Triage Protocol Design for Ventilator Rationing in a Pandemic: A Proposal to Integrate Multiple Ethical Values through Reserves

In the wake of the Covid-19 pandemic, the rationing of medical resources has become a critical issue. Nearly all existing triage protocols are based on a priority point system, in which an explicit formula specifies the order in which the total supply of a particular resource, such as a ventilator, is to be rationed for eligible patients. A priority point system generates the same priority ranking to ration all the units. Triage protocols in some states (e.g. Michigan) prioritize frontline health workers giving heavier weight to the ethical prin- ciple of instrumental valuation. Others (e.g. New York) do not, reasoning that if medical workers obtain high enough priority, there is a risk that they obtain all units and none remain for the general community. This debate is particularly pressing given substantial Covid-19 related health risks for frontline medical workers. In this paper, we propose that medical resources be rationed through a reserve system. In a reserve system, ventilators are placed into multiple categories. Priorities guiding allocation of units can reflect different ethical values between these categories. For example, while a reserve category for essential personnel can emphasize the reciprocity and instrumental value, a reserve category for general community can give higher weight to the values of utility and distributive justice. A reserve system provides additional flexibility over a priority point system because it does not dictate a single priority order for the allocation of all units. It offers a middle-ground approach that balances competing objectives. However, this flexibility requires careful attention to implementation, most notably the processing order of reserve categories, given that transparency is essential for triage protocol design. In this paper, we describe our mathematical model of a reserve system, characterize its potential outcomes, and examine distributional implications of par- ticular reserve systems. We also discuss several practical considerations with triage protocol design.