Maximizing outcomes in triage of critical care resources—is there a consensus?

By Lynette Reid

My university told us to work from home in mid-March; public health asked us to limit shopping and travel—but to get outdoors for exercise—soon after.

I can’t complain. I have secure employment; my partner and I live outside the city in a fishing village with protected wilderness all around. It was like a command to sit out the pandemic Decameron-style: holed up in beautiful surroundings, watching the spring unfold in more detail than usual, connecting with friends, outdoors, with 2m distance, our droplets swept away by the generous North Atlantic breezes.

The village is what real estate agents call a “mixed” community. It’s not a classic gentrification story: for a long time, some professionals have been spending weekends here and (once the roads improved) living here full time. Fishing families who have been here for centuries were hit hard by the collapse of north Atlantic groundfish stocks in the 1990s. The fish plant closed not long before we moved here; it was demolished soon after. The remaining economic activity is in lobstering.

The social determinants of health are stark here, though like everywhere, there is variation and complexity. Not everyone who hikes and jogs and grows a garden of fresh vegetables has the same class identity, and the same can be said for persons living with multiple chronic conditions. But the patterns are pretty clear.

When bioethicists started affirming to clinicians and the public that in pandemic emergency triage, there is an ethical consensus in favour of saving the most lives, my thoughts went to the contrast between me and my neighbours. Are we so certain that my lifetime of privilege and the health advantages it has brought me should also buy me a ticket to the front of the line, while my neighbours might be kept out because of the cumulative health effects of decades of public policy choices that have already disadvantaged them so much? Even if my chance of survival is (let’s say) 60% and their chance is 30%? In many settings these contrasting life opportunities are highly racialized.

I wondered: can I conscientiously object to compounding my privilege this way? Can I put a rider on my advance directive that I would only accept ICU admission if I got in by a lottery giving my neighbours a fair chance at admission? Or only if disabled persons with health vulnerabilities or shortened lifespans aren’t excluded? Should I unilaterally forego ICU admission even if they would just give my spot to the next healthy (and probably wealthy) person?

This isn’t just a gut level moral reaction. It’s a question of legitimacy of public policy in a domain where there is no unanimity about deep value questions.

I sit on a national health technology assessment (HTA) body that, like many HTA bodies, balances multiple values in decision-making. Outcome maximization is an important corrective to short-sighted prioritization of need, but it is not the dominating value. Even in organ transplant, equity and need still play strong roles. This isn’t because these processes are subject to political pressure that interferes with their doing the right thing.

From centuries of debate about consequentialist theory, we know that the plausible ideal of maximizing any single good (even where that single good is lives saved) has deep problems. It is blind to distribution (except through the convenient moral fact that everyone has but one life to be saved). People are committed to many different values; centuries of philosophical attempts to unify these commitments have not (yet?) succeeded. Even where we do agree to maximize one value, we have to grapple with the uncertainties of real world decision-making and how they matter.

Where there is a lot of “low value care” delivered in ICUs, an emergency may offer a chance to address that issue. But that doesn’t generalize to a universal philosophical truth that outcome maximization dominates in emergency triage.

Now, the biggest health inequities from the SARS-CoV-2 pandemic will probably not come from inequities in ICU admission, but from other factors: occupational exposure; urban planning that has left many people without realistic options for socially distanced transportation, work, and recreation; our failures to address long-simmering political struggles that are becoming more urgent to the public than outbreak control.

Nonetheless, even if triage protocols do not affect large numbers of individuals and when we successfully avoid using them by mitigating the outbreak and ramping up critical care capacity, they have tremendous symbolic significance.

As countries experiment with re-opening and as we face subsequent waves of SARS-CoV-2, critical care resource shortages can no longer be called an unanticipated emergency. It’s time to explore principled and contextually appropriate ways to balance multiple values in triage. In my paper “Triage of critical care resources in COVID-19: a stronger role for justice,“ I draw distinctions between relevant interpretations of justice, give examples of their operationalization, and discuss balancing considerations. I’m not the only one pressing this point in the midst of the pandemic. I hope that this paper will be a useful resource for debate and decision-making as we consider lessons learned in the first wave and adjust the protocols that have been put in place.


Paper title: Triage of critical care resources in COVID-19: a stronger role for justice

Author(s): Lynette Reid

Affiliations: Department of Bioethics, Dalhousie University

Competing interests: None

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