Update: According to the April 7, 2020 Boston Globe, “State officials asked a small number of physicians and bioethicists from hospitals across Massachusetts to develop detailed recommendations for allocating ventilators and intensive care beds, which the group did over the weekend of March 27 to 29.” In the context of the concerns raised in the post below, I am disappointed that these life and death guidelines were made by an elite group with no input from the communities that are most impacted.

Rationing health care is not a new challenge. Given the vulnerability of humans to age, accidents, and disease, no society has sufficient resources to respond to every need. And, given the complexities and depth of our social relationships, allocating those resources is always emotionally and morally charged.

In the United States, “rationing” tends to be a dirty word associated with “death panels” and “socialized medicine.” Yet we ration care and we always have. Those who can pay for it are prioritized; those who cannot pay struggle to access care and have worse health outcomes and higher mortality rates than people who can pay. This disparity is tacitly accepted (at least by those who have good health insurance coverage) as the price we Americans are willing to pay for the privilege of being able to “choose” our insurance, even if that so-called choice is mostly a matter of being lucky enough to have a job that subsidizes a good plan.

As COVID-19 sweeps through the country, however, traditional American views regarding free choice and personal responsibility are being tossed aside. Local, state and federal governments agree that no one should be denied a COVID-19 test or turned away from hospitals for treatment because of lack of financial resources. In other words, as a society — at least for this one moment in time — we have rejected rationing based on ability to pay.

With America’s fallback (pay to play) rationing system ruled out, medical institutions are scrambling to figure out how or whom to prioritize for care when equipment such as ventilators are insufficient to meet the need. Early reports from Italy describe doctors forced to make these decisions on their own. In the United States, each state and in many cases each institution sets its own policies, though as of this writing there is little clarity or transparency regarding processes for creating or enforcing policies.

Public discussions and publicly cited comments by physicians show a trend towards rationing based on assessments of likelihood to live a long life after surviving the acute medical crisis. (Click here for White and Lo’s nuanced critique of that trend.) There are many ways to translate that principle into practice. For example, because older people are statistically less likely to live as long as younger people, scarce care could go first to the young. While not necessarily a bad criterion, it rests on an underlying cultural logic that should be made explicit. “Ageism” — the glorification of youthful bodies and dismissal of the wisdom gained through life experience — is deeply entrenched in American society. We may or may not decide that age-based rationing is the least bad of the horrid choices, but first we should ask ourselves why we are less uncomfortable with age-based than with other rationing systems, and what these priorities mean for our society going forward.

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Another way to operationalize the principle of expected years of life post-treatment could ration care based on overall health of the patient. Because people who have other medical conditions may be less likely to survive the virus even with treatment, priority should go to those who are healthy. Why, after all, waste scarce resources on someone who was sick before the pandemic started?

The flip side, of course, is that rationing based on health status reinforces existing health inequalities. Abundant research demonstrates that racism and poverty lead to poor health via stress, discrimination, lack of access to healthy living environments, nutritious food and timely health care, and increased likelihood of incarceration in jails, prisons and juvenile facilities. As with age-based rationing, we may well decide that health-based triage is the least horrible choice. But first, we need to ask ourselves whether it’s reasonable or equitable to re-inscribe existing disparities and essentially punish people for poor health associated with being poor or Black or otherwise marginalized.

More broadly, rationing by pre-existing health status may be as much about cultural values as about “objective” medical fact. Throughout our shared history, American culture has valorized and rewarded good (“glowing”) health and cast blame on unwell individuals for “poor choices” or “failing to take care of themselves.” We also have stereotyped and accused certain ethnic groups, immigrants, and people with devalued social or sexual identities for being carriers of disease who threaten the nation. We may feel that we have moved beyond these prejudices, and that may even be mostly true, but they are woven into the history of our institutions and need to be considered in discussions of rationing.

These observations are not intended to cast aspersions on individual health care providers or institutions, especially at a time in which they are working valiantly without adequate federal support. As this pandemic spreads, choices will be made about who gets the resources that offer the best chance to survive, and who does not. The existential reality — even in the best of times — is that there is no perfect way to ration care. We can, however, hold the rationing criteria up to the light of day. We can insist that processes are transparent, that decisions are not made on the fly, and that representatives of diverse groups of Americans are included as full partners in laying out rationing policies.

Click here to read my Boston Globe column discussing the background to the rationing concerns in this post.