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Posted on April 15, 2020 at 9:00 AM

by Joseph Stramondo, PhD

Recently, I have argued that there doesn’t seem to be any set of rationing criteria that can entirely avoid ableist bias, but there are worse and better options for distributing scarce resources during the COVID-19 pandemic. However, by narrowly focusing on triage protocols as the most morally salient problem that we face during this unprecedented era, perhaps we are not even advancing the most important conversation.  In fact, feminist philosopher of disability, Shelley Tremain, argues that bioethicists should shift the focus of the conversation altogether because targeting these protocols as the primary object of our analysis seems to sanction the idea that these hard choices are inevitabilities.  Rather than carefully parsing how to fairly deny treatment to some patients to maximize lives saved, Tremain maintains that we, as professional bioethicists, should be putting our energy behind efforts to reduce the need to make such choices at all.

As we expand and prolong efforts to slow the spread of the virus by eliminating or radically altering all sorts of features of our daily lives, it becomes more and more obvious that the presumed need for triage will be driven by economic, political, and personal choices, not an inevitable march of events. Tremain points out that there are many ways people at the grassroots can themselves help to expand the capacity of our medical institutions, like using 3-D printers to make personal protective equipment like face shields. Additionally, there have been a steady stream of news reports about engineering innovations that may reduce the need for triage like a new, easier to mass produce ventilator design.  The American Society of Anesthesiologists has stated that “If the pandemic overcomes the capacity of the hospital ICUs to provide ventilators, unused operating room anesthesia machines can be repurposed for use in the ICUs,” even though there are significant differences between the two kinds of devices. While controversial, some hacks are even being proposed to sustain more than one person on a single ventilator.

Art by Craig Klugman

Tremain is suggesting a really powerful paradigm shift, here.  If professional bioethics is serious about maximizing the number of people saved as the top priority, we should put ourselves and our considerable social capital into the service of slowing down the spread of the virus and building the capacity of the medical response.  While we may not be engineers or manufacturers who can try to make up for the shortfall, there are some very specific ways bioethicists can work to reduce the need for triage in the United States that are likely to save many more lives than perfecting a triage protocol.

First, we need to respond forcefully against Donald Trump’s constant flirtation with the idea that we should return life as usual prematurely in the name of economics. Flattening the curve of the infection rate is our only effective means of reducing unmet need for supplies.  The virus is continuing to spread, people continue to die, and we need to call for a national shelter in place order, so that the hot spots can get the equipment they need before infection rates spread and there are shortages everywhere.  The five states without restrictions cannot continue their free rider status and states like Texas should not be readying to lift directives to stay at home. Of course, doing this will put people out of work and cause serious hardship to many folks that live on a shoestring.  Yet, if the political will could be built to do so, this suffering could be assuaged with an even more extensive expansion of the social safety net. Such a move would be met with resistance from corporate interests, however. This is, fundamentally, a moral issue that bioethicists should be willing to address.  That is, it’s simply immoral to starkly trade the lives of the most vulnerable for shareholder dividends and professional bioethicists need to say so

Further, pressure needs to be ramped up on the President to coordinate and drive the kind of massive production of ventilators, masks, and face shields that could help with the surging demand of the COVID-19 pandemic.  We may not completely meet this demand in time, but we could come much closer if Trump more fully utilized authority under the Defense Production Act and acted like the wartime president he aspires to be seen as when the cameras are rolling.  Again, resistance to this has been propelled by corporate interests because prices for these items would be set by the federal government who would have the power to demand the fulfilment of production orders that are in the national interest, rather than others that may be more profitable.  So far, he has used this power sparingly to compel an agreement to produce ventilators between General Motors, Ventec, and his administration. The hope is that this partnership will begin producing 10,000 of these devices per month, starting in April.  However, we still lack a well-coordinated, life-saving national effort to produce supplies and distribute them to where they are most needed.  In fact, the distribution sometimes seems to be driven by a system of patronage.

Consequently, professional bioethicists who are concerned with matters of justice are well positioned to make the case that there is a moral imperative to continue to flatten the curve and expand production to save lives, prioritizing the public good over the limited interests of one percent and well connected. Zeke Emanuel’s very good article in the New York Times is an example of how we can show leadership on this issue.  Of course, not all of us have the megaphone of an Emanuel brother. Even still, in my view, it is important that whatever public facing work we are producing right now balances a discussion of triage protocol with a discussion of how the U.S. can take steps to avoid the nightmare scenario of triage in at least some places, if we continue to act.

While I don’t fault clinical ethicists for making a good faith effort to work on triage protocols that are thoughtful and try to take account of ableist bias, even if it is impossible to eliminate it altogether, it would be a serious mistake for professional bioethics as a whole to exclusively focus on triage protocols in their public work, rather than calling for an end to the kinds of large scale, systemic injustices that are hindering our ability to minimize the amount that triage will be necessary.

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