Triage guides will save more COVID-19 patients with disabilities.

As cases of severe COVID-19 illness spike across America, it is increasingly evident that demand for vital resources, like ventilators and ICU beds, will soon outstrip supply. Some patients who desperately need potentially life-saving interventions will not get them. Life-or-death decisions will have to be made.

In the face of this crisis, states and hospitals around the country are preparing to use triage policies, which establish criteria for deciding which patients will get scarce ventilators or ICU beds. Candidate patients are evaluated on the basis of how much of the scarce resource they need — like how long they are likely to be on a ventilator — and on the probability and size of the benefit they likely would get from treatment. Patients who will probably survive without intensive care are excluded. So, tragically, are patients who will likely die even with it. Among the rest, the triage policies aim to maximize the benefits of these scarce resources.

In recent weeks, some disability advocates have objected to triage policies. These critics argue that people with disabilities are likely to get lower priority under triage policies. They worry that doctors will judge disabled people as having a lower quality of life, and that disabled people who need more medical assistance will be excluded. In a letter to Congress, Maria Town, president and CEO of the American Association of People with Disabilities, urged “a statutory prohibition on the rationing of scarce medical resources on the basis of anticipated or demonstrated resource-intensity needs” or “the relative survival probabilities of patients deemed likely to benefit from medical treatment.” Several senators and members of Congress have made similar requests to the Department of Health and Human Services.

Taking this advice would be bad both for patients with disabilities and for those without them. Abandoning triage leaves us where we were before COVID-19 cases started to overwhelm our hospitals — treating seriously ill patients in the order that they arrive, regardless of how long they will need treatment or how likely they are to survive. This “first-come, first-served” policy is explicitly embraced by some advocates as a way to avoid discrimination against the disabled, although, as some recognize, it will cost lives that triage could have saved.

First-come, first-served works fine in non-crisis times when everyone who needs care can eventually receive it. But in the current situation, more people will die if hospitals use firstcome, first-served than if they use triage policies. Some patients will be kept on mechanical ventilation even though their prognosis is poor, while others who could be saved will die waiting.

Treating severely ill patients in the order that they present to the ER will not only lead to fewer patients overall surviving the COVID-19 pandemic. It will also lead to fewer patients with disabilities surviving. This is because the vast majority of disabilities do not limit a patient’s capacity to benefit from ventilation or an ICU bed. Someone who is blind, or deaf, or can’t walk unassisted, or is autistic, or has Down syndrome, or any number of other disabilities will respond just as well to emergency treatment for acute respiratory distress syndrome as anyone else. Triage policies should not — and properly applied will not — give these individuals lower priority. First-come, first-served also risks privileging wealthier patients who are likely to have better health insurance and more social support. People with disabilities in America are disproportionately likely to be unemployed and living in poverty.

Critics of triage policies are right to remind us of the dangers of widespread prejudice and ignorance about the lives of people with disabilities. These dangers justify ensuring that triage decisions are not based on perceptions regarding the quality of life associated with disabilities. And they require avoiding unsupported assumptions about whether someone with a disability will benefit less from COVID-19 treatments. But well-designed triage policies, including most model policies being proposed for hospitals, do not make quality-of-life judgments or incorporate unjustified assumptions. Most do consider the life expectancy of those saved, raising complicated issues about which reasonable people disagree. Their focus, however, is on saving more lives.

Triage must avoid unwarranted assumptions about what it is like to be a person with a disability. But a first-come, first-served system will cost the lives of people with and without disabilities.