COVID-19: Why “saving the most lives” means treating more white people than Black
You are a physician on a ward full of COVID-19 patients, and you find yourself faced with a difficult decision: you have two patients who have come in with similar symptoms—shortness of breath, cough, and fever. Both have lungs full of fluid, and both are rapidly deteriorating. Both urgently need ventilators. One is a 56-year-old African American woman, with poorly controlled diabetes. The other is a 56-year-old man, who is white, and has no medical comorbidities. There is only one ventilator. What would you do?
The United States is now approaching an unprecedented level of medical resource scarcity. The projected need for ventilators will far outweigh supply, and there will be critical shortages of ICU beds for COVID-19 infected patients as well as medical personnel, medications, and personal protective equipment (PPE). Peak demand is projected to occur in two weeks in some locations. Some people will be denied care.
A consensus is developing around the save-the-most-lives principle in medical journals and popular press: if we have critical shortages, give the ventilator to the person with less comorbid diseases, the healthier one, the one who will most enjoy their life after recovery. Save as many people as you can, whatever that takes. This is an emergency.
Guidelines are now being created in many regions to address these difficult decisions. These guidelines will assist physicians in deciding who gets access to scarce resources. Hospitals are being told by federal civil rights officials that they will not be allowed to discriminate based on disability status, race, age or religion. They also shouldn’t base the decision on a person’s ability to pay. On the surface, this appears to protect the most vulnerable members of society.
To fully understand implications of the save-the-most-lives principle, however, we need a crash course in distributive justice. Several years ago, I created a series of animated videos about medical resource scarcity that has been used in public health curriculum and resident education modules at Harvard School of Public Health, MIT, and the University of Pennsylvania. These thought experiments were designed in collaboration with Dan Wikler, professor at Harvard School of Public Health, who has also served as staff ethicist at the World Health Organization (WHO).
This series uses the technique of thought experiments—short scenarios aimed at helping someone think through their values without extraneous details. The so-called ‘Trolley Problem’ is perhaps the most famous ethical thought experiment.
Here is an example of a thought experiment that I present to other physicians: You are tasked to decide where to set up a medical clinic for hypertension, either in a wealthy white suburb or an urban center with a majority black population. The urban population has low literacy, high rates of the uninsured, and higher rates of hypertension. You only have resources to build one clinic, where would you put it?
In this case, many doctors are horrified when they realize the biggest bang for their health care buck – implementing the save the most lives principle – would lead them to building a clinic in the suburbs and leaving the urban population without care. The suburban population would be more adherent to medications, less comorbid disease, and more able to pay for medications in the long run. If this choice would save the most people, why doesn’t it seem right?
I have sat in on WHO ethics deliberations in Geneva to determine guidelines for scarce medical resource allocation, and one would be hard-pressed to find an ethics document whereby all the authors fully agreed on what was written. It is always a compromise. Ethical solutions are always value-laden, and there are always many possible ‘correct answers’.
In contrast to a pure save-the-most-lives approach to resource scarcity, there is also an approach that takes into account the importance of providing resources to the least well-off people — these are people who might actually require more resources to reach the same level of health. A well-known distributive justice philosopher, John Rawls, in his book, A Theory of Justice, points out that it is sometimes ethically justified to give more resources to the least well-off if these resources ‘are to be to the greatest benefit of the least advantaged members of society’.
Returning to our original two patients, if our primary goal is to save the most people, the answer is clear: save the white man without comorbidities. He will be the most likely to survive of these two patients if given the ventilator. We do this when faced with every decision and we have done our best to save the maximum number of people in the population, not discriminating based on race, gender, disability, religion, or ability to pay.