State ‘Crisis Standards’ for rationing care are not equitable

FACING A POTENTIALLY overwhelming wave of COVID-19 patients, Massachusetts recently released “Crisis Standards of Care” to help hospitals prioritize who will receive scarce medical supplies and services. Intended to provide an ethical strategy for making life-and-death decisions in the face of grossly insufficient resources, when put into practice these will only heighten inequities that the pandemic has already laid bare: loved ones being denied or removed from ventilators due to life circumstances, income, race or abilities.

On its face, “saving the most lives” as a core ethical principle seems sensible. It uses strict evidence-based clinical criteria to predict survival and determine who should receive a ventilator when there is limited supply or even who should be removed from a ventilator to help another patient. Triage teams and oversight committees created by hospitals will oversee and implement these criteria. However, as ethical as this principle may be, it is by no means equitable.

Systemic racism and other inequities in our health system are a fact of American life. They take many forms, from limited health insurance choices to the more subtle redirection of patients and implicit bias. These inequities result in overall worse health outcomes, meaning people of color, the disabled, and those with low incomes, among others, are more likely to have complicating diseases or other negative clinical factors that increase their risks and lead to more severe disease. Already, African Americans appear to be at much greater risk of both illness and death from COVID-19.

As a result, we know these patients will receive lower survivability scores under the Standards and thus be denied or removed from ventilators more often than others. While the Standards say that “race, disability, gender, sexual orientation, gender identity, ethnicity, ability to pay, socioeconomic status, perceived social worth, perceived quality of life, immigration status, incarceration status, homelessness or past or future use of resources are irrelevant and not to be considered by healthcare providers making allocation decisions,” the very foundation of these standards – and the direct correlation between societal disadvantages and health outcomes – ensures that many of these same characteristics will, in fact, play a substantial role in who lives and who dies.

What’s more – these decisions will be made without representation from the populations that will be most impacted. Indeed, the state advisory committee for the Standards appears to have had extremely limited representational diversity, and no patient representatives are included in the triage teams or oversight committees proposed to implement and hear appeals on these life-and-death choices. Furthermore, if the Standards are implemented by hospital rather than statewide, certain populations already seeing a greater burden of COVID-19 will also be more likely to be denied life-saving care.

Of course, there is no good way to make these wrenching choices. Having criteria certainly helps overtaxed providers – but perhaps a decision system should rest on more than simply saving the most years of life. Should it include an assessment of a person’s value in their life circle? Are they a sole care giver for another family member? Are they the primary wage earner for a family? Is this low-wage employee in fact an essential worker – a grocery clerk or truck driver or machinist for respiratory masks?

These difficult decisions should be made not solely by teams of doctors and hospital administrators, but in tandem with the families and communities they will impact most.

Medical professionals across the country should stand up and call for greater transparency and more discussion about the likely impact of such crisis standards, ensure they are implemented for all populations statewide when enacted, and insist that representatives from the patient populations that will be most negatively impacted are recruited to help design, implement and monitor them.

In the meantime, it remains critical that all of us – government, medical workers, individuals – do whatever we can to continue to “flatten the curve,” buying time for hospitals and health systems to adapt and prepare and for whole communities to have the necessary open and difficult discussions about how we may need to ration care.

Once our systems are overwhelmed, health providers will be faced with impossible decisions – decisions that will be inequitable and unfair regardless of what ethical principle is applied. It is our moral duty as co-equal members of humanity to do our very best to never get to that point.  And if it does, we must ensure everyone is equally valued and involved in these decisions.

Jeff Markuns is physician at Boston Medical Center and executive director of the Global Health Collaborative in the Department of Family Medicine at the Boston University School of Medicine.