Massachusetts recently published, “Crisis Standards of Care and Planning Guidance” (1) giving guidance for institutions and providers for allocation of scarce resources, ventilators, if demand exceeds supply during the coronavirus epidemic. Much of the work was based on a Journal of the American Medical Association viewpoint(2) on a framework for rationing ventilators and critical beds during the crisis. The document states
“it should be made explicit that ventilators will not be allocated on the basis of morally irrelevant consideration such as sex, race, religion, intellectual disability, insurance status, wealth, citizenship, social status or social connections”
The claim is that the triage process is ethical and consistent with the values and practices of the medical profession and our society. There is a tragic underlying consequence which is obfuscated by the authors repeatedly.
I am writing this blog to explicitly call out the discriminatory and embedded racist as well as economically disparate outcome of these policies
Tragically as has already been reported, there is enormously disparate involvement of coronavirus infections and deaths in our minorities and in our poor populations. Health disparities have manifested in coronavirus no differently than in many healthcare areas. Predicting healthcare outcomes, mortality and morbidity based on ZIP Code is far more relevant than healthcare services. Social determinants of health account for 85% of health and wellness.
The Massachusetts committee report and the JAMA opinion suggest the use of objective, Sequential Organ Failure Assessment (SOFA) scores to make these difficult decisions. The use of the score is to create an objective measure on which to base medical decisions rather than race religion, wealth, social status. SOFA scores are a mortality prediction score that is based on the degree of dysfunction of six organ systems. This score in combination with age criteria and pregnancy are used to decide who lives and who dies. Below are the scoring medical criteria:
We have known for decades that the poor and minorities have a higher burden of disease and chronic conditions which will automatically generate worse SOFA scores. What the medicalization of triage has done hides the underlying huge discrimination against the poor and minorities that these scores will ultimately reflect. So the internal statements that there will be no consideration of race, insurance status, wealth, citizenship or social status are blatantly false. The social determinants of health are strong predictors of chronic health conditions as well as prognosis with those infected by coronavirus. Therefore the most vulnerable will be disproportionately removed from ventilators or not offered ventilators because of exactly those reasons , wealth, race, socioeconomic status, etc.which are claimed to be not relevant.
There is an obfuscation of the inherent bias by creating the illusion of objective medical data
This is the exact same argument we have heard from years ago when talking about admissions to higher education institutions as well as discriminatory hiring in the workforce.
How often have we heard that the poor, the disadvantaged, minorities do not have the test scores or grades to be accepted to certain educational institutions or jobs. The outcomes were justified by the claim that objective data were used for hiring and acceptance but completely ignored the implicit bias and inherent inability of the most vulnerable to achieve those alleged objective criteria.
It’s time to call out the sophistry.
It’s time to recognize that the criteria being generated discriminate against the most vulnerable in our society
Let the medical profession and decision makers rethink their “objective” criteria and stop hiding behind objective medical numbers which are not objective at all.
Time to scream out the emperor has no clothes
References
https://d279m997dpfwgl.cloudfront.net/wp/2020/04/CSC_April-7_2020.pdf
https://jamanetwork.com/journals/jama/fullarticle/2763953
Please direct all questions to nargy@nicolasargy.com
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