When Scarcity Meets Disparity: “Resources Allocation and COVID-19 Patients with Diabetes”

Abstract

The COVID-19 pandemic raised distinct challenges in the field of scarce resource allocation, a long-standing area of inquiry in the field of bioethics. Policymakers and states developed crisis guidelines for ventilator triage that incorporated such factors as immediate prognosis, long-term life expectancy, and current stage of life. Often these depend upon existing risk factors for severe illness, including diabetes. However, these algorithms generally failed to account for the underlying structural biases, including systematic racism and economic disparity, that rendered some patients more vulnerable to these conditions. This paper discusses this unique ethical challenge in resource allocation through the lens of care for patients with severe COVID-19 and diabetes.

The allocation of scarce resources is among the most challenging issues in both medical care and contemporary bioethics. ¹ As fraught as this subject is in the course of routine healthcare decision making, the stakes rise considerably during times of crisis, such as mass-casualty events and disease outbreaks, when large numbers of lives may become subject to rapid triage. ² Policymakers and clinicians must determine how to allocate limited reserves of manpower and supplies in ways that comport with underlying values such as life preservation, suffering mitigation and justice. Frequently, politics and optics also matter: systems of allocation that radically challenge existing hierarchies or societal norms are unlikely to prove stainable. What is too often overlooked in discussions surrounding resource allocation during crises are how these decisions can reflect and exacerbate underlying inequities in the healthcare system. The COVID-19 pandemic in the United States, which strained and threatened to overwhelm hospitals during the spring of 2020, helped to shine light on the complex interplay between previously existing disparities, which often reflect racial and economic fault lines, and guidelines for scarce resource allocation during crises that strive to achieve fair outcomes.

Medical experts in March and April of 2020 predicted a wide range of impending shortages of both equipment and personnel in American hospitals.^3-8 The preponderance of debate surrounding triage during the early stages of the pandemic focused upon the allocation of mechanical ventilators used in respiratory support. A “Perspectives” column published in April 2020 in the New England Journal of Medicine spelled out the predictions of health care authorities: With only 60,000 to 160,00 ventilators available in the United States and a larger number of critically-ill COVID-19 projected to present for care, the authors feared there would not be “enough ventilators for patients with COVID-19 in the upcoming months” and, without coordinated action, this shortage would lead to “frontline clinicians . . . making difficult decisions about who will and who won’t receive care.” ⁹ Anticipating the need for such triage required American policymakers to grapple with ethical and practical allocation choices more directly than at any time in the prior half century. While the United States had been rationing care all along in a manner that shortchanged the poor and racial minorities, most Americans only become aware of these disparities in a meaningful way when they were themselves forced to compete for resources—such as ventilators—with those who had been historically shortchanged. ¹⁰ COVID-19 requires policymakers to confront the structural disparities in healthcare that render some citizens more vulnerable to chronic illnesses like diabetes, and the implications of these underlying inequalities for the just allocation of resources.

Systems of Resource Allocation

A wide range of approaches have been adopted over the years to the allocation of scarce healthcare resources. Historically, in the absence of formal policy regimes, those with wealth and social power were able to gain access to resources at the expense of others. In 19th-century epidemics, including the yellow fever outbreak in Philadelphia in 1798 and the New York cholera eruption of 1832, the prime limited commodity was real estate outside the city to which the affluent could flee until the scourge abated.^11,12 (One can see echoes of this in the 420,000 affluent New Yorkers who fled their city during the early months of the COVID-19 pandemic. ¹³ ) During crises, governments often favor military personnel and essential workers, as the United States did when allocating penicillin preferentially to soldiers during World War II. ¹⁴ In arguably the most well-known example of resource systems favoring those with economic advantage, the so-called “God committee” at Seattle’s Swedish Hospital controversially used “social worth” to distribute scarce slots on dialysis machines in 1962. ¹⁵ The post-war period witnessed efforts to create more equitable allocation systems that might include a “first come first served” approach, as was used for iron lungs during the polio epidemics of the 1940s and 1950s, or a pure lottery, in which resources are randomly allotted among those in need. ¹⁶ However, most proposed approaches to resource allocation since the 1960s have emphasized medical criteria (such as prognosis, comorbidities, age) intended to save “the most lives, maximizing the number of ‘life-years’ saved” and/or prioritize “those who have had the least chance to live through life’s stages.” ¹⁷ Variations on these approaches form the basis of the current solid organ transplant system, state guidelines developed in anticipation of pandemic flu, and even Oregon’s Basic Health Services Act—a successful effort to steer Medicaid dollars in the most cost-effective manner.^18,19

Crisis Standards during COVID-19

Although nearly all of the early proposals for allocating ventilators during COVID used some medical measures related to the prognosis, life stage, and life expectancy, they varied widely in specifics. While the Institute of Medicine had advocated for the creation of state crisis management guidelines as early as 2009, many states still had no publicly available guidelines available in the spring of 2020.^20,21 As a result, individual hospitals also faced the daunting challenge of designing ethical allocation systems. Many existing crises guidelines utilized what White and colleagues described as a “narrow utilitarian perspective in which allocation decisions are based primarily on patients’ chances of survival to hospital discharge.”^17,19 Additional challenges involved how to address the needs of non-COVID-19 patients who might need ventilators, such as those with spinal cord injuries who, if placed on ventilators, were likely to remove those ventilators permanently from the available pool, and whether to consider withdrawing non-COVID-19 patients with poor prognoses in care facilities from ventilators if those machines might be harnessed to save more lives.

A broader understanding of “maximizing overall benefit to populations” was proposed by Massachusetts in April 2020. ²² The state’s “Planning Guidance for the COVID-19 Pandemic” stated that: “To the extent resources become scarce, maximizing benefit will involve attempting to maximize life years saved, not only attempting to save the most lives. This will involve determinations of eligibility for critical care resources based on a combination of prognosis for short-term survival and prognosis for long-term survival. ²² A point system was developed the incorporated a Sequential Organ Failure Assessment (SOFA) and the presence of “significant life-limiting comorbid.” ²² White and colleagues had proposed their own point system (“multi-principle allocation strategy”) that included these two factors and also considered the “life cycle principle” that favored younger patients over those further advanced in age as a factor independent of prognosis. Under both of these approaches, and most others seriously debated, how healthy patients were prior to contracting COVID-19 played a large role in determining whether they might qualify for a ventilator. While a range of exceptions were frequently proposed to standards that focused on prognosis and life expectancy—favoring healthcare workers, political figures, and pregnant women, ²² proposed guidelines generally did not address the causes of the underlying healthcare inequities that made some patients more vulnerable to COVID-19 than others. ²¹

This oversight was unfortunate in that diseases such as hypertension, obesity, and diabetes are related to structural inequities in society and to susceptibility to severe morbidity and mortality from COVID-19. In fact, Type 2 diabetes is so heavily correlated with both that it proves an ideal window through which to examine the ethical challenges of ignoring these connections in the allocation of life-saving crisis care.

Diabetes, Social Determinants of Health, and COVID-19

An extensive body of literature links both the “development and progression of Type 2 diabetes” to social determinants of health. ²³ These determinants have been defined by the World Health Organization as “the conditions in which people are born, grow, live, work and age” and include “socioeconomic factors such as income, wealth, and education.” ²⁴ Among the most significant direct causes of Type 2 diabetes progression are diet and exercise. ²⁵ Structural factors have been also found to affect the self-management in patients with diabetes, leading to a long-term negative impact on health outcomes. ²⁶ However, these primary factors are themselves highly dependent upon underlying forces—ranging from the availability of nutritious and healthful foods at affordable prices to having both time and safe outdoor spaces to engage in physical activities. Access to primary care, health literary, and a peer group supportive of care engagement all likely play a role in outcomes. Each of these factors is correlated with income and impeded by structural bias and historic racism. As a result, Blacks and Hispanics suffer higher rates of type-2 diabetes, a greater likelihood of complications (e.g., retinopathy, lower extremity amputations) and death. ²⁷ Glucose intolerance has even been shown to be correlated with internalized racism. ²⁸

Diabetes has been shown to be a significant independent risk factor for mortality from COVID-19. ²⁹ A population-based British study found that elevated “COVID-19-related mortality was associated not only with cardiovascular and renal complications of diabetes but, independently, also with glycemic control and BMI.” ³⁰ In fact, the CDC now warns that having Type 2 diabetes “increases your risk of severe illness from COVID-19” and urges a series of actions including testing and tracking blood sugar under the supervision of a healthcare provider, maintaining a 30-day supply of diabetes medicines, including insulin, and contacting a physician if one feels ill. ³¹ Of course, following these guidelines if far easier for those individuals endowed with sufficient resources and social capital.

The Challenge of Achieving Equity

The application of crisis standards relying upon underlying health status would be just only if underlying health risks were themselves distributed roughly evenly across society. In other words, if every human being in the United States had a equivalent chance of being in good health and living to approximately the same age, or conversely of suffering from diseases like Type 2 diabetes, a plausible argument might be advanced in favor of the trio of criteria advanced by White and colleagues—noting outstanding challenges related to age and disability. But that is not remotely the case. ¹⁷ The pernicious confluence of racism, indigence and healthcare disparities raise serious ethical questions about an approach that relies upon risk factors such as diabetes.

Not surprisingly, Blacks, Hispanics, and those of lower SES are more likely to be in the pool of patients in need of ventilators. Occupational exposures that are directly correlated with race and socioeconomic status (SES) may place a role in this risk. ³² But economic status also plays a role in vulnerability to severe disease, and structural racism likely does so as well. African-Americans have “a higher mortality with COVID incompletely explained by age, multiple reported comorbidities and available metrics of sociodemographic disparity.” ³³ Yet these risks are compounded by the fact that disadvantaged populations are also more likely to suffer the preexisting conditions that make one vulnerable to severe COVID-19 such diabetes. ³² As Leonard Egede and Rebekah J. Walker wrote eloquently in the New England Journal of Medicine, the COVID-19 pandemic occurred following a “history of marginalization of and discrimination against Black Americans, including 250 years of slavery, 100 years of Jim Crow laws, high rates of incarceration, and unanswered calls for action after police shootings of unarmed Black Americans.” ³⁴ It also occurred in the aftermath of generations of structural bias within and outside the healthcare system that affect work conditions, food access, and medical treatment that result in widespread disparities in risk factors for the need for artificial ventilation during COVID-19. The effect of this structural bias is clearly visible with low income and minority patients with diabetes. These patients receive less diabetes care in non-crisis times, leading to more vulnerability, and then that vulnerability is held against them in the allocation of resources when a crisis occurs.

A Path Forward?

On July 20, 2020, the Office of Civil Rights (OCR) or the Department of Health and Human Services issued a bulletin on the Application of Title VI of the Civil Rights Act of 1964. ³⁵ The document emphasized the prohibition on the use of “race, color and national origin” in providing care or establishing criteria for access to resources. ³⁵ Yet the guidance entirely ignored the underlying systemic healthcare inequities that made the existing and proposed crisis guidelines problematic. It was not that state policymakers and hospitals were refusing care for non-whites or those of low SES. Rather, they were allocating resources based on existing health conditions, but those conditions were reflective of long-standing biases that disadvantaged certain racial and economic populations, making them at higher risk for conditions like unchecked diabetes and hypertension. One is reminded of the caustic observation by French novelist Anatole France that “the law, in its majestic equality, forbids the rich as well as the poor to sleep under bridges, to beg in the streets, and to steal bread.” ³⁶

The injustice here is grave. However, developing a solution that is both fair and politically acceptable remains daunting. Affirmative action or holistic review lenses, which may serve well to address existing inequities in fields like education or employment, are far less palatable in medical triage: Few are the clinicians willing to sacrifice a larger number of lives or life years by rejecting medical eligibility criteria in order to redress underlying racial or economic disparities. Reparations for slavery or segregation may appeal to some when the proposed payments come in monetary form; when the payments take the form of life-saving ventilators, at the cost of other human lives, the equity claims are more troubling and the resistance likely to prove far more entrenched. So what is to be done? Obviously, the long-term solution is to devote greater healthcare resources to the medical needs of underserved communities—such as Blacks and Hispanics with diabetes—to ensure they are more equitably situated at baseline before the next national crisis emerges. But that seems insufficient. If crisis guidelines are taking into account stages of life through a “life cycle principle,” maybe they should also take into account an “adversity principle” that accounts for underlying social determinants of health.

Any such proposal that incorporates race or economics into triage is likely to prove highly controversial. Practical considerations are also bound to arise: the complicated nature of scoring adversity, of example, and resistance—intentional or subconscious—by providers. Moreover, how much weight to give to “adversity,” especially when human lives are at stake, defies an objective or rational answer; in its essence, it is a subjective calculus. Maybe the weight given to non-medical factors will prove small. Yet even symbolic incorporation of such factors into scoring systems might prove valuable, drawing public attention to existing inequities, and acknowledging that the specious neutrality of current approaches actually exacerbates existing injustices.