Rationing care in Canada and U.S. in the face of COVID-19

By Jennifer L. Herbst

As an American health law and ethics scholar, I have spent the last several weeks working with colleagues in U.S. hospitals, medical schools and state legislatures trying to provide guidance and assurance to frontline healthcare workers anticipating the surge in COVID-19-related patients. We’re trying to figure out the best way to allocate critical care resources like ICU beds, ventilators and resuscitation teams when there aren’t enough for everyone who needs them.

The same need to prepare for the triage of scarce health resources is happening in Canada too.

As a visiting Fulbright scholar to Canada, where I’ve been based in the nation’s capital for the last several months, I’ve noticed that the U.S. has more of the things that complicate these allocation decisions than Canada — more COVID-19 cases, more extremes of haves and have nots, more uninsured and underinsured people, more distrust of our health care system and of our government’s ability to provide equitable care, more legal and cultural variety amongst our states than Canada’s provinces.

But both countries share similar challenges — and pitfalls — in determining who gets care when there’s not enough to go around. And the problem is that even our best evidence-based, data-driven triage protocols still reflect and exacerbate historic and systemic inequities outside the hospital.

Triage protocols can’t solve long-standing inequities.

COVID-19 triage requires us to use imperfect tools and incomplete information to directly compare patients and pick the ones most “deserving” of critical care resources. Unfortunately, our most familiar rules for picking or prioritizing people have always perpetuated and exacerbated existing power imbalances.

When picking teams on the playground (and our various personal and professional circles in adulthood), most of us pick our friends, those most likely to help us win and those we feel for. Some patients are more likeable, influential and sympathetic than others. Frontline clinicians, like the rest of us, are human and prone to the same biases as the rest of us.

Likeability, influence and sympathy should not guide triage decisions if we want to fairly and consistently allocate resources to those most likely to survive their illness.

Similarly, our usual rules for “objectively” allocating resources don’t work fairly either. A “first come, first served” queue, where patients receive critical care resources in the order they arrive at the hospital, tends to prioritize well-insured people with better access to information, reliable private transportation and time to stand in a line over the likelihood of actually benefitting from critical care.

Flipping coins and lotteries risks wasting resources, leading to more people dying.

We have spent weeks identifying and weighing “clinically relevant criteria” with consistently measurable information. Criteria include the amount of oxygen getting into a patient’s bloodstream, blood pressure, eye movement, liver function, kidney function, verbal and motor responses to stimuli, and more, in an attempt to predict whether critical care, including mechanical ventilation, will eventually get someone home. Unfortunately, because we’re still learning how COVID-19 progresses and affects different patients, we don’t have good data yet on whether this information reliably predicts survival for all patients.

What we do know, though, is that the inequities outside the hospital affect how well care works within the hospital.

In the U.S., we’re seeing that our Indigenous, Black, Brown, and rural patients are getting sicker and dying more than our urban and suburban White patients because of our historic systemic inequalities in housing, education and health care. We see this only because some of our cities and states are gathering and releasing demographic data with our COVID-related hospitalization and death counts. The U.S. federal government should be doing this.

Canada should do this, too, to inform and focus the policy decisions for increasing stable housing, effective education and culturally relevant health care moving forward.

Unsafe and unpredictable housing makes social distancing more difficult, if not impossible, especially for larger households living in smaller spaces. Historically under-resourced schools and health care in these communities increases distrust of governments and health care systems and makes it easier for these communities to fall prey to misinformation.

Distrust and misinformation often mean that these patients, especially those dependent on prescription drugs for effective management of chronic conditions like asthma, diabetes, and hypertension, will be sicker when they get to our hospitals.

These systemic problems are not uniquely American. Canada has them too. And they make all of us less safe in a pandemic.

Jennifer L. Herbst is a Professor of Law & Medical Sciences at the Quinnipiac University School of Law and Frank H. Netter, MD, School of Medicine and the 2019-2020 Fulbright Research Chair at the Centre for Health Law, Policy and Ethics at the University of Ottawa.