks for crisis standards of care. This framework entails how and what to consider when making triage teams, criteria for the allocation of scarce resources, and the reassessment criteria to determine whether to provide ongoing care or not to a patient in critical condition (White). It is inevitable that sacrifices will be made to an individuals’ health when crisis standards of care are implemented, but the question remains: who should be the ones who are left with the short straw?

It is important to consider the systems in place today that help physicians to determine the priority of individual patients. The most recognized scoring system in the U.S. for triage in the Covid-19 pandemic is the SOFA score, or the Sequential Organ Failure Assessment. The SOFA score was developed in 1994 to diagnose the acute morbidity of a critical illness at a population level in the ICU. It is most associated with the diagnosis of sepsis, and the degree to which the patient’s organs are experiencing failure or dysfunction. The SOFA score assesses the six major systems of the body: respiratory, cardiovascular, neurological, renal, hepatic, and coagulation. Each system is given a score from 0 to 4, higher numbers reflecting a higher level of dysfunction (Lambden). Patients with the best SOFA scores, or those patients with the least amount of organ dysfunction, are given the highest priority. On the other side of the spectrum, those with the highest amount of organ dysfunction, and the lowest score, are placed in the category for lowest priority. In this category, those patients would only receive the needed resource if the patients in the categories of higher intensity have their needed resource. 

There are many advantages of this scoring method, most prominent being its ability to quickly and accurately assess priority under a limited time window, giving it the title of a rapid assessment. The SOFA score only has 6 points of data as opposed to other systems which can have upwards of 36 variables. Additionally, the SOFA score removes doctors from a position of bias so that they do not have to make emotionally draining decisions on their own, where their knowledge and relationship to individual patients may influence their decision (Nelson and Francis). It is important for a doctor to limit their bias as much as possible because according to the American Journal of Public health, ⅔ of health care providers hold some form of implicit bias (Hall et al.). 

There are still some disadvantages of the SOFA score which should not be left out. While using this scoring system, it can be seen as discriminatory if patients choose to deny treatment on the basis of criteria for short term survival. In this way the physician would be denying treatment for the patient’s ‘best interest,’ something easily impacted by a physician’s own bias (Nelson and Francis). Second, SOFA scores were not designed to take into account racial injustices. Some might see this as a benefit, but in the framework of justice, it is an area of consideration, something I will discuss in detail later in this paper. Third, certain acute illnesses like isolated respiratory failure have been shown to score lower than they would in similar types of assessments. Conversely, end-stage renal disease has been diagnosed with a higher score than they would score in similar types of assessments (Tracie). From these disadvantages we can see how triage scoring methods are far from perfect. It is important to consider the fact that scoring methods for crisis standards were not intended to be fair in every circumstance or exception, because crisis standards call for temporary solutions. This does not mean that hospitals have to continue with the guidelines they established at the start of the crisis, but rather learn the flaws and conceive of a more ethical resolution that they can either adopt now, or implement in the future. 

Maximization, however, is not the only triage approach. In fact there are many methods to consider when determining the most ethical response to a crisis situation. The first come first serve approach gives resources to those who arrive first, and although it has been used in many scarce allocation settings, it has been rarely used in Covid-19 settings. The issue with this approach is that it favors those who have greater access to care rather than the general public, raising many equity concerns for individuals who don’t have as much access to routine medical care (Solomon et al.). Due to these equity concerns, this approach significantly reduces public fairness, something public health officials have overwhelmingly deemed unethical for the circumstances of Covid-19. 

An allocation lottery is another approach. This method completely ignores factors of race, age, or socioeconomic status, so it seems ethical because it offers a level playing field. However, a lottery fails to take into consideration the severity of a patient’s condition, and does not differentiate a patient with a high likelihood of benefiting from the resource to one who is most likely to die regardless of the resource (Tolchin et al.). By not determining who is most likely to benefit, individuals who are likely to die regardless of the resource would be given the same priority as one who could not survive without it, potentially leading to an outcome of fewer lives saved overall. 

When determining criteria at the population level for the allocation of scarce resources, age has been a controversial topic. At its first surge, Covid-19 caused ICUs worldwide to begin rationing under extreme time restrictions. This led to the implementation of age cut-offs in countries like Italy, for example, which refused to treat patients with ages as low as 65 in some regions (Lintern). The University of Pittsburgh School of Medicine suggests age should be used only as a tiebreaker if two or more patients have the same score. In this circumstance, priority will go to the younger patient. They argue this is not on the basis of social utility or intrinsic value, but simply because they have lived through less life stages than the older patient (White and Lo). By using this same logic, however, valuing younger patients outside of a tied circumstance can be justified. Consequently, this would shift the focus of prioritization to saving the most life-years. Valuing life-years in triage would devalue older patients, who are the most at risk comparatively speaking, and would not necessarily save the most lives if no other medical considerations were taken into account. 

Comorbidities are a major criteria for the allocation of scarce resources. In simple terms this means patients with conditions that significantly lower their overall health will not be prioritized. This criteria will hurt the communities that are more prone to developing comorbidities far more than those without this life-determining risk. Systemic injustices affect most significantly the development of comorbidities in Black and Hispanic communities like chronic kidney disease, diabetes, chronic obstructive pulmonary disease, and hypertension (Manchanda et al.). As you can see from the graph below, the combination of one of these conditions plus Covid-19 results in a substantial percentage of deaths. The highest contributor to mortality is chronic kidney disease, something that Black patients are four times more likely to develop than white patients. Additionally, Hispanics are just about two times as likely, in comparison to all non-Hispanics, to be diagnosed with chronic kidney disease. In African American adults over 20, a shocking 42% have hypertension compared to the percent of hypertension in Caucasion adults at 28.7% (Carratala and Maxwell)(Tartak et al.)(NIDDK). The SOFA score is solely meant to diagnose the severity of acute diseases, and with a systemic predisposition to developing these conditions, it begs the question: Is it fair to prioritize allocation of scarce resources to individuals based on the SOFA score (or similar assessments), when structural inequalities make it more likely that people of color will score lower on these scales? 

Results from studies done in the U.S. in 2020 show that Black individuals were 3.7 times as likely to be hospitalized than white individuals when diagnosed with Covid-19 and Hispanic individuals were 4.1 times as likely to be hospitalized than white individuals when they are diagnosed with Covid-19 (CDC). If the SOFA score takes a holistic approach to prioritization, including race and ethnicity in its assessment instead of just focusing on the acute morbidity of the patient, then more Black and Hispanic individuals might be treated with greater fairness by being assessed only in comparison to other patients of the same race or ethnicity. 

In crisis standards of care, hospitals claim to be trying to maximize survival. When deciding who will benefit the most from treatment, they are generally weighing a patient’s short-term survival. This encompases the time up until a patient’s discharge and up to a year after (White and Lo). Taking into account long-term survival is an entirely different consideration and raises many more ethical concerns like agism and ability. 

Saved life-years is determined by a patient’s life expectancy, something that is impacted by one’s disabilities or conditions stemming from social injustices. Not to mention, long-term life expectancy is extremely difficult to predict and those predictions can be easily impacted by a physician’s biases. From 2019 to 2020, life expectancy for Black and Hispanic individuals has decreased disproportionally. The largest decline of life expectancy for individuals was for African Americans which dropped by 2.7 years in comparison to 2019. The second largest decline was by Hispanic individuals whose life expectancy dropped by 1.9 since 2019 (Rodriguez). 

Taking into account intrinsic value, meaning someone’s social utility, in prioritization is another issue of fairness because it can lead down a path towards discrimination if one group of individuals is valued higher over another for their contribution to society. Despite this consideration, healthcare workers have been deemed exceptions based on their unique position to help others. It is argued that prioritizing healthcare workers in ICU triages will limit absenteeism and prevent a decline on the frontline which could potentially lead to less patients being treated. Additionally, the concept of reciprocacy plays a major role because of the risk medical professionals take on every day to provide care, and society’s duty to prioritize those who put themselves in harm’s way for the greater good (Kirkpatrick). Few disagree with the prioritization of healthcare workers, but it is important to consider this as an exception to the concept of maximization because those healthcare workers who have been infected may not be the patients most likely to survive, as determined by the SOFA score. Further, individuals who would normally get priority without the inclusion of healthcare professionals in the decision, may not receive their needed resource as early as they would have or they could potentially not receive the resource at all. 

The devastating effects of the pandemic have fallen disproportionately on the Black community and the Hispanic community, both of which have a higher likelihood of contracting the virus than people of any other race. Many Black and Hispanic individuals work essential jobs in a field that does not allow for remote working and makes social distancing difficult. The rate of transmission in many types of essential jobs will be higher for this reason. According to the U.S. Bureau of Labor Statistics in 2020, only 16.2% of Hispanic individuals could work from home and only 19.7% of Black individuals could work from home compared to almost 30% of white people who were reported to have been able to work from home (Gould and Shierholz). Not having the option to work from home puts those individuals’ health at risk, and is a factor in considering why Black and Hispanic individuals are at a much higher risk for both attracting the virus and getting hospitalized because of the virus. 

These statistics speak for themselves: counties that are majority Black population have an infection rate three times the rate in majority white counties and a staggering mortality rate of six times that of white counties. Failing to address this disparity in mortality rate between Black and white counties only deepens the divide in health equity and access to care. Public transportation is another huge risk that puts people who live closer together, and do not have the luxury of working from home, at a much higher risk (Manchanda et al.). Although choosing not to consider location while ranking priority was done in the hope of saving the most lives, failing to consider this factor is threatening the fairness of the prioritization for those living in higher-risk areas. 

Factors like the access to affordable healthcare and housing along with adequate schools are an ongoing mechanism of disparity, one that has only grown in vigor since the start of this pandemic. An alarmingly high unemployment rate of 11.4% for Black individuals in 2020 is the highest unemployment rate compared to any other race. Hispanic individuals in 2020 had the highest rate of people who do not have health insurance, when compared to any other ethnicity, at 27.2% uninsured (Statista). These statistics, paired with the ongoing and deep-rooted distrust of the healthcare system by Black and Hispanic individuals due to discrimination and racism in the past, significantly reduces their accessibility towards public health resources. During a crisis in particular, public health goals affirm greater access to care for all, an objective that does not reign true for these populations in particular. 

The theory of utilitarianism is defined by generating the greatest good for the greatest number of people as determined by its number of positive outcomes. Under a utilitarian-centered triage approach the goal is simple: save the maximum number of lives. This maximization works alongside crisis standards to optimize the health of the greater public by prioritizing those with a greater chance of surviving beyond Covid-19 with the scarce resource.

Consider this simplified example, if you have two patients in need of a ventilator, one with a 90% chance of survival, and another with a 10% chance of survival, under this form of utilitarianism you would give the ventilator to the patient with the higher chance of survival. If you are consistent in this approach, for every 10 people, 9 would be saved as opposed to just 1 person. This example, however, is a simplified model and does not accurately represent how someone’s predicted survival plays out because, as the name suggests, it is a prediction and is not guaranteed that one person will survive or another will die. 

In a utilitarian-guided approach, long-term survival would be taken into account. If you have a 40-year-old patient and an 80-year-old patient, both in otherwise good health, a utilitarian approach would favor giving the scarce resource to the 40-year-old patient on the basis that they are expected to live a longer life. Long-term survival doesn’t always come down to age, however, and this is because comorbidities play such a big factor in the assessment criteria. Taking that same example, if the 40-year-old patient suffers chronic kidney failure and scores significantly higher than the 80-year-old patient on the SOFA score, the 80-year-old patient will be prioritized (Savulescu).

One might wonder how a framework that works to save the maximum number of lives and benefit the greater good of a population can be unethical in its motives. It is in fact the very basis of the utilitarian ethical framework that leads to this objection. What the utilitarian approach fails to consider is how likely a patient is to develop score-raising comorbidities or what factors are contributing to their shortened prognosis for long-term survival. If this approach does not address systemic inequalities, it will perpetuate those same inequalities. If Black and Hispanic populations are significantly more likely to develop comorbidities in their lifetime, shouldn’t there be a correction factor that takes their disadvantages into account?

While one might consider a justice approach to hinge on equality, it instead focuses on equity, meaning social determinants of health are taken into account in order to give proportional care to individuals who are disadvantaged. There are no strictly justice-centered triage systems in place now, but if they were to be instituted they would be determined on the basis of health equity and maximizing justice outcomes. In the United States, Black individuals have an average life expectancy that is five years shorter than white individuals (White and Lo). Choosing not to factor life-expectancy would therefore prevent inequities in regard to race in justice-centered triages. 

Let’s consider this example of two patients. One is 55 years old with an average life expectancy and who is in good health, can work from home, and lives in a spacious house in the suburbs. The second patient is 55 who works an essential worker job where they cannot work from home. This individual shares a crowded home and they live in the city where they must take public transportation. There is a greater chance that the second person, who is at a greater risk for contracting the virus, is also a member of a racial minority. A justice triage would take these factors into account and give more priority to the individual facing greater systemic inequalities because their focus, unlike the utilitarian approach, would be on mitigating inequalities and maximizing justice outcomes, no matter the outcome of their health assessment (Tolchin et al.). 

Many argue taking into account social justice concerns is not easily determinable for the limited timeframe in a public health crisis. In this approach, there are potentially fewer lives saved if scarce resource allocation is no longer (primarily) driven by projected survival, e.g., if a member of a disadvantaged population who has a lower projected chance for survival is given priority. If priority is instead allotted to those individuals in disadvantaged groups it fundamentally changes the reaction to a public health crisis, meaning if those disadvantaged by race or ethnicity receive greater priority, then so should every other individual in a disadvantaged position, no matter their circumstances. If this logic is continued, what would make this system of allocating priority distinguishable from non-crisis standards when the most at-risk are given the highest priority?

The utilitarian approach of saving the most lives often conflicts with a justice framework in its focus on systemic injustices and equity. Health inequalities often increase a patient’s risk for comorbidities and shorten their life expectancy, placing them higher on a justice-centered framework, but lower in a utilitarian framework because they are less likely to benefit, or survive, from the treatment. It is also important to consider that when choosing  triage guidelines, the framework does not have to be merely utilitarian-guided or merely justice-guided. One might argue, however, that a utilitarian framework with justice adaptations is not utilitarian anymore because it no longer maximizes benefits to its utmost degree. In addressing this view, one must consider that public health is not restricted to one ethical doctrine and it is most often a combination of concepts that takes the most ethical aspects of each framework. 

In the words of bioethicists Ruth Faden and Madison Powers, from the Kennedy Institute of Ethics at Georgetown and the Berman Bioethics Institute of Johns Hopkins University, the goal of public health ethics is

“To improve human well-being by improving health and related dimensions of well-being and to do so in particular by focusing on the needs of those who are most disadvantaged.”

– Ruth Faden and Madison Powers

In a crisis, the scope of care is expanded to a greater population rather than focusing on the individual. Sacrifices must be made and hospitals must choose between many deserving candidates, and some will inevitably be left behind. It is the goal of public health, to determine “who will benefit the most” in the most fair way, which cannot exclude the most disadvantaged. 

Due to the fact that utilitarian-centered and justice-centered frameworks conflict in many areas, it is difficult to determine where to draw the line between saving the most lives and mitigating existing inequalities. On the one hand, disregarding the save-the-most-lives goal of utilitarian triage results in an obvious outcome: more lives will be lost. But on the other hand, disregarding the framework of justice leads to an perpetuation of racial inequities and systemic injustices, creating an even larger divide in health equity. 

The pandemic has heightened racial inequities in the Black and Hispanic communities in particular, and in my opinion, this has made it clear there is no ‘best’ time to make efforts towards reducing the strain of inequities in healthcare. What the utilitarian approach fails to consider is how likely a patient is to develop score-raising comorbidities or what factors are contributing to their shortened long-term survival. This is why I believe that more of a justice-centered lens needs to be adopted into the already existing utilitarian framework through correction factors and limits.

My suggestion for an ethical triage would keep aspects of the utilitarian approach while also adding more correction factors to increase priority of those who are systematically disadvantaged. First, I would not take into account long-term survival because it perpetuates inequalities for individuals with shortened life spans for reasons relating to their age or conditions arising from social determinants of health. It is important to note the distinction between long-term and short-term survival, as I would take into account those who are predicted to have a short life expectancy after recovery from Covid-19, and I would reject considerations relating to the life expectancy of the individual far beyond their predicted recovery from Covid-19 (hospital discharge being the cut off). With respect to long-term survival, I believe correction factors should be added to the existing SOFA score for comorbidities like hypertension and chronic kidney failure which disproportionately affect Black and Hispanic individuals and significantly increase one’s mortality rate with the addition of a Covid-19 diagnosis (Galiatsatos et al.).

Another factor I would take into account is the area in which each patient lives and the degree of poverty, education, and environmental factors in that area. Dr. White and Dr. Lo from The University of Pittsburgh Department of Critical Care Medicine suggest using the ADI (Area Deprivation Index) because it ranks areas by socioeconomic disadvantage and census information and takes little time to calculate. It has been proven that living in an area with a high ADI score is related to the rate of developing certain health conditions like cardiovascular disease and diabetes (Neighborhood Atlas). Taking into account the environmental and socioeconomic considerations that impact a given area would make it less likely for individuals living in the same area to continue to be deprioritized. Another method would be to use the hospital data on patient’s zip codes to find where the sickest live to determine who is at the highest risk geographically. This would reduce the inequalities between patients coming from different zip codes and give more proportional care to those who need it.

Finally, I believe that patients in disadvantaged populations should be granted more time with a life-saving resource if the race or ethnicity they identify with, for example, has been proven to need a longer recovery period. For example, evidence shows that to reach the same rate of mortality as white patients, Black patients need a longer recovery in the ICU (Galiatsatos et al.). This suggestion would reduce the times a life-saving resource was taken from a patient before they had enough time to use it, and most likely prevent their need to use the scarce resource again if they had too little time with it previously. 

In this paper we have discussed crisis standards of care, triage frameworks of maximization and justice, and the issues of equity for disadvantaged populations. Triage frameworks can take the form of a first-come first-served approach or a lottery, and while these methods may remove physician bias, they fail to tailor the care to the needs of the patients. The SOFA score is widely acclaimed as the best option for the current circumstances because of the minimal points of data and clear levels of priority. The SOFA score, however, does not take into account race or the effect of racial inequities, which can be seen as inequitable through a justice lens, but suitable for a maximization triage.

This pandemic has heightened the impact of systemic inequalities on the Black and Hispanic communities, making it more likely for these communities to contract the virus, be hospitalized, and die from it. It raises the question, should racial barriers be taken into account when allocating priority in ICU triages, similar to what has been done for healthcare workers?

A key component of crisis standards in hospitals is to prioritize patients with a greater chance of survival. Debate exists between keeping a utilitarian triage that focuses only on maximizing the number of lives saved, and prioritizing those in the most optimal condition for long-term survival, or shifting our efforts more towards mitigating those inequalities that are disproportionately affecting certain minorities. Both the utilitarian approach and the justice approach value fairness in different ways, and it is important to consider both approaches to triage in order to have a system that both aimes to save the most lives possible, and avoids deepening existing barriers to care in disadvantaged populations.