As doctors on the front line caring for patients affected by COVID-19 in Seattle, we cannot ignore the question we never wanted to ask: What do we do if multiple patients require life-saving interventions, but limited resources allow intervention on only one?
Over the past two weeks, many have opined on this matter. There have been multiple publications in the medical literature reviewing the ethics of rationing care, and even more in the general media (New York Times, Los Angeles Times, ABC News, New York Magazine and Forbes have all weighed in). While such discussion is prudent, one critical aspect has been missing from this conversation: The proposed guidelines will intrinsically reflect, and exacerbate, existing health care inequities affecting poor communities and communities of color.
There is growing consensus that, when making allocation guidelines, health conditions contributing to patient survival should be evaluated, but also that allocation of limited resources should not be based on morally irrelevant considerations, such as race, sex or socioeconomic status.
In a way, this will be impossible. The biases inherent in our assessments cannot be easily dismissed or compartmentalized, because the starting line for health is not equal.
The imbalanced starting line for COVID-19 is already being reflected locally and nationally. Locally, compared with patients at the University of Washington or Swedish Medical Center, low-income patients at community health centers in King County have had significant delays in even getting tested for coronavirus. Nationally, we are beginning to see divides in outcomes. In Michigan, African Americans constitute 35% of COVID-19 cases and 40% of COVID-19 deaths, despite a state population that is only 14% Black. Meanwhile, in Milwaukee – one of the few cities tracking the racial impact of disease – African Americans account for nearly 50% of COVID-19 cases and over three-quarters of its deaths, even though they make up only a quarter of the population.
We know that people with lower incomes develop chronic health conditions many years earlier in life than those who are wealthy. While medical experts and ethicists might agree that an individual’s wealth shouldn’t determine who receives potentially life-saving care in this crisis, any criteria that include chronic health conditions will inevitably prioritize care for the rich over the poor.
Similarly, we know that historical and ongoing trauma has resulted in increased stress levels for African Americans and Native Americans. This means that these communities have a higher likelihood than whites to live with hypertension, diabetes or heart disease. If the absence of these chronic conditions drives our criteria for who receives ventilators among those in respiratory distress, even the most well-intentioned guidelines will walk an impossible line between racialization of resources and equitable distribution of care.
To some degree, the legacy of slavery, broken treaties and Jim Crow laws will be woven into any guideline we create. COVID-19 has forced our hand and shines an ugly light on existing racial and socioeconomic inequities in not only access to and quality of care, but also in the baseline health characteristics with which we walk into a clinic or hospital.
Groups across the country are fastidiously and sensitively trying to answer this ethical dilemma. Professional society guidelines have emphasized increasing acute survival, at the expense of patients with severe heart, lung or kidney disease. Alabama’s plan strives for maximal health benefits, but compromises those living with severe intellectual disability. Pennsylvania and Minnesota have endorsed a holistic approach, while acknowledging that no single factor can encapsulate all relevant values. Locally, the University of Washington has supported a multifaceted, utilitarian plan, but its guidelines have already been criticized for limiting care for people living with disabilities.
All of these conversations are valuable, important and difficult. Yet without a critical lens that includes health care disparities, we fear that our implicit biases will manifest themselves in our protocols and the lives of our patients. This is critically important in Seattle and across the country. Because of effective social distancing, Washington state has started to flatten the curve, reducing the acute need for more ventilators. However, across the country, the situation is much more dire, with the Institute of Health Metrics and Evaluation projecting over 16,000 COVID-19 patients needing ventilators.
The decision of how to allocate limited resources in this crisis is crucial because de novo guidelines hold immense power in either exacerbating health disparities or increasing health equity.
This may be our opportunity to reinvent the practice of medicine in a manner consistent with justice and health equity. What if our goal is not simply to achieve the best outcomes for as many patients as possible, but also to maximize racially and socioeconomically equitable outcomes? Can we imagine how the development and implementation of guidelines for the allocation of ventilators – and all limited COVID-19 resources – would look if our ethical success was measured by both lives saved and health equity?