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The Harm Of A Colorblind Allocation Of Scarce Resources

Doi: 10.1377/forefront.20200428.904804

COVID-19 will not only have a disparate impact on historically under-resourced and marginalized communities, but also carries the risk of deepening pre-existing racial inequities in health care access, treatment, and social service delivery. Even a health care system striving to provide fair and equal treatment to all persons is not immune to structural racism and the other inequities that exist throughout society. To achieve equitable access and distribution of care, critical race theory must be a part of the process utilized to create broad, population-focused guidelines. This is particularly true in the face of the COVID-19 pandemic which is stressing both our health care system and society.

Both the New England Journal of Medicine (NEJM) and the Journal of the American Medical Association (JAMA) have recently published articles attempting to provide an ethical framework by which to allocate scarce medical resources during the COVID-19 pandemic. Unfortunately, neither article acknowledged the structural racial inequities that inherently bias its proposals, nor did either piece adequately acknowledge how its care rationing plan might worsen already racially disparate health outcomes.

‘Rationing Is Already Here’

As pointed out in the NEJM piece, the United States is already a place where rationing of care occurs. However, rationing extends far beyond access to personal protective equipment (PPE) and existed long before the COVID-19 pandemic. The United States health care system has rationed access to care for decades. Health care access has long been linked to wealth and geography. Increasing premiums, deductibles, and use of prior authorization for drugs and services are all tools of rationing due to escalating costs, and all more manageable by those with means.

Underneath this tiering of health care access by wealth, often justified by the false notion of meritocracy, is where we see the impacts of structural racism. Health care rationing is associated with both health disparities and social determinants of health. Though often ignored, race, vis-a-vis racism, restricts access to wealth, education and employment with health insurance. Amidst the COVID-19 pandemic, we urgently need to utilize critical race theory to analyze recommendations regarding allocation of scarce resources and ensure they do not unintentionally perpetuate and uphold structural racism.

While examining who gets health resources in a COVID-19 pandemic, the NEJM authors argue, “Limited time and information in a COVID-19 pandemic make it justifiable to give priority to maximizing the number of patients that survive treatment with a reasonable life expectancy and to regard maximizing improvements in length of life as a subordinate aim. The latter becomes relevant only in comparing patients whose likelihood of survival is similar.” While this could hold true in a vacuum, the United States is no such environment. In the United States, life expectancy at birth for white females is nearly 10 years longer than black men (81.2 years versus 71.9 years).

During the COVID-19 pandemic, physicians in New York have been among the first in the United States to make decisions about who lives and who dies because of scarce resources. Yet, these decisions are only a compressed version of the kind made, year after year, to assign differential worth to humans. Racial covenants, racist redlining, and housing segregation all translate into life expectancy that varies widely by zip code. In New York City a zip code of 10030 (Tract 232, Harlem) carries a life expectancy at birth of 72.7 years; less than five miles away in 10075 (tract 142, Upper East Side of Manhattan), life expectancy is 89 years. To prioritize life expectancy without intentional regard to the underlying structural racism that defines it in the United States will undoubtedly reinforce disparate mortality rates by race and ethnicity.

Structural Racism And Physician Racial Bias

In the NEJM article’s first recommendation, “prioritizing the value of maximizing benefits,” the authors state, “We believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission.” However, it is important to acknowledge the widening and deepening evidence that physicians’ own racial biases will likely impact which patients are offered these discussions—and which ones will have the decisions made for them. There is literature identifying worse outcomes in pediatric pain management, appendicitis treatment and physician-patient communication due to the racial bias of providers.

The impact of physicians’ racial biases on their decision making and the effectiveness of their communication with patients therefore warrants a systematic approach to these conversations. Specifically, fatigued physicians, those under time constraints, and with incomplete information are more likely to rely on or default to these biases. The COVID-19 pandemic has catapulted physicians into situations where they are encountering those stressors and more. How these critical decisions are approached and made needs both clear communication to the family and a protocolized approach that limits racial bias and increases consistency in decision making.

The combination of unaddressed structural racism, social drivers of health, and physician bias creates similar concerns in how both the JAMA and NEJM pieces weigh the presence of certain underlying medical conditions and their influence on prioritization within the guidelines. In addition to an age of 65 years or over, the Centers for Disease Control and Prevention (CDC) currently lists the following as underlying medical conditions that place one at a higher risk from COVID-19: chronic lung disease, moderate to severe asthma, heart disease, severe obesity (a body mass index of greater than 40), diabetes, chronic kidney disease on dialysis, liver disease, and those who may be considered immunocompromised. Due to structural racism, Black Americans and American Indians/Alaskan Natives are more likely to have almost every one of these conditions when compared to non-Hispanic Whites. Prioritizing ICU beds and ventilators, antivirals, and other experimental treatments for those who have few or no comorbidities will inherently lead to a disproportionate number of deaths among Black Americans and American Indians/Alaskan Natives.

Prioritizing Clinical Trial Participants And The Health Care Workforce

The NEJM authors’ recommend, “People who participate in research to prove the safety and effectiveness of vaccines and therapeutics should receive some priority for COVID-19 interventions.” On the surface, this may seem unassailable. However, underrepresentation of racial and ethnic minorities is a chronic issue in clinical trials. Data from 2011 showed that African Americans and Hispanics at the time comprised 12 percent and 16 percent of the United States population, but only 5 percent and 1 percent of clinical trial participants, respectively.

Compounding this is the fact that while nearly 20 percent of Americans receive health insurance from Medicaid, most state Medicaid programs do not cover routine care costs (like physician visits and lab studies) for patients participating in clinical trials; this limits participation in clinical trials among Medicaid enrollees. Among patients age 65 years or younger, Medicaid serves Black, Hispanic and American Indian/Alaskan Native patients at a rate higher than their overall representation in the United States, which may result in lower participation in COVID-19 trials among these populations.

The concerns that arise from both articles’ recommendations exemplify the importance of applying a racial equity lens to healthcare and health policy. The JAMA authors advise, “It should be made explicit that ventilators will not be allocated on the basis of morally irrelevant considerations, such as sex, race, religion, intellectual disability, insurance status, wealth, citizenship, social status, or social connections,” Both they and the NEJM authors advocate for prioritization of health care workers, however. While we agree health care workers must be prioritized to be able to continue providing care, this pandemic once again highlights the chronic underrepresentation within the medical field: white workers are overrepresented in 23 of the 30 medical occupations compared to their representation in the United States workforce.

Additionally, there are roles besides clinical care providers that are critical to our healthcare infrastructure, especially during an infectious pandemic. These roles include workers in the custodial and other fields. Many times, people in these roles lack the privilege and power of physicians; however, they too require protection. It is our duty to make sure any recommendations around ethical allocation of limited resources embodies all the members of the healthcare team.

Leading With A Racial Equity Lens

Congresswoman Ayanna Pressley (D-MA) and Senator Elizabeth Warren (D-MA) have led a call for the federal Department of Health and Human Services to ensure that racial and ethnic data are being collected regarding the country’s response to the COVID-19 pandemic. Likewise, organized medicine must make every effort to view our response to the COVID-19 pandemic through the lens of critical race theory. From how research is conducted, to the policies that expand access to health care, to the protocols we use to fairly allocate increasingly scarce medical resources, we must analyze how our actions or inactions will impact racial inequities.

Existing racial equity tools, like the Seattle Race and Social Justice Initiative’s Racial Equity Toolkit, or the Government Alliance on Race and Equity’s Racial Equity Tool, provide health care leaders prompts to guide their decision making with questions like: What does data tell you about existing racial inequities that influence people’s lives and should be taken into consideration? What are the root causes or factors creating these racial inequities? How will the policy, initiative, program, or budget issue increase or decrease racial equity? How will you address the impacts (including unintended consequences) on racial equity? How will you be held accountable for the impacts on communities?

The NEJM and JAMA articles offered recommendations that disregarded underlying racial bias and racism; they failed to acknowledge the failure of our society and medical system to account for the impact of structural racism. While physicians will be plagued by daunting and unimaginable decisions and need consistent guidance, providing colorblind recommendations for allocation of scarce resources is assured to lead to more morbidity and mortality for our Black, American Indian/Alaskan Native and other marginalized communities. Health care should not be led to believe there is “Fair Allocation” when starting from a racially inequitable society. 

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