Explainer: When there isn’t enough medicine to go around, who gets it?

For nearly seven decades of marriage, Dorothy M. Lampkin and her husband have gone everywhere together and done everything together — until she contracted COVID-19 in mid-January, and he did not.

They’d been vaccinated and boosted, and had both managed to survive the first two years of the pandemic unscathed. But in the evening on Friday, Jan. 14, Lampkin, who’s 87, struggled to breathe. She found out she was positive the next morning in the emergency room of Texas Health Harris Methodist Hospital Southwest in Fort Worth.

After an overnight stay, she returned home, stable but sick, and on the recommendation of some relatives who work in medicine, began to seek monoclonal antibody treatment. Her primary care physician, whose referral she needed to secure the treatment, told her there was a line of others also waiting.

If she could find Lampkin a slot, her physician would call her back. She never did.

“It wears on your heart and your mind and everything else, when they tell you that this (treatment) would help you and then you can’t get it,” Lampkin said.

An ethical framework for determining who gets treatment when supplies are scarce isn’t one-size-fits-all, said Marie-Catherine Letendre, who teaches at Cristo Rey Fort Worth College Prep and has a PhD in bioethics. Each decision requires an assessment of sometimes conflicting priorities that can leave people like Lampkin out in the cold.

“That’s what makes the part of talking about bioethical dilemmas difficult,” Letendre said. “You have to balance things out in careful consideration.”

The shortage

Demand for COVID-19 treatments outpaced availability as cases far surpassed previous peaks around Texas and the country in January. The shifting nature of the virus, as well as restrictions imposed by the federal government, also complicated supply, said Dr. Gregory L. Kearns, a pharmacist and professor at the TCU School of Medicine.

As the omicron variant swept through communities, for example, monoclonal antibody treatments that had worked against the delta variant no longer proved effective. In late December 2021, around the same week the omicron variant became dominant in the U.S., the federal government paused shipments of the ineffective treatments.

But the delta variant continued to circulate, and determining which variant caused a person’s COVID-19 isn’t often feasible. The government decided to resume shipments of all three authorized treatments just over a week later.

Then, in late January, after data from the Centers for Disease Control and Prevention determined omicron accounts for nearly 100% of current COVID-19 cases in the U.S., the government once more stopped shipments of the two treatments that don’t work against omicron.

Not long before Lampkin fell ill, providers experienced a dearth of sotrovimab, the therapy that still works. Providers around Texas asked for tens of thousands of treatments during the final two weeks of the year but the state received just under 2,300 from the federal government the last week of December, said Douglas Loveday, a spokesperson for the Texas Department of State Health Services.

The guidelines

In late December, the National Institutes of Health offered guidelines to help providers navigate an onslaught of patients amid too few supplies.

The guidelines address how providers should select patients to receive monoclonal antibody therapy when supply is low: by order of risk for severe disease.

A person’s age, vaccine status and projected immune response help determine that risk, according to the guidelines. Immunocompromised people, regardless of vaccine status, and people with risk factors like advanced age or pregnancy and who aren’t vaccinated take priority. People like Lampkin, who is boosted, in her late 80s and otherwise healthy, come next.

“You want to make sure that the people who get the treatments are the people who need it the most, who are least likely to get better without them,” said Eli Shupe, an assistant professor of biomedical ethics at the University of Texas at Arlington.

Tier 1, the highest priority, comprises people who are immunocompromised, regardless of vaccine status; unvaccinated people 75 years or older; and unvaccinated people 65 years or older with other risk factors like diabetes or obesity. The guidelines don’t clarify which subgroup to prioritize within Tier 1 in the case of extremely limited resources.

Representing the concerns of that first subgroup is “really important,” Shupe said. People who are immunocompromised are less likely to mount an adequate immune response to the virus. At times, they’ve also felt alienated by COVID-19 messaging from the CDC, she said.

Older people, too, have increased risk for severe disease, and the second and third groups in Tier 1 reflect that vulnerability. Age is the “strongest risk factor” for developing severe COVID-19, according to the CDC. In 2020, people 65 and older accounted for more than 80% of all the COVID-19 deaths in the U.S.

The ethics

But ethical decision-makers must also weigh concerns about justice, or fairness, Shupe said. For example, prioritizing people by age may disproportionately exclude people from communities who have lower life expectancies, she said. The life expectancy between Black men and white women differs by almost 10 years, according to the CDC.

“Prioritizing the elderly is justified if that older cohort is at much higher risk than other groups,” Shupe said, “but you should be aware of how even simple criteria like that can cut across demographic boundaries in a way that might be unfair, or that people might perceive as unfair.”

For Kyev Tatum, pastor of New Mount Rose Missionary Baptist Church in Fort Worth, prioritizing people who chose not to be vaccinated over people who chose to be vaccinated feels like racial injustice.

As of late January, white people account for the majority of people who are unvaccinated in the U.S. Initial disparities between white, Black and Hispanic people who’ve received at least one dose of the vaccine have diminished over time. Compared to their share of the population, white people are now less likely to have received at least one dose of the vaccine than Black or Hispanic people.

In 2020, Tatum spearheaded Clinic Without Walls, a COVID-19 relief initiative that provides food, personal protective equipment, tests, vaccines and other supplies — including monoclonal antibody therapy — to people in underserved communities.

But “personal responsibility” arguments that prioritize access based on a person’s behavior can be ethically fraught, too, Shupe said.

“You don’t always know why somebody hasn’t sought out vaccination,” she said. “They might have suffered at the hands of the medical establishment in the past in a way that has left them jaded or mistrustful. I think it’s important to set aside our personal feelings when we’re thinking about who gets care.”

Providing care to people most at risk for developing severe disease is also a form of fairness, said Letendre, with Cristo Rey Fort Worth College Prep. “What I needed when I was hospitalized for COVID may have been more than what somebody else needed, or it may have been less,” she said. “So it’s not about everybody getting the same amount. It’s about equity, people getting what they need.”

Other “allocation frameworks” exist in health care, Shupe said. For people waiting on kidney transplants, for example, how long they’ve been waiting partially determines their place in line. In the emergency room, providers may treat patients first based on age, with younger patients receiving attention before older patients, if the patients’ conditions are equally critical, Letendre said.

Throughout the pandemic, varying ethical frameworks also dictated access to resources. When the vaccines first rolled out, a person’s occupation mattered; people in priority groups like health care workers received early access. Guidelines from the Extracorporeal Life Support Organization advise providers to discontinue ECMO, a heart-lung machine that provides oxygen to the body, for patients whose chances of survival are slim when the hospital reaches “crisis capacity.” The U.S. government recently made available, for free, four testing kits to every home, regardless of size.

Lampkin, a retired teacher from Fort Worth Independent School District, doesn’t know why she wasn’t selected for monoclonal antibody therapy. She passed her sick days by waking to eat her favorite breakfast — fried potatoes, onions and sausage — and then going back to bed.

She’s feeling better now. Her sense of taste and smell have returned, but her energy has not.

“I feel lazy,” she said. “And I’m not a lazy person.”

Ethical frameworks aside, decision-makers should be prepared for how the public perceives their choices, Shupe said, and how that perception could hinder or harm COVID-19 prevention efforts.

“If your decision about who gets access to treatment seems fair, then that might promote public trust. That’s a good thing,” Shupe said. “And if it seems unfair, that could harm public trust — and during a pandemic, public trust and cooperation is really important.”

Alexis Allison is the health reporter at the Fort Worth Report. Her position is supported by a grant from Texas Health Resources. Contact her by email or via Twitter. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here.