The Bottom of the Health Care Rationing Iceberg

“Since February, like ethicists around the world, I have spent most of my time thinking about the tip of the health care rationing iceberg. As Covid-19 cases exploded across epidemiologic maps, I scrambled to write new guidelines for my health network for the ethical allocation of mechanical ventilators, just in case we ran out.

[..] Despite that heady challenge and the urgency of the Covid-19 pandemic, I couldn’t shake the feeling that this effort was all a distraction. Here I was, trying to do a perfect job allocating a handful of mechanical ventilators for an unprecedented viral pandemic, while every day the entire health care system utterly fails to fairly allocate all kinds of health care to an enormous number of vulnerable people.

From hospital beds to primary care appointments and funding for expensive medications, health care resources are finite. We have to choose who gets what, and there is no question that wealth opens doors in health care that are closed by lack of insurance. Geography shapes health care destiny. Bias, we should admit, is not the exception but the rule.

What really differentiates the fair, transparent, systematic, and formal Covid-19 rationing plans we have drafted is that on most days, health care rationing happens ad hoc, in the shadows, nonsystematically, and without formal guidance. We are making it up as we go, and the results aren’t great.

[..] It is not wrong to put limits on generosity. Resources are in fact finite. We do have a duty to allocate community resources wisely. The solution to homelessness isn’t to house homeless patients indefinitely in the hospital. Doing so begets other risks. It wastes community resources on low-value care. Hospital overcrowding — which is exacerbated by keeping stable patients in house — endangers the lives of emergency department patients awaiting a bed. Unnecessary hospitalization also exposes patients who are homeless to real risks, such as hospital-acquired infections and blood clots.

We argue at the bedside about when to discharge homeless patients because we don’t have the right options available.”

Full editorial, Lahey T. New England Journal of Medicine, 2020.11.28