Rationing, racism and justice: advancing the debate around ‘colourblind’ COVID-19 ventilator allocation

Abstract

Withholding or withdrawing life-saving ventilators can become necessary when resources are insufficient. In the USA, such rationing has unique social justice dimensions. Structural elements of dominant allocation frameworks simultaneously advantage white communities, and disadvantage Black communities—who already experience a disproportionate burden of COVID-19-related job losses, hospitalisations and mortality. Using the example of New Jersey’s Crisis Standard of Care policy, we describe how dominant rationing guidance compounds for many Black patients prior unfair structural disadvantage, chiefly due to the way creatinine and life expectancy are typically considered.We outline six possible policy options towards a more just approach: improving diversity in decision processes, adjusting creatinine scores, replacing creatinine, dropping creatinine, finding alternative measures, adding equity weights and rejecting the dominant model altogether. We also contrast these options with making no changes, which is not a neutral default, but in separate need of justification, despite a prominent claim that it is simply based on ‘objective medical knowledge’. In the regrettable absence of fair federal guidance, hospital and state-level policymakers should reflect on which of these, or further options, seem feasible and justifiable.Irrespective of which approach is taken, all guidance should be supplemented with a monitoring and reporting requirement on possible disparate impacts. The hope that we will be able to continue to avoid rationing ventilators must not stand in the way of revising guidance in a way that better promotes health equity and racial justice, both to be prepared, and given the significant expressive value of ventilator guidance.

Health inequities and the inappropriate use of race in nephrology

“…For instance, calculators that predict risk of in-hospital mortality for patients with acute heart failure assign a lower mortality risk to Black patients (compared with non-Black patients), potentially withholding recommended medical therapy from this population 73 . The COVID-19 pandemic has further highlighted how current algorithms or clinical measures that do not specifically account for racial differences due to structural racism, such as life expectancy predictions that are heavily skewed by neighbourhood characteristics, might further disadvantage individuals from minority populations 8 , 156 , 157 . Yet, studies commonly assume racial differences are due to biology, with limited mention of contributing structural factors and without performing analyses that explicitly include these domains 33 , 158 , 159 .…”

The potential impact of triage protocols on racial disparities in clinical outcomes among COVID-positive patients in a large academic healthcare system

“…Black individuals are more likely to get sick and die from COVID, and they are also more likely to suffer from the severe comorbidities that lead to worse SOFA scores and COVID outcomes; this important reality is not reflected in the use of SOFA scores or simple comorbidity calculations in triage protocols [ 2 , 37 , 38 ]. If used, these protocols have the potential to further exacerbate racial and ethnic disparities.…”

Who will receive the last ventilator: why COVID-19 policies should not prioritise healthcare workers

“…These groups also have long histories as targets of outright discrimination or implicit bias in healthcare and other spheres of life, including biases built into the clinical algorithms commonly used for prioritising patients for ventilators, which further disadvantage persons already disadvantaged by social determinants of health. 28 This is the context in which we must imagine implementing a policy prioritising a physician who has many privileges over an equally sick patient who has had none.…”