As the new coronavirus pandemic spreads across the United States, we must learn from those countries that are already feeling the brunt of the crisis. Reports from Italy describe doctors making decisions on the fly regarding whom to prioritize for medical resources as waves of very sick patients turn to hospitals for care during the COVID-19 crisis. These stories highlight the urgent need for the United States to come together as communities and within health care institutions to craft clear, equitable, and transparent policies for rationing health care services. We must prioritize making these decisions before the crisis begins to overwhelm our health care system.
Modeling conducted at the Harvard T.H. Chan School of Public Health indicates excess demand for ICU beds throughout the country will outstrip capacity by as much as 600 percent if the current trajectory stays in place. And, even in a best-case scenario of “flattening the curve” of new infections, excess demand will likely remain at 200 percent. While specific numbers are hard to pin down, reports from hospitals around the country show severe shortages of ventilators as well as supplies such as filters, tubes, and anesthesia that are used together with ventilators.
Rationing health care is not a new problem. Given the vulnerability of humans to age, accidents, and disease, all societies prioritize care for certain individuals or conditions. Countries with national health services typically make those priorities clear. For example, there may be national decisions to pay for a limited number of rounds of cancer treatment rather than for as many rounds as a patient chooses — as has been in the case in Canada, or to prioritize low-cost public health measures such as immunizations over high-priced experimental treatments for rare diseases — as is the case in Denmark.
Here in the United States, “rationing” of health care tends to be seen as a dirty word, yet we ration care too: Those who can pay for it are prioritized. Those who cannot often struggle to access care and, as a whole, have worse health outcomes and higher mortality rates.
There are a variety of criteria that are already used to triage care. Allocation of organ transplants typically prioritizes those who are in the greatest immediate danger of death without treatment. Other systems prioritize those who are most likely to benefit from treatment; that is, those who not have other serious health conditions. Geography can also play a role.
Decisions around triaging always involve social considerations. Do we prioritize children whose lives are ahead of them? Or do we prioritize adults who have skills that are needed especially during times of crisis? Should prisoners be at lower priority levels, even when we know that the criminal justice system has disproportionately criminalized people of color? How about those with substance use disorder?
To make these kinds of decisions, US hospitals and health care facilities typically have ethics review boards, though there is variability in how they are constituted and how they function. Unfortunately, not all have yet convened their boards in response to the COVID-19 pandemic.
Though COVID-19 presents unique challenges, boards can draw on guidelines developed in the past by the Department of Health and Human Services and by a variety of medical disciplines. These guidelines emphasize the importance of uniform policies and careful monitoring of how those policies are implemented. This is crucial for taking pressure off of doctors and nurses to “play God” in critical situations, making the most of the resources that are available and ensuring patients and their families of fair treatment.
Ethics review boards include health care professionals, professional ethicists, and some community representation, though what that means is fairly vague. Given recent racist attacks on people of Chinese descent, longstanding inequalities and implicit bias in the health care delivery system, and new conversations regarding the risks and responsibilities of older versus younger people during the pandemic, it is crucial to expand the community participation in review boards. They can and should include people of diverse ages, races, ethnicities, genders, and economic and citizenship statuses.
Without fair and transparent triaging policies in place, our soon-to-be overwhelmed health care system risks allocating care based on the personal preferences of individual providers and losing the trust of the American public. It is past time to acknowledge that we do not have adequate resources to provide the best health care to everyone in an optimal manner. When the dust from this crisis settles, we need to be able to look back and say that we, as a nation, did our best to balance rationality with compassion.
Susan Sered is a professor of sociology at Suffolk University and the author of seven books.
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