Şerife Tekin asks us to be aware that existing socio-economic disparities could adversely affect access to medical care under triage plans for scarce resources.
The prominent fear that defines the COVID-19 pandemic is “scarcity.” Confronted with the scarcity of medical resources, healthcare professionals around the world are struggling to come up with the fairest guidelines for triage protocols. Such protocols outline the criteria by which patients are classified according to the type and urgency of their conditions so that they receive the right care at the right time. How we determine what is “fair,” however, is a perplexing issue. Healthcare professionals, hospital beds, ventilators, personal protection equipment, and organs available for transplant are all examples of limited medical resources. In this post, I consider some existing schemas for distribution of scarce medical resources and argue that they are not adequate for triage protocols in the COVID-19 pandemic because they fail to be sensitive to the impact of socio-economic disparities on health.
For example, in the US, the United Network for Organ Sharing (UNOS) considers medical criteria such as the match between the available organ and patient’s tissue and pragmatic criteria such as the organ’s geographic proximity to the patient in the allocation of donor organs. Additionally, they have adopted a set of criteria prioritizing the treatment of those who are the sickest, who have a longer life expectancy, and a lottery approach – when all else is equal – to determine the allocation of resources. The necessity of having the financial means, whether through insurance or privately, is an important factor in whether the patient receives the transplant in the end, which unfortunately puts people with low-income status in a vulnerable position.
Recently, Italian healthcare professionals were put in the unenviable position of having to make tough moral decisions on who gets to receive intensive care. The Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) established a set of criteria to follow in triage protocols. SIAARTI recommends “maximizing benefits for the largest number” by prioritizing the treatment of those “with the highest chance of therapeutic success.” This means that it could be necessary to “establish an age limit for access to intensive care” or to not prioritize “those with pre-existing health problems.” The age limit criterion has led to controversy among commentators. Here, I address the “pre-existing conditions” criterion with the hope that these considerations are useful for physicians in the US and Canada who may have to make similar decisions.
Guidelines such as those provided by UNOS’s combination-criteria and SIAARTI’s framework are utilitarian: they aim to maximize the expected net amount of overall good. While utilitarian frameworks empower healthcare professionals to make timely decisions to save lives, they are limited because they don’t pay attention to existing health disparities in society – the differences in health among different social groups that stem from discrepancies in quality of life and access to health care. The disparities in social structures that shape a person’s material and psychological resources are further exacerbated by the COVID-19 pandemic. Using a utilitarian approach may have the unintended consequence of stymying the needs of vulnerable populations who suffer from health problems due to socio-economic discrepancies. Some of these kinds of concerns have been recently addressed in the context of persons with disabilities and individuals with mental disorders. Echoing these concerns, ethical guidelines that put vulnerable social groups at a disadvantage must be avoided as well.
Consider asthma, a respiratory disease that disproportionately impacts low-income workers in painting, agriculture and plastics manufacturing. If COVID-19 triaging protocols prioritize patients without pre-existing conditions, patients with asthma would have more difficulties accessing the life-saving medical support they need, compared to their peers. In other words, the triaging guidelines would disproportionately result in damage to those who develop asthma or COVID-19-related pneumonia, due to socioeconomic disadvantages.
What is the alternative, then? It is not easy to come up with one but we can at least set the tone of thinking about these complex realities by sharing a commitment to social justice, diversity, and inclusion in healthcare. Thus, it is an opportune time to turn to the fundamental commitments of feminist bioethics. Unlike the principle-based guidelines provided by utilitarian frameworks, feminist bioethics avoids one-size-fits-all approaches and takes seriously the context of the medical case in question. It recognizes the web of interconnected social relationships that shape health – and illness. Feminist bioethics considers human beings as deeply relational beings whose identities and well-being are established and maintained through relationships. Taking this as our starting point, the values that guide us in triage protocols should be care, responsibility, and generosity, not competitiveness over scarce resources.
As the Canadian Bioethicist Françoise Baylis aptly put recently, the “watchword in the time of pandemic is solidarity, not autonomy.” How we treat those who are the most vulnerable in such difficult times will not only determine who lives and dies, but will also help us define the kind of world we want to give to future generations.