First-Come, First-Served Healthcare No Longer Applies. We Must Now Allocate Care To Those Who Will Benefit The Most | Opinion

As a medical student at the University of Pennsylvania in the late 1990s, I had the privilege of participating in the care of two patients in their twenties, both with devastating stories. The first was a young male immigrant dying from the ravishes of AIDS and, more specifically, the social inequities that had denied him access to what were by then truly life-saving medicines. Perhaps even worse, this young man was dying alone—his family in a faraway country with insufficient resources to travel, and FaceTime a decade from having been created.

The second was young woman dying from the final stages of cystic fibrosis. A breathing machine was keeping her alive while she awaited news about whether she would be placed on a waitlist for lung transplantation – the only option that could possibly save her life. Unlike the man, she was surrounded by family in her ICU bed around the clock, including her mother, a practicing nurse whose compassion was matched only by her courageousness. When the doctors broke the news that her daughter was being denied lung transplantation because her chances for survival were not as high as those of other patients awaiting this scarce resource, the mother teared, nodded knowingly, and asked whether her daughter's kidneys or other organs might be donated to others.

I think back to these patients regularly now, as twenty years later I'm engaged in some of the most difficult aspects of our response to the COVID-19 pandemic. Who will receive ICU beds and breathing machines when not everyone can? How will we balance our typical commitments to try even the most unlikely-to-succeed interventions, such as cardiopulmonary resuscitation (CPR), with the reality that doing so will jeopardize scarce and under-protected clinicians, thereby limiting their abilities to help future patients? And for those we cannot save, how will we prevent them from dying alone when distancing policies and scarce personal protective equipment require strict limits on family visitation to hospitals?

Although thinking back to my two patients is always hard, these memories now help me appreciate how the problems we're facing due to COVID-19—unprecedented as they are—have roots in longer-standing imperfections in our health care system. We have never had enough resources to serve all who may benefit from them. This is most obvious in how we allocate scarce organs for transplantation, but is pervasive throughout health care. Though the U.S. has more ICU beds per capita than nearly any other country, even routine upticks in the number of critically ill patients in a U.S. hospital alter patient care, including by having patients discharged from ICUs to hospital wards earlier than they otherwise would be.

Similarly, we have always had to make tradeoffs between the good of the one and the good of the many. Every time I allow a trainee to perform a procedure that I have performed a thousand times, I am making a small but certain sacrifice of that patient's well-being in exchange for the greater benefits to all the future patients that trainee will encounter. Finally, we have never been able to save all lives, even the youngest, nor promise that everyone will experience a "good" death. Specialists trained in palliative care are now among the scarcest of all medical resources, and so can only see a small minority of the hospitalized patients they might help.

There are, of course, key differences between these underlying realities of health care and what COVID-19 has forced us to confront. In less trying times, we work hard to narrow the gaps between these realities and our ideals, whereas in crises we have no choice but to make more blatant tradeoffs with far more dire consequences. But as we face the tragic choices that now confront us, it helps to keep these longer-standing imperfections of health care top of mind. Because the lessons we've already learned point to principles that, if broadly adopted in crisis, should help minimize the harms of COVID to the American population.

First, consistent with the principle of doing the greatest good for the greatest number, scarce resources must be allocated to those most likely to benefit from them. Traditional approaches to allocating care such as first-come, first-served, are unacceptable because they give priority to those who have the greatest access to care, and because they do not optimize population health outcomes.

Second, it is essential that treating physicians and nurses are not the ones who make decisions about prioritizing patients for scarce beds, breathing machines, and other resources. Treating physicians should maintain their commitments to their own patients while independent "triage teams" are tasked with applying consistent prioritization criteria to all patients.

Third, standardizing our approach to making these tragic choices—at least at the regional, and ideally the national level—is essential for promoting public trust, patient equity, and clinician morale. Because it is impossible to overstate the importance of consistent approaches, colleagues and I have made guidances for resource allocation and decisions to offer CPR during this crisis freely available.

Fourth, as our guidances emphasize, no patients should be excluded from being eligible for mechanical ventilation, CPR, or any other medical therapy. Such blanket exclusions are unnecessary to achieve the greatest good for the greatest number, and may wrongly suggest that not all lives are equally worth saving. For similar reasons, personal characteristics including race, income, and disability should never be considered in allocating scarce resources.

Finally, though it is easy to get caught up in these tragic choices, now is the time for clinicians to renew our most fundamental commitment: to relieve our patients' and their caregivers' suffering. If we do find ourselves with insufficient beds or breathing machines for all patients who may benefit from them, patients who do not receive high enough priority for those resources should immediately become our top priorities for the best possible emotional support and pain control. Though FaceTime couldn't help connect our dying young man with his distant family twenty years ago, and remains an imperfect substitute for bedside engagement, this crisis requires that we use all technologies possible to optimally link patients, families, and clinicians.

Scott D. Halpern, M.D., Ph.D. is the John M. Eisenberg Professor of Medicine, Epidemiology, and Medical Ethics and Health Policy at the University of Pennsylvania Perelman School of Medicine, where he is also a practicing ICU physician and Director of the Palliative and Advanced Illness Research (PAIR) Center.

The views expressed in this article are the author's own.​​​​​