From the New York Times‘ opinion page:

The Way We Ration Ventilators Is Biased
Not every patient has a fair chance.

By Harald Schmidt
Dr. Schmidt [Email him] is an assistant professor in the department of medical ethics at the University of Pennsylvania.

April 15, 2020

Rationing ventilators might be a necessary response in the new Covid-19 world. Many hospitals decide who gets them by selecting patients most likely to benefit. Experts agree this is the best way of saving most lives. The approach, the model guidance, may sound fair. But baked into it are biases that disadvantage groups who, even without a Covid-19 infection, experience worse health because of historical and structural reasons, especially black people.

Consider this case. Three patients are waiting to be admitted to an intensive care unit that has one remaining bed. All have equally severe Covid-19 symptoms. John is an otherwise healthy, white 40-year-old man. Rosa is a 45-year-old African-American woman with underlying health issues. Linda is a white 56-year-old woman with Down syndrome. Who should be admitted?

Linda has high blood pressure and complications from an earlier heart surgery. She would need care for longer than John. Clinicians might also consider her age; life expectancy for people with Down is around 60 years. Linda has fewer years left than John or Rosa. Implicitly or explicitly, clinicians might not admit her on this ground.

Rosa grew up in a “redlined” part of town. Accessing health care has been as challenging as accessing loans or healthy food. Her community has significant distrust toward the health care system. The Tuskegee Syphilis Study still casts a long shadow.

Sadly, this article misses the hat trick. While it cites redlining and the Tuskegee Syphilis Study, there is no mention whatsoever of Emmett Till.

Day-to-day racism experienced in the hospitals adds to this. Some years she had insurance, some years she did not, which did not help with managing her asthma and diabetes. Taken together, Rosa’s health is such that her statistical odds are similar to Linda’s.

The “saving most lives” model would admit John. He is likely to spend the least time in the intensive care unit, allowing more patients to be put on the ventilator. And since his life expectancy is the greatest, the time he spends on the ventilator enables him to live longer than Linda or Rosa.

But this “colorblind" approach ignores the structural reasons underlying Rosa’s health issues. And it has also come under legal scrutiny for unfairly disadvantaging disabled people. In response, guidance for ventilator rationing emphasizes that “race, ethnicity, gender, insurance status, perceptions of social worth, immigration status, among others” should be irrelevant — but even this approach can risk leaving several of the identified groups at a major disadvantage.

It would be one thing if only personal choice accounted for differences in health and life expectancy. Or, if across racial or ethnic lines, income or insurance statuses, each group had the same share of people with major health conditions like diabetes or asthma, which can affect baseline health.

But that is not the case. Baseline health is far worse among lower-income, uninsured, disabled and particular racial and ethnic groups. Life expectancy likewise differs across groups. The reasons are overwhelmingly structural and historical.

That’s why whites live so much longer than Mexican-Americans. Oh, wait …

Anyway, the good news is that ventilators aren’t in short supply most places. The bad news is that in part that is because they don’t work as well as expected at saving lives. But in turn, the good news is that doctors seems to have discovered some low cost work-arounds, like laying on your stomach, that seem to work at least as well.