Equality of care

The unprecedented scale of the COVID-19 pandemic and ensuing efforts to provide critical hospital care have raised serious questions about rationing (limiting access) based on disability or age. Although, like everything else, health care is subject to the problem of scarcity, principles exist for determining the appropriate allocation of medical resources, especially during a pandemic.

COVID-19 offers an opportunity to reflect on those principles and to consider how they apply in concrete circumstances to avoid discrimination. Those considerations underscore the importance of Catholic hospitals and Catholics, more generally, to witness to the broader community the best care practices that value human dignity and uphold the common good.

According to the Center for Public Integrity, 25 states have scarce resource policies and protocols for hospitals. These policies could potentially harm people because they may limit access to life-saving medical equipment such as ventilators.

States are using a patchwork of rationing protocols in hospitals: first come first serve (first to the hospital gets treated); a lottery (random selection sidesteps triage); categorical exclusions (age, disability, pre-existing conditions place you at the back of the line); resource intensity (less care if your care drains resources); and fair-innings (if you’re “late in the baseball game,” your resources are allocated to someone younger). Depending on the level of scarcity and patient need, each protocol can lead to discrimination.

A recent Hastings Center essay noted that Minnesota’s “resource intensity” model permits prioritization based on expected or documented length of need, either in the initial decision to allocate a scarce medical resource or in a later decision to re-allocate the resource. Some might argue that this is appropriate because it does not imply an overt prejudice against people who are disabled. But, according to the author, this protocol can slide into less obvious forms of discrimination when categorical exclusions creep back in and inform an unspoken rationing policy.

The problem of health care rationing reveals biases based on a medicalized view of disability and older age, which can place less value on such lives compared with younger or able-bodied persons. Catholic bioethicist Charles Camosy has recently warned, “If rationing arrives, we must stand up unambiguously for the marginalized and vulnerable, the elderly and disabled, lest what Pope Francis has decried as the modern throwaway culture deems them expendable.” Resource scarcity shouldn’t be a driver that overtly devalues certain persons and the dignity of their lives.

Health care decisions must be made primarily on clinical factors such as the patient’s condition and his or her ability to respond to certain forms of treatment. Disability and age should not be used as categorical exclusions when deciding the allocation of scare resources like ventilators.

Furthermore, if we ask caregivers to balance an individual patient’s “quality of life” possibilities against the medical needs of everyone else, there’s greater risk of bias and discrimination. To avoid this, the federal government should issue national triage protocols based on sound principles to make certain that care is allocated in a fair and equitable manner that doesn’t discriminate.

To prevent unjust discrimination, organizations such as the Catholic Health Association and National Catholic Bioethics Center have outlined sound principles for providers to address these challenges during a pandemic. And the Ethical and Religious Directives for Catholic Health Care Services from the U.S. Conference of Catholic Bishops ensure Catholic hospitals follow appropriate principles and ethical norms.

Ultimately, COVID-19 hospital care is a cautionary tale for other issues. We should support a consistent ethic of life where care is based on the dignity of the human person and not their perceived “value” to others. Rationing often works against this idea in the same way as physician-assisted suicide, which has been justified on similar discriminatory grounds, that is, that life can be ended when it’s thought to no longer have meaning or purpose.

Just like with physician-assisted suicide, however, the current pandemic is a powerful reminder that we ought to more fully support better forms of care, such as palliative and hospice care. There is an urgency to create holistic care models that support the medical needs of all people.

Varco is a member of the Minnesota Alliance for Ethical Healthcare, an advocacy partner of the Minnesota Catholic Conference. The views represented here are solely the author’s own.

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