Imagine there are two individuals who have been admitted to a hospital due to COVID-19, and both desperately need ventilators. One is a 60-year-old with a heart condition, and another is a 63-year-old with chronic kidney disease. Because of resource constraints, you have to decide which patient will be able to receive a ventilator. Both patients’ families are looking to you to help their loved one through this illness. With COVID-19 cases spiking across the country, doctors across the country may increasingly find themselves facing such a gut-wrenching decision.
In response, state governments are creating points-based systems to decide who can receive a ventilator if doctors need to ration care. These points are based in part by the presence of chronic health conditions. The more points a patient has, the more likely they would be denied a ventilator if there is a shortage of resources. One glaring omission from this points-based system is an adjustment for race or socioeconomic status. Poorer patients tend to have higher rates of chronic disease, which will lead to more points and eventually less access to ventilators. As a doctor on the frontlines, I believe state governments should reconsider the inclusion of race or socioeconomic metrics in the event hospitals need to ration ventilators.
Early epidemiological studies are demonstrating that the incidence and mortality of COVID-19 is significantly higher in marginalized communities across the United States. In New York City, Hispanic coronavirus patients make up 34 percent of all fatalities from COVID-19. In Michigan, a majority of cases are clustered in poor working communities in Detroit. In Chicago, 71 percent of the deaths from the virus have occurred among black individuals. The reason for this disparity is likely multifactorial, ranging from unstable housing that does not allow for social distancing or lower-paying jobs that require individuals to work outside their homes.
If ventilator rationing goes into effect at a hospital, ventilated patients will be subjected to a points-based system to determine whether they can receive a ventilator. In Massachusetts where I practice, there are points for short-term clinical parameters, such as blood oxygen levels. There are also points for long-term clinical parameters, such as the presence of chronic diseases like heart failure, hypertension, or lung disease. These long-term clinical parameters fail to capture that there are social determinants that lead to these chronic conditions. For example, lack of access to healthy food options, which often impacts our poorer patients, will increase the risk of heart disease. As a result, these patients get penalized twice. Not only are they more likely to be stricken with this disease, but they are also deprioritized for a ventilator in a points-based system.
A reasonable solution to this problem is providing a point adjustment for a patient who is either Black, Latinx, or resides in a neighborhood with a median income at or below the federal poverty line. Lowering the points accumulated by a patient in one of these social groups would not fully equalize health disparities from COVID-19, but it would at least acknowledge that health conditions are not blindly assigned to patients. Rather, it would capture the reality I see every day that health conditions are a product of structural inequities that my patients have faced historically and in the present day. For example, in Boston, black communities continue to suffer housing segregation and instability that is linked to historical injustices such as redlining and exclusionary zoning. This lack of housing has been associated with chronic lung and heart disease, metrics that are being measured in ventilator rationing frameworks.
Some may argue that in a pandemic, the priority should be to maximize the number of lives saved as much as possible. This is a morally defensible argument, but we must acknowledge that, intentional or not, blind utilitarianism will favor the lives of wealthier Americans at the expense of poorer communities. On the other end of the spectrum, some may argue that this adjustment doesn’t go far enough, and that there are other marginalized groups that should be adjusted for, such as homeless populations and disabled patients. These groups should be included in these frameworks, if we are able to get input from representative groups on how to best classify the severity of these conditions.
Of course, the hope is that hospitals will not need to resort to rationing measures for our patients. But if this does happen, we must remember that there have been many moments in America’s recent history where marginalized communities have been implicitly oppressed in obtaining housing, employment, financial assistance, and health care. We should not let this pandemic mark a moment in our country where our governments and health system unintentionally exacerbated underlying health inequities by denying lifesaving care for marginalized Americans.
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