Pandemic reveals unethical bias

Michael Hickson was a 46-year-old African American resident of Texas, a quadriplegic with a brain injury. Despite these challenges, he was leading a fulfilling life with his family. Then he contracted COVID-19.

Over the objections of his wife, doctors at a Texas hospital refused to treat Hickson, stating that lifesaving care wouldn't be justified because his underlying disability would provide a "poor quality of life." He was never given a chance to recover and instead he was starved to death.

Hickson's tragic death was preventable but for a medicalized and biased view of disability that concluded his life didn't matter.

The unprecedented scale of the COVID-19 pandemic can provide critical lessons to ensure that patients like Michael Hickson are not discriminated against based on their disability or age. Understanding the roots of rationed hospital care during the pandemic can help shape the future of ethical health care, such as preventing the legalization of physician-assisted suicide in Minnesota.

According to the Center for Public Integrity, 25 states have scarce resource policies for hospitals that can lead to rationing and ultimately limit access to lifesaving medical equipment such as ventilators.

States are using a patchwork of rationing protocols in hospitals: first come first served; a lottery; categorical exclusions (age, disability, pre-existing conditions place you at the back of the line); resource intensity criteria (less care if your care drains resources); and fair-innings (if you're "late in the game," resources are allocated to someone younger).

Depending on circumstances, each protocol can lead to inequity. And bias related to rationing in the midst of the pandemic has led, in part, to other unethical practices.

COVID-19 raises the specter of further discriminatory practices. Some public health experts have argued that "immunity passports" (allowing for freedom of movement) should be issued to those who have had COVID-19, recovered and have tested positive for antibodies. China has employed this model which uses digital codes to limit movement and curtail liberties.

This could especially harm otherwise healthy older adults who, lacking the antibodies, could be further alienated from society without a passport. Such isolation could result in higher rates of death and serve as a health care savings measure to "cull" the vulnerable from society.

Unethical practices deployed in the pandemic's aftermath are the byproduct of a throwaway culture. Such a utilitarian and monetized health care ethic is not based on the dignity of human life but rather, on a person's perceived "value" or "benefit" to others.

Health care decisions ought to be made primarily on clinical factors such as the patient's condition and his or her ability to respond to certain forms of treatment. Rationing care turns this strategy on its head by prioritizing care for the able-bodied and healthy, not people who are vulnerable and disabled, but who can nonetheless achieve healthy outcomes.

Three remedies could be considered. First, Minnesota's Department of Health "Patient Care Strategies for Scarce Resource Situations" guide could include a statement that disability and age cannot be used as categorical exclusions when allocating of scare resources like ventilators.

Finally, it is worth noting the related discriminatory and growing movement in Minnesota to legalize physician-assisted suicide (PAS), now lawful in nine states and the District of Columbia.

Since 2015, the Legislature has considered PAS legislation that would enable patients with a terminal illness to end their lives. The so called "end-of-life options act" has been justified on the same biased grounds as rationing hospital care: death can be hastened when it is thought that a person's life no longer has meaning or purpose.

Not surprisingly, medical rationing and PAS also share a lack of conscience protections for providers and patient protections for older adults, people with disabilities and those with mental illness.

The current pandemic is a wake-up call to avoid creating new health care policies that target the most vulnerable. Let's create principled care models that support the medical needs of all people and ensure that Michael Hickson's life mattered and that his death was not in vain.