Posted on May 8, 2020 at 6:34 PM
The Covid-19 pandemic has imposed tremendous risk on doctors, nurses, and other health care workers not seen in a century. It is time to reconsider prioritization of health care workers’ access to scare critical resources.
Historically, for multiple reasons, health care workers have not been prioritized for access to medical care during a pandemic. First, health care workers willingly accept some level of personal risk. Second, in previous pandemics, health care workers who became ill were not expected to return to their jobs quickly enough to maintain the workforce, and thus it was not imperative to prioritize their care. Third, there was concern that prioritizing health care workers over the general population could lead to an erosion of the public’s trust in the health care system because of the possible perception that this policy was self-serving. However, given the unprecedented circumstances surrounding the Covid-19 pandemic, it is justifiable to prioritize health care workers when all else is equal between two patients.
Health care workers are bound by a duty to treat, a professional obligation to tend to the sick despite personal risk. There is, however, a corresponding duty, which is society’s obligation to reasonably mitigate such risk to health care workers. In an active shooter incident, emergency medical services are not expected to enter a scene to provide care until the scene is secured by police. With respect to the coronavirus pandemic, such safety assurances are lacking. The unusually high transmission rate of Covid-19 to health care workers, further exacerbated by the shortage of personal protective equipment, reduces the ability to safely provide care. Nurses, physicians, and other personnel have contracted Covid-19 in significant numbers resulting in critical illnesses and deaths. In certain epicenters of the pandemic, health care workers represent 3% to 11% of the total infections in the United States and more than 1,000 have died worldwide. In this context, the principle of reciprocity presses society to recompense health care workers by giving them priority access to care should they fall ill from the virus. Moreover, this reassurance can be expected to boost morale, allay fear, and prevent attrition in an already overburdened workforce.
Second, prioritizing health care workers for care during this pandemic offers the valuable and practical benefit of returning key staff to their roles. This logic did not always hold true in past pandemics, which were often shorter in and, therefore, did not allow for health care workers to recover from a serious illness in time to rejoin the workforce. Given our current understanding of the expected length of the Covid-19 cycle (and potential seasonal reemergence), infected health care workers will be able to return to hospitals. Further, these workers may be immune to the virus for some period. There is a significant benefit to society in healing and returning health care workers during the prolonged battle against Covid-19.
Finally, the application of resource allocation systems triggers challenging but necessary changes to our typical standard of care. To maintain public trust, the drivers for change must be made explicit and policies should be made widely available to the public. Allocation procedures must be transparent and consistently applied. Triage places emphasis on saving the most lives. When patients with high likelihood of survival outnumber crucial resources such as beds or ventilators, the choices are limited: first come, first served; younger patients over older (the “cycle of life” preference) or, we propose, health care workers who may return to work in time to save other patients. Given the worldwide public displays of support for health care workers and media attention on the shortages of personal protective equipment, the public should be able to accept the benefits of prioritizing health care workers.
The surge of Covid-19 cases will continue to overwhelm portions of the U.S. health care system, inevitably forcing difficult decisions about the allocation of limited resources. Health care workers treating the pandemic will themselves become among the most limited resources as they succumb to the virus. While prioritizing these workers to receive care has not been a standard policy in past pandemic planning, doing so now will save lives by maintaining a functioning and resilient health care workforce. Health care workers bravely on the front lines should have reasonable assurances to critical care access during this pandemic.
David Blitzer, MD, MBE is a cardiothoracic surgery resident at Columbia University Irving Medical Center. Susan Regan, JD, is an assistant clinical professor of medical ethics at Weill Cornell Medical College. David Fischkoff is an investment professional in New York City. Katherine Fischkoff, MD, MPA, HCEC-C is an assistant professor of surgery and critical care and an ethics consultant at Columbia University Irving Medical Center.
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