America's looming experiment in health-care rationing
Arizona on Monday announced its pandemic "crisis care standards," which is a euphemism for rationing. If the state's confirmed COVID-19 cases continue to trend sharply upward, as they have throughout the month of June, the standards will provide statewide triage rules for doctors determining which patients receive which treatments when resources are too scarce to provide ideal care to all. Such guidance is "not needed today," said Arizona Gov. Doug Ducey (R), "but we're anticipating that it will be there in the future."
Arizona's spiking caseload isn't unique. Between 33,000 and 45,000 new U.S. cases of COVID-19 have been confirmed daily over the past week. The hospitalization rate has not reflected that spike, nor has the death rate. Perhaps that forbearance will continue, and care resources will never be stretched thin like they were in Italy. Perhaps we're simply experiencing a lag. If all three numbers rise in unison, coronavirus "crisis care standards" could be implemented by every state.
Ah, but what should those standards be? This is a near-impossible question to answer. Italy chose an explicitly utilitarian approach: "Informed by the principle of maximizing benefits for the largest number," its guidelines said, "the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care." As COVID-19 is often most severe in older patients, some hospitals ordered age cutoffs for intubation. "[An unnamed Italian physician] offered a hypothetical scenario involving two patients with respiratory failure, one 65 and the other 85 with coexisting conditions," reported The New England Journal of Medicine. "With only one ventilator, you intubate the 65-year-old."
The surface-level logic of a utilitarian approach makes sense. It's a medical trolley problem, and you pull the lever to kill one person instead of five. But under scrutiny, it's messy. Uncertain. Is it our best option? Is it right? Does it even provide all the answers it promises?
In concrete example: "Would you remove a ventilator from one patient who was having a rocky course, for instance, to give it to another in the throes of an initial decompensation?" the NEJM story asks. "Would you preferentially intubate a healthy 55-year-old over a young mother with breast cancer whose prognosis is unknown?" Should comorbidities trump age? What about when health-care workers are themselves infected: Should they receive priority because, once recovered, they might save other lives? Or is a "first come, first served" approach better? Can we decide on purely objective considerations, like oxygen saturation or viral load? Can we make a formula so the data decide for us? Would that release us of moral responsibility for the results?
The Arizona standards have a points system in which, like the grimmest game of golf, you want to come in below par. But they also allow for subjective consideration of factors like whether the patient is pediatric or pregnant, whether they work in health care or are someone else's sole caregiver, and — in what seems to be a proxy for age without running afoul of age discrimination laws — how many "life stages" they have had the opportunity to experience.
Then there's the question of disability. Arizona's rubric is already getting pushback from advocates, who argue it doesn't include adequate protection for people with disabilities. Among other revisions, the guidelines should be changed to ban "making health-care decisions based on disability, perceived quality of life, age, underlying conditions, and a person's need for disability-related accommodations," they say. (The guidelines already pledge triage choices will not consider "ethically irrelevant criteria" like age and disability, and that, "No one will be categorically denied care based on stereotypes, assumptions about any person's quality of life, or judgement about a person's 'worth' based on the presence or absence of disabilities.")
Similar objections, including a federal civil rights complaint, were raised to Washington State's triage plan in March. That complaint does not seem to have been resolved, but reviews of how disability is handled in COVID-19 triage and treatment plans have been concluded for Tennessee, Connecticut, Alabama, and Pennsylvania. The question of who should be given or deprived of care has come to red, blue, and swing states alike. A good friend of mine here in Minnesota worries his disability could be used to limit care were he hospitalized with COVID-19.
A Texas case making news in pro-life and disability advocacy circles this week may be a portend of things to come. A man named Michael Hickson was diagnosed with COVD-19. He died after he was given pain medication but denied other care, including nutrition and hydration, for six days. Hickson, who was Black, had a cardiac arrest three years ago which left him quadriplegic with an anoxic brain injury (a reportedly milder version of the injury present in the better-known case of Terri Schiavo).
The decision, said a doctor in a recording of a conversation with Hickson's wife, Melissa Hickson, depended on state guidelines and medical judgment of likely treatment outcomes and quality of life. It's that latter, more subjective criterion which has drawn attention to Hickson's story: The doctor can be heard saying Hickson "doesn't have much of" a quality of life because of his disabilities. Hickson's wife, who didn't have legal authority to direct his care because of an intra-family dispute, disagreed, and she alleged the doctor would not make the same call if his own spouse's life were at stake. She characterizes her husband's death as "murder."
Melissa Hickson's assumption of how the doctor would handle a case in his own family can be instructive. She accused him of lying, and his casual rebuttal was jarring to hear. But doctors are far more likely than the average person to refuse invasive, life-sustaining treatments for themselves and advise against them for their loved ones. Our health-care system too often incentivizes futile over-treatment which, though they witness and even perform it, physicians tend to reject in their private lives for compelling ethical and practical reasons. The Texas doctor may well have spoken honestly. Were he in Michael Hickson's position, this could truly be the decision he'd want.
But it was not the decision Melissa Hickson wanted, and if COVID-19 care rationing begins in earnest, such disagreements will multiply, and not only in connection to disability. Ad hoc guidelines created for a still little-known illness, pandemic anxieties and exhaustion, compressed timelines, and sincere ethical differences will intensify every such dispute. The only good scenario here is the hope that we never reach a triage point at all.
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