When medical resources are limited, who should get care first?

The Toughest Triage

When medical resources are limited, who should get care first?

Long before the new coronavirus, ethicists have contemplated the moral dilemma of who is first in line when medical resources are strained, creating frameworks for apportioning treatment so that doctors and hospitals could avoid making fraught decisions on the fly.

This kind of guidance informs a variety of situations, from large-scale disasters to organ transplants. After Hurricane Katrina in 2005, for example, doctors had to decide who to evacuate first from hospitals left without power or running water as temperatures soared above 100 degrees fahrenheit.

A paper released March 2020 in the New England Journal of Medicine outlined four ethical values to guide decision-making when rationing care: maximizing the benefits of treatment, treating people equally, promoting those who are likely to help others, and giving priority to the worst off.

The Lancet, a peer-reviewed medical journal, laid out several approaches to translate these values into real life practices. While each system has its own benefits and flaws, they offer insight into the physiological and social factors that could be considered when prioritizing care.

Approaches to rationing care

Sickest first

A prioritarian approach treats the sickest first. In emergency care, for example, a patient suffering from a heart attack would be seen before a patient with a broken arm.

This approach assumes that resource constraints are temporary and that additional resources will soon become available to treat other patients.

But during a period of prolonged scarcity, such as the current COVID-19 pandemic, this approach fails to consider the trade-off between treating one critically ill patient for a long period of time versus quickly treating several patients who are not as sick.

An equal chance

An egalitarian approach seeks to treat patients equally. In this system, patients would be chosen at random in a lottery.

This practice requires no information about the patient, removes any decision-making burden on hospital staff and, in theory, eliminates personal influence on the process.

As a result, patients get an equal chance to access treatment but not necessarily an equal allocation of resources. A very sick patient selected first could use up a lot of resources, for example, creating an even greater scarcity for patients selected later.

Maximizing the benefits of treatment

A utilitarian approach would allocate resources with the goal of returning the greatest overall benefit for the population.

One example could be to aim for the longest life-years. A younger person with more years to live would be prioritized over an older person.

Another maximizing approach could look to save the most number of lives. Patients with less severe symptoms would be prioritized because they seem more likely to recover.

Saving the most lives serves as the guiding principle to rationing care, though this approach raises questions about what criteria is used to determine priority or exclusion.

Factors that could influence decisions about prioritizing care

The primary considerations for most established protocols for adults include some combination of physiological factors, such as short-term and long-term survival.

Both the U.S. Centers for Disease Control and Prevention and the British Medical Association highlight additional ethical considerations when deploying limited medical resources.

The multiplier effect

Prioritize healthcare workers who may be able to return to work after treatment.

Social worth

Prioritize care for government leaders, professionals, heads of families or caregivers.

Life cycle

Prioritize those in the early stages of life.

Regardless of which factors are given priority, ethicists say that a triage officer or committee should make the decision based on data. This relieves doctors of the burden of having to choose between patients and allows them to focus on medical care.

How states have been establishing protocols

In preparation for hypothetical flu-like outbreaks, several states have weighed these ethical considerations and have established guidelines for triage officers or committees.

In New York, before a patient is placed on a ventilator, his or her short-term survival score is determined by a Sequential Organ Failure Assessment (SOFA) measuring the functioning of body systems. That score is assigned to one of four colors; greens do not need a ventilator, yellows must wait, reds are prioritized and blues will not be saved by one.

But some guidelines are more complex.

Maryland’s multi-factor scoring system considers short-term survival – also determined by a patient’s SOFA – and long-term survival based on pre-existing conditions. Here’s how the system prioritizes patients in a few scenarios.

Patient A, age 24, has a short-term score of three on a scale of 0-4 and no pre-existing conditions. Patient B, age 52, has a short-term score of two and no pre-existing conditions. The patient with the lowest score is prioritized.

Both patients have a short-term score of one and no pre-existing conditions. To break the tie, points are assigned according to age group. They each receive one point because they fall in the same group. A patient is chosen at random.

Patient E, age 45, has a short-term score of four and no pre-existing conditions. Patient F, age 74, has a short-term score of one and a long-term score of three due to advanced-stage metastatic cancer. Lifecycle points are awarded to break the tie - the younger patient receives one point and the older patient receives three points. The patient with the lowest score is prioritized.

An imperfect system

Deciding who to treat first ultimately forces societies to weigh their values and create a standardized set of rules to apply everywhere. Establishing Maryland’s protocol, for example, included a community outreach process including those in and outside the medical community.

Regardless of whether protocols prioritize some factors over others, their efficacy will need to be regularly assessed as new situations arise, and new data about patient outcomes and other treatment options become available.


Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators during a Severe Influenza Pandemic or Other Public Health Emergency U.S. CDC

Covid-19 ethical issues. A guidance note. British Medical Association

“Fair Allocation of Scarce Medical Resources in the Time of Covid-19” The New England Journal of Medicine

“Principles for allocation of scarce medical interventions” The Lancet

“Maryland Framework for the Allocation of Scarce Life-sustaining Medical Resources in a Catastrophic Public Health Emergency” University of Maryland


Illustrations by Catherine Tai
Editing by Sarah Slobin and Tiffany Wu