Allocate ventilators, other Covid-19 resources based on evidence, not political hunches

The emergence of Covid-19 and its worldwide spread has some of the United States’ top leaders — at least those without public health or infectious disease expertise — succumbing to speculation and calling for action based on political hunches. If policymakers really want to effectively control the spread of the virus, they need to rely on expertise and thoughtful deliberation, especially when it comes to addressing complex and nuanced questions of allocating scarce resources, ordering quarantine and isolation, and controlling infection.

As influenza, SARS, and H1N1 have taught us — and as we are now learning from Covid-19 — individuals with severe cases of these respiratory infections can experience acute respiratory distress syndrome and need to be on a ventilator to breathe. But during an overwhelming pandemic, there may not be enough ventilators to meet the demand for them. In such an emergency, an equitable and efficient way to determine which patients receive ventilators should be in place.

Given time and resources, leaders can prepare for a pandemic and avoid the politicization of scientific and ethical actions by investing in solid research. When guidelines and actions reflect evidence-based reasoning and societal values, the public can trust that its leaders have given thoughtful consideration to their well-being and the well-being of the greater community.

But when time and resources are at a premium, they need to rely on pandemic preparedness resources previously created by state and federal institutions over the course of many years in response to earlier bacterial and viral threats. New York’s Ventilator Allocation Guidelines are one such example.

In 2015, the New York State Task Force on Life and the Law — which was established in 1985 to address bioethical questions of significance to citizens of the state — and the New York State Department of Health revised their 2007 ethical and clinical guidelines for allocating ventilators to adults, children, and infants during an influenza pandemic. The original guidelines were among the first of their kind to be released in the United States and were widely cited and emulated by other states.

Genuine public outreach, education, and engagement are essential to developing just policies and establishing public trust. In that vein, the task force asked for and evaluated input from various stakeholders and focus groups. To achieve its goals, the task force was intentionally comprised of diverse and expert voices in medicine, public health, law, religion, philosophy, and bioethics. This makeup enabled it to remain objective and autonomous as it translated recommendations into concrete clinical protocols, even amidst changing political and philosophical tides.

The ventilator allocation guidelines it produced provide an ethical framework for using this potentially scarce resource. This framework is based on a several ethical principles:

• Duty to care: respecting the fundamental obligation of health care providers to care for patients
• Duty to steward resources, duty to plan, and distributive justice: preventing inequities by devising a just system in advance for allocating ventilators in a time of critical shortage
• Transparency: engaging in clear, consistent communication among health care providers, patients, their families, and the general public

Based on these principles, the task force examined various nonclinical approaches to allocating ventilators. These included distributing ventilators on a first-come first-served basis, randomizing ventilator allocation (sometimes known as a lottery), requiring only informal clinical judgment in making decisions about ventilator allocation, and prioritizing certain patient categories, such as health care workers, older patients, and those with certain social criteria.

The task force, however, determined that these methods should not be used as the primary triage strategy because they are often subjective and/or do not support the goal of saving the most lives.

Instead, it concluded that an allocation protocol should use only clinical factors to evaluate a patient’s likelihood of survival and determine his or her access to ventilator therapy. The linchpin of the evaluation is the sequential organ failure assessment (SOFA) score, which measures function in six key organs and systems. The guidelines stipulated that decisions regarding ventilator allocation should never be based on nonclinical factors such as race, ethnicity, sexual orientation, socioeconomic status, perceived quality of life, ability to pay, or role in the community. This objective approach was determined to be the best way to increase the number of survivors while abiding by important social values.

Thoughtful, reasoned decisions like these are needed to cope with potential public health emergencies. As the staff members responsible for the publication of the task force’s revised ventilator allocation guidelines, we oversaw the extensive deliberative process that went into their making. We facilitated the complex decision-making that went into choices about allocating scarce resources in public health emergencies and participated in identifying the primary philosophical values and ethics underlying the guidelines’ recommendations. We experienced firsthand how this kind of prudent planning encourages public trust and helps ensure, in a disaster, the greatest benefit to as many patients as possible.

This kind of work requires time and resources — neither of which are generally available when faced with an imminent pandemic. Conflicting claims from the Trump administration about the danger of a coronavirus outbreak in the United States are contributing to confusion and mistrust, and the response appears to be muddled and dashed off. In light of what appears to be a politicization of the threat of Covid-19, policy and lawmakers must not rely on fear and misrepresentation. Instead, they should turn to vetted public health preparedness initiatives that can provide expert guidance for the circumstances we now face.

Politics must take a backseat when the public’s health is on the line. Without the time and the resources to create sound public policy, turning to previous pandemic response efforts is a good option to identify key scientific and public health issues, explore and reconcile diverse viewpoints, and appropriately gauge risk.

Susie A. Han was the deputy director of the New York State Task Force on Life and the Law and the project chair of the Ventilator Allocation Guidelines and is currently a partner at Venture Catalyst. Valerie Gutmann Koch was the senior attorney and special consultant to the New York State Task Force on Life and the Law and is currently the director of law and ethics at the MacLean Center for Clinical Medical Ethics at the University of Chicago and faculty fellow at DePaul University College of Law.