Who gets care in a pandemic? Assuring human rights is part of preparedness

Imagine being an emergency medical technician called to the scene of a car accident and finding dozens of people injured and needing help. With limited supplies, a single ambulance, and people with varying severity of injuries, where do you start? I remember a scene like that 30 years ago, when I was working as an EMT in Springfield, Mass. Two cars crashed into each other and then plowed through a crowd of people waiting at a bus stop. Hospitals are experiencing something similar with the COVID-19 pandemic, as patients overwhelm the capacity of intensive care units, doctors and nurses.

In response, bioethicists and medical societies have discussed various approaches to triaging patients — in other words, deciding who gets care. But the issue is broader. My fear in the current pandemic is that we are watching as a tragedy unfolds and are not being asked by our political leaders to do anything more than to stay home. We are asking health care providers to put themselves on the line; we are hoping that supplies will arrive from somewhere; we are assuming that vital information about how to protect us will reach everyone and be understood — despite contradictory messages on things as simple as whether to wear a mask.

Traditionally, in deciding who gets care, hospitals or EMTs might use a “first come, first served” approach, prioritizing those who are in urgent need and right in front of you. That means some patients who may be in severe need but, because of income or race or other criteria, are less able to get to a health care provider will not receive care. 

Many have backed a utilitarian approach: seeking the greatest benefit for the greatest number. But in practice, this is not so simple and can discriminate against people based on age or disability. The director of the Office for Civil Rights at the U.S. Department of Health and Human Services raised this concern at the end of March and announced that the office was opening civil rights investigations to ensure that states did not engage in “ruthless utilitarianism.” He said that “persons with disabilities, with limited English skills, and older persons should not be put at the end of the line for health care during emergencies.” 

There’s no simple or right or best approach when care must be rationed. However, we need to start the conversation by reflecting upon the broader “rationing” that occurs in our society and manifests itself as vast health inequalities. Health care providers intuitively understand this, because they see how socially and economically disadvantaged groups struggle daily to stay healthy and to access care.

It is not surprising that the same people will fare worse during a pandemic — less able to get information about the virus, less able to practice “social distancing” because of their need to work or because of where they live, including crowded apartments, on the streets or in a county jail awaiting trial because they can’t pay bail for a minor offense.

Thirty years ago, facing that car accident, the first thing I did was get people who were well enough to help me. There was a limit to how much people who were untrained in first aid could do, but their extra hands helped me and helped those who received even a small amount of care, regardless of their ultimate outcome. 

With more than 2.6 million cases of COVID-19 worldwide, we need to find greater social solidarity and we need political leadership that will direct that solidarity toward ensuring that those who are most disadvantaged are cared for and protected. This can be as simple as neighborhoods checking in on those who are elderly, disabled or have underlying health conditions, but it also needs to be about expanding social safety nets and maximizing justice and fairness. 

In response to the pandemic, Portugal extended full citizenship rights to all migrants and asylum seekers. Immigration authorities in Spain said they would release people from detention because of the high risk for transmission in closed institutions. Barcelona’s street vendors, out of work amid the lockdown, joined forces with a clothing company to sew masks and aprons for health workers whose supplies were running low. Yet in the U.S., some states took advantage of the crisis to try to limit access to abortion and pass discriminatory laws against transgender people. 

When this crisis abates, there will be a lot of discussion about “lessons learned” and how to ensure we are ready for the next pandemic. Part of the answer is to invest more in our public health and health care systems. But at least as large a part of pandemic preparedness is building solidarity and ensuring the resilience of our communities by fighting for human rights, social justice and the protection of the disadvantaged. If we succeed at that, we will have much less need for crude criteria for rationing care or asking doctors to decide who will get life-saving care and who will not.

Joe Amon is director of global health at the Drexel University Dornsife School of Public Health and the former Human Rights Watch health program director. Follow him on Twitter @joeamon.