More than a year into the COVID-19 pandemic, one of the most enduring challenges of the pandemic response in the United States has been shortage: of masks, ICU beds, ventilators, and vaccines. As a physician and ethicist serving on the Disaster Clinical Advisory Committee of Washington State’s Department of Health and the Northwest Healthcare Response Network, Health Services Master of Public Health (MPH) alum Douglas Diekema (1993) has played a unique role in helping to develop Washington state’s approach to allocating precious resources during the pandemic.
Ten years ago, Diekema started working with a small group of ethicists at the request of the King County Disaster Clinical Advisory Committee to develop basic guidelines for crisis standards of care, particularly for situations where triage of scarce resources became necessary. He later worked with the committee to further refine the guidelines, to cover everything from blood to ventilators.
“When the COVID-19 pandemic hit, the Disaster Clinical Advisory Committee, and especially the ethics sub-group, had to move quickly to refine all of those algorithms to fit the unique nature of this particular pandemic,” Diekema said. “As we began to think about a fair allocation of needed resources, I quickly discovered that my peers around the country were all struggling with the same problems.” As the pandemic situation evolved, Diekema collaborated with colleagues across the United States to share ideas and generate creative solutions, both through informal debate, and through publications. As one example, Diekema and his colleagues published a paper in the American Journal of Bioethics providing an argument for why health care providers should be prioritized for intensive care and ventilators, at least in some cases. Diekema worked with another group of colleagues across the country to look at similarities and differences in ventilator triage algorithms that had been developed at 29 US health care institutions.
Diekema and his colleagues learned several key lessons through this work. First, they discovered that it was extraordinarily difficult to be completely fair and equitable in making choices about who would be prioritized in the receipt of scarce resources. “There were no good predictive clinical measures for COVID-19 to help us accurately identify the most efficient way to distribute resources,” Diekema said. “And since scarcity requires trade-offs, trying to be fair to one group almost inevitably leaves other groups feeling that they have not been treated fairly.” Second, there were complex nuances in the strategies used to prioritize different kinds of resources. “We took a very different approach with something like a ventilator, where we tend to prioritize those who are the most likely to survive, over those who are likely to die regardless of access to a ventilator, compared to something like a vaccine where we prioritized those most likely to die if they got infected, such as the elderly, along with those most likely to spread the disease if they got infected, such as those in crowded work environments, congregate living settings, and jails,” Diekema said.
However, there is still much we must learn about how to most equitably distribute scarce resources. “This pandemic provided an opportunity to try various options for distributing scarce resources that reflected different interpretations of justice, especially with regard to vaccination,” Diekema said. “But who gets prioritized for a vaccine has been different from state to state, and even between regions within a state.” Diekema hopes that future research will carefully analyze these various allocation approaches, to determine which approach is the most effective (in terms of controlling disease spread and death), as well as the most equitable and fair. “My guess is that those two considerations are pretty closely aligned for COVID-19,” he said. “But we need to try to study that empirically.”
As decisions about scarce resource allocation can have serious, even life or death, implications for individuals and communities, the interpretation of any data about distribution and efficacy must incorporate a health equity framework. “So many of the decisions we are making with regard to COVID-19 involves value judgments, and that’s where it becomes helpful to have people with ethics training at the table,” Diekema said. “Historically, marginalized groups have frequently ended up toward the back of the line when scarce resources are distributed. Washington state has tried really hard to keep equity as a primary goal in identifying which groups to prioritize for vaccination, but at least the early data suggests that we are still falling behind in getting vaccine to some high-risk and historically disadvantaged groups. The degree to which these gaps are related to access, scheduling, vaccine hesitancy, distrust in government and organized medicine, systemic racism, implicit biases, or some other factor or combination of factors, is still not fully understood at this point. It is crucial that we take this opportunity to figure out how best to serve those communities and individuals who typically get left behind.”
As a pediatrician and pediatric emergency medicine physician, issues related to public health, environmental health, infection control, injury prevention, and disaster response are “just part of the territory” for Diekema. This fluency is thanks in part to his MPH training at UW, which he considers the most relevant and important time he spent in school. “I think every pediatrician would probably benefit from a degree in public health,” Diekema said. “Learning how to critically evaluate the scientific literature, understanding how the health care system operates (and how it falls short), seeing problems through a population or public health lens, and gaining insight into health law and economics were all opportunities I got during my MPH and continue to use every day, including in my clinical work. The two-course series in Epidemiology was essential to my training, and the wonderful class I took on Health Law probably remains the most impactful in my career.”
Diekema has an abiding interest in infection outbreaks and disaster response, and thinks about these issues regularly in his clinical work at Seattle Children’s, where he also serves on the COVID-19 Vaccine Leadership Team. His academic work has focused on bioethics, particularly, how bioethics intersects with the care of children in a medical setting. Prior to the pandemic, he had developed a particular interest in vaccine hesitancy, including its historical roots, the reasons for its existence, its impact on public health and disease spread, and how the law interacts with parental choice. He has published more than a dozen papers on many aspects of vaccine hesitancy and refusal, from the perspective of law and ethics. For Diekema, the COVID-19 pandemic provided a unique opportunity to contribute his combined expertise in disaster response and bioethics, to help make meaningful contributions to community health in Washington state.
Looking to the future, Diekema plans to continue working on issues related to disaster preparedness, the public health aspects of infectious disease and vaccination, and the many ethical issues that arise when difficult decisions need to be made in the realms of triage, resource allocation, and epidemic control.
Ventilator Triage Policies During the COVID-19 Pandemic at US Hospitals Associated with Members of the Association of Bioethics Program Directors. Antommaria A, Gibb TS, McGuire AL, Wolpe PR, Wynia MK, Applewhite MK, Caplan A, Diekema DS, Hester DM, Lehmann LS, McLeod-Sordjan R, Schiff T, Tabor HK, Wieten SE, Eberl JT.
Annals of Internal Medicine (2020)
Prioritizing Frontline Workers During the COVID-19 Pandemic. Jecker NS, Wightman AG, Diekema DS.
American Journal of Bioethics (2020)
The Ethics of Creating a Resource Allocation Strategy During the COVID-19 Pandemic. Laventhal N, Basak R, Dell ML, Diekema DS, Elster N, Geis G, Mercurio M, Opel D, Shalowitz D, Statter M, McCauley R.
Should we mandate a Covid-19 vaccine for children? Opel DJ, Diekema DS, Ross LR.
JAMA Pediatrics (Sept 24 2020)