If we run out of ventilators, who should survive?
Australia needs a policy in place now to ensure equity of care for our most vulnerable populations.
Picture this: two COVID-19 patients arrive at a Sydney hospital emergency department in critical condition. Both need a ventilator, but there’s only one available. One of the patients is a 32-year-old woman with no underlying health conditions. The other is a 65-year-old man with early-stage dementia and a previous history of stroke. So, who should receive the life-saving care?
From the outside, the answer may look obvious – if one patient is younger, has no other health challenges and is more likely to survive, surely they should receive care over someone less likely to prosper. After all, isn’t that the fairest way to allocate limited health resources in a scenario where not everyone can be saved?
Not necessarily, according to UTS Faculty of Health researchers Professor Joanne Travaglia and Dr Hamish Robertson, who specialise in health care access and equity issues. If you want to save the greatest numbers of people, then a model that prioritises the young and the healthy is likely to be most successful. But the grim reality is that this type of approach actively disadvantages some of society’s most vulnerable groups, further entrenching existing patterns of inequity that shape the determinants and outcomes of health.
“There’s a seductiveness about a decision-making system that prioritises otherwise young and healthy people, because it looks like it’s objective,” says Professor Travaglia, a sociologist and health services management specialist.
“But if you think about the social determinants of health, people who are poorer are almost inevitably going to be in worse health, so when you start using these sorts of systems to decide who gets treatment, you’re invariably advantaging those who are already better off.”
Access to health services, even without the added pressure of COVID-19, is far from a level playing field. According to Professor Travaglia’s research, even health care professionals recognise that the elderly, people from culturally and linguistically diverse backgrounds, people with physical and intellectual disabilities, and First Nations people are likely to be marginalised in accessing and consuming care.
“There are always increased risks when vulnerable people enter health care; that’s a given,” Travaglia says.
“But this is also partly due to the stereotypes held about them, and also because of the system’s inability to respond well to anybody whose life, body or experiences who aren’t ‘standard’, whatever standard is considered to be at any particular place and time,” she says.
These deep-seated inequities are often exacerbated during emergencies like COVID-19, where some overseas hospitals have already run out of intensive care beds and ventilators while others are trying to mitigate a looming crisis. In the US, African Americans are dying of the virus at rates far higher than their white counterparts. In Britain, the National Institute for Health and Care Excellence issued COVID-19 critical care guidelines (now revised) that disadvantaged patients with learning disabilities and autism, while in Wales, care homes reportedly placed do not resuscitate (DNR) orders on the files of elderly patients without proper consultation with patients and their families.
While Australia is currently faring well – at the time of writing, approximately 6800 Australians had been diagnosed with the virus, with a death toll of 93, far beneath the tipping point at which the health system becomes overwhelmed – although existing weaknesses in our health care system could leave us vulnerable to similar outcomes in the event of a second wave of the virus.
“Even if you look at, for example, the relationship between the mainstream public health care system, private health care system, residential aged care, disability care – the fact that these things don’t necessarily coordinate particularly well under normal circumstances means that the likelihood of adequate oversight in a crisis is far reduced and therefore there is a potential risk for those groups,” says Dr Robertson, a health geographer and senior lecturer in health services management at UTS
But, while there may be no singular answer about who should survive, when it comes to choosing who will survive, Professor Travaglia and Dr Robertson say, we need to consider how we value and protect different patients.
In April, Australia’s Department of Health released an operational plan that outlines how people with a disability will receive equitable access to health care, supports and services in response to COVID-19. Similarly, the government’s Emergency Response Plan for Novel Coronavirus (COVID-19) cites equity of care for vulnerable people as key to its ethical framework.
But, while these are promising signs, there is currently no singular policy approach that details how care should be rationed if and when we reach a tipping point.
“Issuing guidelines on how people with disability should be treated and their access to care under COVID-19 is an acknowledgement that we don’t want to go down the same pathway of leaving marginalised groups to their fate,” Dr Robertson says.
“But in order that we don’t go down that pathway, given some of the situations which have happened in aged care facilities to date, it needs to be made explicit as a protocol.”
Australia is not out of the woods yet. The time to have the difficult conversations is now.
Professor Travaglia and Dr Robertson have been working on a series of monographs for the Agency for Clinical Innovation and the Clinical Excellence Commision on patient safety and vulnerable populations. To find out more, please contact Professor Joanne Travaglia.