In recent days, multiple states across the United States have recorded new highs in COVID-19 infections and hospitalizations. Data show more than half the country is seeing significant increases in COVID-19 patients, with many hospitals nearing or reaching capacity in their intensive care units. In several areas, test positivity rates have climbed into the double digits. (Positivity rate equals the number of positive test results divided by total tests administered, expressed as a percentage.)
For example:
- In Arizona, hospitals are reporting their highest levels of hospitalization since the pandemic began in March, with around 85 percent of hospital beds occupied and approximately 91 percent of ICU beds full. As of Friday, only a small number of ICU beds remained available statewide.
- ICUs in Los Angeles County—the nation’s most populous county—and nearby Riverside County were warned they could run out of beds within weeks.
- Three of southwest Florida’s nine acute care hospitals reported no available ICU beds in midweek, and COVID-19 hospitalizations in that region have doubled in recent weeks.
- In Texas, Austin reported one of the highest test positivity rates in the country, with more than one in five tests returning positive. Texas’ largest metropolitan areas—Houston, Dallas, and San Antonio—also ranked among the highest nationwide for positivity rates.
As hospitals fill, shortages extend beyond beds to critical supplies like personal protective equipment (PPE), hand sanitizer, and cleaning products. In severe outbreaks, shortages may also include crucial life-support equipment such as mechanical ventilators.
U.S. acute care hospitals have roughly 62,000 full-function ventilators and about 98,000 basic ventilators, with the Strategic National Stockpile holding an additional several thousand. Yet as cases surpass millions nationwide and deaths continue to rise, some regions may face ethically wrenching choices if demand for ventilators exceeds supply.
A life-or-death supply and demand issue
CDC estimates vary widely, projecting that between 2.4 and 21 million Americans could require hospitalization over the course of the pandemic. Based on international data, the CDC anticipates that roughly 10 to 25 percent of hospitalized COVID-19 patients may need mechanical ventilation, and many of those patients could remain ventilated for weeks.
Applying those estimates could yield a startling ratio of potential patients per available ventilator in the hardest-hit scenarios. These projections do not predict when or where ICU surges will occur; ideally, cases will be spread over time so patients who need ventilators can receive them. Some hospitals have explored ventilator-sharing techniques to support more than one patient with a single device, though this is not optimal because ventilator settings normally must be customized to each patient’s condition.
When ventilators run short, clinicians confront agonizing questions: How should scarce devices be allocated? What criteria should determine who receives or retains life-saving ventilation?
The bioethics of resource allocation
Patients who deteriorate to the point of requiring mechanical ventilation often have a narrow window for intubation; without ventilation, many will die within minutes. In some states, crisis standards of care have been adopted to guide difficult allocation decisions when resources are overwhelmed. These standards typically consider factors such as severity of illness, comorbid conditions, and age to estimate potential remaining “life years” a patient might gain if successfully treated.
Life years refers to the years of life a person is expected to live as a result of receiving a treatment.
One of the most wrenching ethical dilemmas is whether a ventilator could be removed from one patient to save another who might have a greater potential benefit. To reduce the moral burden on bedside clinicians, some institutions have developed structured triage frameworks. For example, a scoring system can estimate a patient’s odds of surviving to hospital discharge and guide allocation decisions. These protocols often assign triage decisions to committees of clinicians who are not directly caring for the patient, minimizing conflicts for treating physicians.
The value of a life
COVID-19 has disproportionately affected older adults and minority communities in the United States, with a large share of deaths occurring among people aged 70 and older. Many had underlying health conditions, prompting the painful question of how many additional life years they might have enjoyed absent the virus.
At the same time, an increasing number of younger adults are becoming seriously ill and requiring hospitalization. In some states, the median age of confirmed cases has fallen, bringing younger patients into competition for scarce ICU resources as demand rises. When younger and older patients both need the same limited equipment, ethical tensions intensify around whether age or comorbidity should influence prioritization.
If clinicians are forced to decide which patients receive life-sustaining treatment because equipment is limited, the situation will mark a distressing escalation of the crisis. Most would agree it is unacceptable to judge a person’s worth solely by age or preexisting conditions. The focus must be on preventing shortages through rapid innovation, manufacturing, and distribution of critical supplies, alongside public health measures that reduce transmission and hospital surges.
As a nation, leaders at all levels must act swiftly to prevent scenarios in which tragic choices about who receives care become necessary. Ensuring adequate supplies, equitable allocation frameworks, and transparent decision-making can help preserve lives and uphold ethical standards during this ongoing public health emergency.