The Covid-19 pandemic has overwhelmed hospitals around the world, forcing individual health care institutions and providers to ration limited medical resources including ventilators amongst their patients.
A NEJM article written by several bioethicists outlines 6 recommendations for fair and effective resource allocation in the event of resource scarcity.1 This group suggested that, all else equal, health care workers (HCWs) should get priority over medical treatments. Although “promoting and rewarding instrumental value” appears both just and practical in a pandemic, providing HCWs unique, preferential access to ventilators is neither a fair nor necessary allocation criteria.1
Proponents of prioritizing ventilators for HCWs cite two main arguments: (1) HCWs who recover from Covid-19 will be able to return to work to care for the rest of the population and (2) neglecting to promise optimal treatment for HCWs will promote absenteeism. The first argument initially appears pragmatic, as HCWs are scarce resources: if thousands of HCWs become sick or die, Covid-19 will more easily overwhelm hospitals, leading to more suboptimal treatment and death. Prioritizing treatment for infected HCWs would therefore promote utilitarianism if the medical intervention enabled HCWs to return to work or avoid infection all together. While PPE, a theoretical vaccine, and a medication that reduces disease severity would satisfy this requirement, HCWs with severe enough disease to require a ventilator are unlikely to be able to return to work in the near future should they survive. Given the long recovery times and medical complications associated with mechanical ventilation for both Covid-19 and non-Covid-19 patients, providing HCWs priority over ventilators likely has limited utility in reducing HCW scarcity.2,3
Second, some contend that HCWs need reassurance of optimal treatment in order to risk their lives at work each day. This concern for absenteeism stems from a long history of HCWs neglecting to treat patients with infectious diseases. During 14th century plague outbreaks, doctors commonly fled affected towns, leaving thousands to die untreated. In the 1980s, many HCWs refused to treat patients with HIV. In the years after these historical epidemics though, the medical community and the AMA have largely affirmed that physicians must “apply [their] knowledge and skills when needed, though doing so may put [them] at risk.”4, 5 While professional duties regarding acceptable risk are less clear for other HCWs including nurses, an existing social contract between HCWs and society states that HCWs agree to put themselves in harm’s way by caring for the sick and, in return, receive trust, esteem, and financial stability. HCWs who reap these societal benefits have a responsibility to continue working in a pandemic regardless of whether they are promised preferential care or not. So far in this pandemic, we have seen little absenteeism despite the lack of clear guidelines giving HCWs priority over ventilators or even adequate PPE, demonstrating a collective adherence to this social contract.
Although promising HCWs preferential access to optimal care is not necessary to prevent absenteeism, I agree HCWs may deserve such a privilege for their valued efforts. However, it is unfair to provide HCWs priority over treatments without giving other essential workers—such as food service, transportation, and social workers—who similarly jeopardize their health to aid the pandemic response the same privilege. While HCWs who undergo years of education and training to obtain their positions are potentially more prone to scarcity than other types of essential workers, giving HCWs preferential access to ventilators may not prevent HCW scarcity, as previously outlined. Without a clear reason to provide HCWs treatment priority besides that “they deserve it,” we cannot justly accept this allocation criteria without applying it to all essential workers who equally deserve optimal treatment. Not only does this allocation criteria lack fairness, it lacks equitability. Unlike HCWs, other types of essential workers are not protected by preexisting social contracts rewarding them esteem and financial stability for their high-risk work. Other essential workers are also more likely to be people of color and of lower socioeconomic status.6 Providing health care workers but not all essential workers preferential access to treatments may thus exacerbate the disproportionate burden of Covid-19 on marginalized and underserved populations.
Overall, while some bioethicists have proposed giving HCWs priority over medical interventions including ventilators, doing so is neither fair nor necessary. Unless a given medical intervention can reliably prevent HCW scarcity, there is no strong argument as to why HCWs should receive resource priority over other essential workers. In order to promote fair, equitable, and effective resource allocation amidst Covid-19, HCWs should not receive priority over ventilators.
By Leigh Berman
Leigh Berman, a third-year medical student at the University of Wisconsin School of Medicine and Public Health, received the 2020 Dr. Norman Fost Award for the Best Medical Student Bioethics Essay. The contest—sponsored by the school and its Department of Medical History and Bioethics—asked students to choose a topic related to ethics surrounding the COVID-19 pandemic. An edited version for publication appeared in the Quarterly Magazine, this is unedited essay with references.
- Emanuel E, Persad G, Upshur R, et al. 2020. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. NEJM, DOI: 10.1056/NEJMsb2005114
- Bhatraju P, Ghassemieh B, Nichols M et al. 2020. Covid-19 in Critically Ill Patients in the Seattle Region—Case Series. NEJM. DOI: 10.1056/NEJMoa2004500
- Rawal G, Yadav S, and Kumar R. 2017. Post-intensive Care Syndrome: An Overview. Journal of Translational Internal Medicine, 5(2): 90-92.
- Medicine’s social contract with humanity. 2001. AMA Declaration of Professional Responsibility.
- Clark C. 2005. In Harm’s Way: AMA Physicians and the Duty to Treat. Journal of Medicine and Philosophy, 20(1).
- A Basic Demographic Profile of Workers in Frontline Industries. 2020. Center for Economic and Policy Research.