As the COVID-19 pandemic evolves, it is offering some hard lessons about how American healthcare fails patients. The pandemic brings into focus inequities that pervade the system—in strategies intended to guide how limited resources are distributed among patients and in its impact on communities made vulnerable by decades of neglect, disinvestment and marginalization.
The public health crisis of a pandemic challenges medicine's ethical duty to place the care of each individual patient first and foremost. The rapid spread of COVID-19 and the acute needs of patients who have become seriously ill have forced healthcare professionals and institutions across the country to confront the prospect of rationing and the disproportionate impact of disease across the population.
The goal of crisis standard-of-care plans is to allocate resources fairly. To do so, they must rely on clinically based considerations of medical need, prognosis and effectiveness, and on fundamental standards of equity and fairness. When these plans focus on process issues such as transparency, consistency and accountability they can be helpful tools. But when they rely on criteria that discriminate against categories of persons, notably, elderly individuals or individuals with disabilities, they are not ethically defensible. The more directly they address clinical decisions such as triage, inappropriately constituting the practice of medicine, the more problematic crisis standard-of-care plans become. The pandemic has revealed a need for a much more thoughtful and ethically, medically justifiable approach to the clinical aspects of preparedness planning.
Further, significantly higher mortality rates from COVID-19 among residents of long-term care facilities and in Black, Latinx and Native American populations vividly highlight issues of the pandemic's disproportionate impact and that we must recognize these outcomes as the product of structural barriers to appropriate healthcare.
To be sure, in the midst of a crisis, resource allocation tools that guide decisions for individual patients cannot by themselves redress deep-rooted problems, especially structural and social determinants that generate long-standing health inequities. Leveling the playing field will require sustained collective efforts to change not only how society prepares for public health emergencies, but fundamentally how patient care is organized and delivered, moving toward a system that cares for all and directly challenges the taken-for-granted inequities of our current system.
The American College of Physicians and the American Medical Association urge all physicians to heed the hard lessons of COVID-19. We cannot go back to business as usual after this pandemic passes. We must work together to build a society that supports optimal nondiscriminatory healthcare for all.
