COMMENTARY

COVID-19 and Healthcare Rationing: A Disabled Doc's View

Dinesh B. Palipana, MD, LLB, OAM

Disclosures

May 21, 2020

In Australia, where I practice, the Australia and New Zealand Intensive Care Society stated that access to intensive care should not be based on "irrelevant and discriminatory considerations," including disability. In the United States, they had somewhat similar guidance. The Office of Civil Rights at the Department of Health and Human Services encouraged healthcare providers to remember their obligations to people with disabilities. They reminded providers that "persons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person's relative 'worth' based on the presence or absence of disabilities or age." The emphasis was on not treating the entirety of the disabled community as one entity, but tailoring treatments based on individual patients.

That said, after critically analyzing the guidelines and statements, the ethical dilemma still stands. The materials discourage discriminating against people with disabilities broadly, but they don't help in weighing the physiologic vulnerabilities caused by many disabilities that affect likelihood of survival. For example, compromised respiratory function in a patient with a cervical spinal cord injury is associated with a higher risk for death from pulmonary infection. How do you decide access to intensive care between a person who has preexisting physiologic compromise and one who doesn't?

Him or Me?

Let's take an extreme circumstance in which only one intensive care bed is available in a hospital. This is not a far-fetched consideration, as reports from various COVID-19 hotspots have showed. Imagine that the medical team has to decide who gets that bed: a healthy 35-year-old man with no significant medical history, or me. This is a sobering scenario. I'd rather not die, but I also know that the other guy would have a better chance of survival.

That friend who joked that I was "just a head" after my accident is now a physician. He is someone who actually has to make these decisions. He admitted, "Realistically, we need to choose people who can make it out of the intensive care unit." I was sad to hear him say that, although I've always valued his honesty. As someone who helped me pick up the pieces of my life after the accident, he knows all too well that he's talking about me. I'd be someone who has a lower chance of making it out. He's not alone. Callous though it may sound, his view is in line with guidelines from National Institute for Health and Care Excellence (NICE).

That guidance also argues that clinicians should consider a clinical frailty scale of 5 or more as a reason to exclude intensive care admission in these scenarios. Although that scale is typically applied to elderly people, my score is more than 5. I don't feel frail. I'm a doctor actively working to care for those who are affected by the pandemic. Should I automatically be disqualified from intensive care if I get sick? This is the problem with objective measures without context. They don't take into account anything about a person's life other than their physicality.

I became a doctor to save lives. If the decision was between me and that other person described, I would want them chosen. I know that my chance of survival is lower. However, even if my chances weren't lower, I would still want that other person to be chosen. Helping others is the whole reason we do this. The philosophy behind my decision in this scenario is personified in every frontline healthcare worker fighting COVID-19 today. That said, I wouldn't want such a decision made for any other disabled person.

No Good Choices

As a disabled doctor who stumbled through a degree in law before medicine, I understand the complexities of resource allocation. I've learned the ethics of law. I fought for the right to be educated and employed. Society has many different views on this difficult issue. The reality is, there is no obvious right answer. The question we need to ask is, "What's the most right answer we can find?"

First and foremost, we need to strengthen guidelines to protect the interests of those with disabilities and all vulnerable populations. As Mahatma Gandhi once said, "The true measure of any society can be found in how it treats its most vulnerable members." Guidance that tells doctors not to discriminate on the basis of disability are useful, but providing specifics about how to do that is more useful.

For example, if a person with multiple sclerosis and a person without that condition both need the last remaining ventilator, one approach would be to take multiple sclerosis completely out of the equation. Another approach, controversial though it may be, would be to give the most vulnerable person priority to the resource. After all, isn't that how we triage patients in emergencies?

Another underexplored avenue is involving patients. If possible, we could include their opinions and wishes after informing them of the scenario. Either one may suggest giving the other life-saving treatment. The world is full of heroes hiding in plain sight.

The most immediate thing we can do as doctors is not make judgments about people with disabilities. Although disabilities often overlie complex medical comorbidities, we also lead real, full lives. There are people who love us. We make a valuable contribution to this world, making it diverse, rich, and innovative. We can't allow this pandemic to be the time where we are left behind.

Dinesh B. Palipana, MD, LLB, OAM, is a senior resident in the emergency department at Gold Coast University Hospital and lecturer at Griffith University. He is a disability advocate and researcher in spinal cord injury. He was the recipient of an Order of Australia Medal for service to medicine in 2018.

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