Who’s first in line for COVID-19 treatment? It depends on medical need, money, drug use

The California Department of Public Health released guidance this month that helps doctors decide who needs care, based on their likelihood of survival. But which patients should be first in line if resources run short?

These decisions are based on military triaging, says Dr. Michael Wilkes on today’s Daily Dose. He’s professor of medicine and global health at UC Davis.

“You usually let the gravely ill go because they're not going to survive [on the trip] to the hospital,” he says. “You focus on those with serious life-threatening injuries that could survive if you stabilize them and transport them to the hospital.”

The nature of triaging is complicated and controversial, says Wilkes.

“The concept is well baked in American history and American medicine. Rationing is ugly because some people get, and by definition, some people don't. America has always implicitly rationed health care.”

COVID-19 has amplified concerns around this practice, says Wilkes.

“At the core is that everybody's worried that some important group is going to be sidelined, [such as] people of color, the elderly, [or] people with disabilities,” he says.

How do doctors decide?

Wilkes says much of the decision depends on the ethical concept of justice. Medical providers consider occupation, medical need, ability to pay, and current or prior behaviors such as alcohol or drug use. He says each factor can be used in the argument for or against treatment.

But he says the decision ultimately falls on the health care provider.

Wilkes gives a hypothetical example: A teacher and an unhoused mother have the same severity of disease.

“One physician may provide the respirator to the teacher, believing that treating her is going to have a greater benefit to society. Another physician might decide to treat the homeless woman, believing that she's had a much harder life.”

Wilkes says money may or may not play another factor, using the example of a wealthy person needing care.

“What if a wealthy person comes in, and they buy their own ventilator, and they hire their own doctor? Is that ethical? After all, it is their money.”

Overall, he says the decision making isn’t easy: “Doctors are going to be forced to make horrendous decisions. Patients and families and society members are going to be upset.”

Are there federal policies on these decisions?

No federal policies currently exist, but local governments and medical groups have put guidelines in place. Wilkes hopes a larger conversation — that doesn’t just involve the government — starts around this.

“My hope is that what drives any of these decisions is based on who's going to do the most good for the most people. ... [It can] can be fair and equitable and transparent. The community at large should be at the table as well,” he says.