COMMENTARY

A Better Way to Prioritize 'Essential' vs 'Elective' Care During COVID-19

Arthur L. Caplan, PhD; Shailin A. Thomas

Disclosures

April 15, 2020

The COVID-19 epidemic has put unprecedented strain on the US healthcare system. Equipment is running out, physicians are falling ill, and case numbers are still growing exponentially from day to day.

To accommodate this increase in volume, the Centers for Medicare & Medicaid Services, along with many state agencies, has issued directives that nonessential care be discontinued, in the hopes that those resources and personnel can be redeployed to fight the spreading coronavirus.

This is a well-intended move but it has not been well executed. The term "essential care" is amorphous and ambiguous. It has left patients and hospital systems wondering what should and should not fall under that potentially wide umbrella. It's also important because decisions will almost certainly be made about how and in what order to restore services as the pandemic abates.

Arthur L. Caplan, PhD

Efforts to determine what care should qualify as essential have devolved into emotional appeals and publicity campaigns for different interest groups hoping that the squeaky wheel will get the grease. These efforts are understandable but they undermine the fundamental purpose of restrictions on nonessential care, which is to limit resource utilization. Instead, they're designed to secure as many resources for a particular group of patients, regardless of whether funneling resources to that group is the best use of those resources in a time of scarcity.

To determine which care should be proceeding in the age of COVID-19, we need to dispense with terms like "necessary" and "essential" and instead focus on the purpose of limiting care provision.

Two Critical Resource Questions

The goal should be to divert as many resources as we can to fight COVID-19. That can be condensed into two questions:

  1. What lifesaving procedures must we do? Our healthcare system has a responsibility to protect patients from the terrible outcomes of serious health issues whenever possible: lifesaving surgeries, chemotherapies, etc. These are the actions that must be taken, even if they take resources away from COVID-19 patients.

  2. What else can we do? In other words, what non-emergency/non-life-sustaining medical care can be undertaken or gradually restored without drawing significant resources away from the COVID-19 effort?

Ultimately, the challenge is: How can we achieve the most good with limited resources? On the one hand, there's a global pandemic that we know will kill people, including healthcare workers, thereby stretching our resources thin. On the other hand, there are patients with chronic and critical healthcare needs, many of which cannot safely be ignored for months while resources are diverted to COVID-19 patients.

These two basic considerations of what we must do and what else we still can do combine into a two-part framework that is simple but potentially useful. The framework doesn't try to answer the question of which particular medical services should be continued, but instead provides a structured, ethical way to think about which sorts of services should be considered essential and which services might be offered even if not deemed essential. This framework also provides guidance for thinking about the order in which services are to be restored in hospital settings as the pandemic abates.

The first question to address using this framework is: Does delaying treatment worsen a life-threatening or debilitating prognosis?

If yes, the treatment is probably essential. This covers a substantial segment of healthcare; emergency care, aggressive cancer treatments, dialysis, and organ transplants are all examples of services that would qualify.

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