It’s no accident that people describe something that’s calculated, cold, and unemotional as “clinical.” Taking care of people’s health isn’t emotion-free by any means, but the clinic is where physicians and nurses have to make life-and-death decisions under time pressure—including which patients go first, and what kind of care they get. When resources like, say, ventilators, intensive care beds, oxygen, staff, and time are scarce, that decisionmaking is called triage. And last week, The Dallas Morning News reported that some Texas hospitals were considering a massive change to how they do it. The question in play: Would it make sense to take into account the vaccination status of their Covid patients? With ICUs filling up with severely ill Covid-19 patients and a shortage of beds and nurses, should clinicians (all other things being equal) care for vaccinated people before—or differently than—unvaccinated ones?
Now, that hasn’t happened, and probably won’t. The idea came from a memo from the North Texas Mass Critical Care Guideline Task Force, a regional organization of physicians, nurses, and other stakeholders, who developed the procedures for hospitals to follow during rough times like a pandemic. The team that wrote the memo rushed to say they weren’t pushing a new policy, just trying to talk it out. “People are burned out, they’re exhausted, they’re angry. So one of the questions that’s been coming up is: Can we consider a patient’s vaccine status if we’re making a triage decision?” says Robert Fine, a physician and co-chair of the team that wrote the memo about vaccine status. “No decisions were made,” Fine says. “We urged the task force, ‘Please share this with your triage and ethics committees and your clinical care doctors so we can continue this discussion.’”
The memo Fine mentions was of the “Come on, we’re all thinking it” school of talking points—which is a good thing! It would’ve been a troubling change, to say the least. Emergency rooms are legally required to care for everyone, no matter what sets of decisions got them there—it doesn’t matter if you’re the innocent cyclist or the seat-belt-eschewing drunk driver who crashed into them. And then after admission, a hospital’s care guidelines define what treatment patients get. Texas doesn’t have statewide guidelines for critical care and triage, which means that caregivers are left to their own local organizing. But tough times like the ones brought on by low vaccination rates and the Delta variant require a reexamination of priors. This fourth wave of Covid hospitalizations differs from all the others, because almost everyone who is severely ill is also unvaccinated. In Texas, more than 12,800 people are in the hospital because of Covid-19, and between 93 and 98 percent of them are unvaccinated. It’s tempting to blame this wave not on the virus but on the people who didn’t get their shots. “This has been bubbling up—this anger, this frustration, this fear, this worry. Every day, we’re seeing the ascent of the curve. Now it’s the steepest it’s ever been,” Fine says. “So I and the other leaders of the task force, we decided, you know, these numbers are not looking good. These questions are coming up.”
Sure. You get it, right? “I have tremendous empathy for the doctors and particularly for the nurses there. It’s just a terrible situation they’re in. They’re working as hard as they can, under great stress, and the patients and families often lash out at them and they’re not grateful,” says Bernard Lo, director emeritus of the Program in Medical Ethics at UC San Francisco and author of Resolving Ethical Dilemmas: A Guide for Clinicians. “It’s really hard to take care of people thinking that they could have done something very simple: Get two shots that would have avoided this, in the overwhelming majority of cases.”
The problem, as Fine and Lo readily acknowledge, is that’s really not how triage is supposed to work. It’s a complicated medical and ethical issue, but the plainest version is that the most effort goes to the people most likely to survive. That’s not always easy to determine in advance, and in places hardest hit by the pandemic, triage has always been tricky, because the disease differentially affects poor people and ethnic minorities. Triage guidelines are there to keep clinicians from unintentionally giving in to their biases, to make sure treatment is equitable and ethical in all the ways the disease and society are not. Worse, if resources are unlimited, you don’t have to triage—so clinics with less money have to do more triage and they’re also, by dint of their locations and populations served, also most likely to see the people most affected by the disease.
Around the world, hospitals and clinicians have broadly agreed that both Covid and non-Covid patients should have the same triage principles applied, that care shouldn’t be first-come, first-served (because of differences in accessibility), and that the primary metric should be getting the greatest number of people to leave the hospital alive. Cultural values sometimes come into play about whether to consider a more subtle prognosis: quality of life, or years lived, or, like, which person is somehow more valuable, if that was even calculable. (And triage isn’t the only way to divide vaccinated and unvaccinated people; the fact that private insurers are pulling back on paying for Covid care seems like a pretty good repudiation of the idea of forgoing one’s shots.)
One thing ethicists and clinicians have come back to again and again is avoiding “categorical exclusion criteria,” attributes that knock someone out of the triage running. For example, before the widespread availability of vaccines, elderly Covid patients died at a much higher rate than younger ones. But nobody wanted to exclude old people from treatment, right? That’d be monstrous. Or, as a team of Swiss ethicists argued last spring, you might distinguish between “first-order criteria,” like demographics, and “second-order criteria,” more subtle stuff that’d only come into play in a tiebreaker—two patients, alike in every possible way, similar prognoses, similar diagnoses. But deciding what differences to take into account is very tricky. If it’s health status, how do you assess that? How might socioeconomic status influence prognosis, and can you account for that equitably? What ethicists and the Texas task force were floating is, essentially, whether vaccination status might be a second-order exclusion criterion—even though, to be clear, one of the task force’s main points is that vaccination status could not, by itself, be a categorical exclusion criterion.
In part, that’s because the whole idea comes with a caveat the size of, well, Texas. Yes, far fewer vaccinated people get severely ill. But no one knows if severely ill vaccinated people have better outcomes—more survivability—than severely ill unvaccinated people. It seems likely that once you’re sick enough to be in the hospital, you’re sick enough to be in the hospital. But as far as I can tell, no such published data exists. “I personally have that sense from the data I’ve seen, but that is very preliminary data. There is no peer-reviewed study showing that,” Fine says. “So one has to be careful.”
Careful indeed. A big part of the rationale for triage guidelines is consistency, so individual doctors don’t have to rely on their intuitions. “Covid has taught us lots of things, but certainly that there’s a lot of implicit bias within the health care system, and certainly with Covid outcomes,” Lo says. “And we want not to make that worse.”
Plus, as much as we all might understand and empathize with the rage and frustration of health care workers—emotionally drained, epidemiologically at risk—whatever blame we might place could well be misdirected. “We know people are frustrated and angry, but that’s not a basis for decisionmaking,” Fine says.
Vaccination status, as Fine notes, is more complicated than that anger might allow. “I think we have to be really careful about saying someone chose not to be vaccinated. Some people do,” Lo says. “But there are still people who have difficulty making an appointment, who aren’t internet-savvy, who don’t speak English as a first language. A lot of people work in jobs where they don’t have time off, or if they get even a day of adverse effects from the vaccine and can’t work, their pay gets docked.” And how would a clinician trying to triage based on vaccination status distinguish among those groups, even if they were allowed to?
For that matter, even the people who resist vaccination because think they’ll never get sick, or that if they do then a horse deworming drug will save them, or that vaccines contain magnetizing 5G antennas through which Bill Gates can turn them into werewolves (They don’t! None of those things are things!)—those people have been lied to by leaders they trusted. Bad information is cheap; better information is expensive. And as ugly as the Covid numbers might be getting across the South, rage might be better directed at political leaders who are resisting basic public health measures instead of the people suffering as a result.