How NEJM’s ethical recommendations on the fair allocation of scarce medical resources perpetuate inequity

This past March, the New England Journal of Medicine (NEJM) published six ethical recommendations to guide the allocation of scarce medical resources during COVID-19. In their second recommendation, they stated that “critical COVID-19 interventions — testing, PPE, ICU beds, ventilators, therapeutics, and vaccines — should go first to frontline health care workers and others who care for ill patients.” This makes sense because health care workers have the technical skills to maximize lives saved during this pandemic. The recommendation then goes on to include that individuals who should also have priority access to COVID-19 interventions include those “who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace.” The authors do not explain how they define individuals that are critical to our infrastructure. While more individuals are now explicitly classified as essential workers, the resource allocation proposed in the NEJM guidelines continues to perpetuate exclusionary systems that solely benefit those in positions of power. COVID-19 has illuminated the true broader definition of an essential worker, presenting an opportunity for the NEJM, members of the health care community, and others to redistribute resources more equitably, as a mechanism to begin shifting power to those who are critical to our infrastructure but often forgotten.

Individuals critical to our infrastructure include agricultural workers and other frontline workers such as bus drivers, grocery store clerks, janitors, and countless others, and we argue that these non-health care workers also need priority access to COVID-19 interventions. Just like health care workers, they also face a high risk of infection, are irreplaceable, and allow our society to function at its most basic level. As noted in the article, recommendation #2 states that priority access allocation for health care workers is not because they are “somehow more worthy,” but instead because they hold “instrumental value: they are essential to [the] pandemic response” and essential to our society. Without farm workers, food prices go up as farmers destroy crops, and more people struggle to afford groceries – in short, the chain collapses. Without people cleaning buildings, infection rates would rise, overwhelming our health care system. These high-risk jobs maintain our society.

High-risk essential jobs and the people that work them in our society are sadly not valued equally, setting up a paradox of essential versus expendable. This paradox is a direct result of capitalism and systemic racism. In this paradox, our crucial non-health care workers in perceived low-skill jobs are viewed as expendable based on a false value hierarchy informed by race, ethnicity, SES, immigration status, language spoken, gender, ability, and other factors. While black individuals are 13.4% of the US population, they comprise 17% of essential workers, yet only 5% of physicians. Similarly, Latinx people represent 18.3% of the population, 16.3% of frontline workers, including 40.2% of building cleaning services, but only 5.8% of physicians. In contrast, 56.2% of physicians in this country are white. When viewed as a proportion of their subgroup population, a disproportionately large number of minorities work as non-health care essential workers in comparison to their white counterparts.

The NEJM published recommendations prioritize white people to receive critical COVID-19 care and resources, while marginalized individuals are quite literally pushed to the margins of care. Furthermore, no hospital in this country has reported a shortage of doctors or nurses, only shortages of PPE, which happen to be produced by essential workers who are disproportionately minorities. Such inequities implicit in the NEJM recommendations further strengthen the unjust power dynamic in this country, uphold white supremacy, and reinforce the paradox of essential versus expendable for non-health care essential workers.

The definition of frontline workers in current and future ethical guidelines, therefore, must explicitly include farmworkers, environmental services staff, childcare providers, bus drivers, trash collectors, factory workers, cashiers, and countless others who cannot work from home. Also, they must clearly state that immigration status is not an eligibility requirement for the future vaccine and treatment. We need explicit language and enforceable oversight to ensure our non-medical front line workers are equally protected as they perform critical societal roles. In order to achieve a more equitable distribution of resources, America’s framework to protect a subset of the population must be dismantled.

Amalia Elvira Gomez-Rexrode and Daniel Rizk are medical students.

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