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Considering preexisting conditions in a crisis like coronavirus is not discrimination | Expert Opinion

Pennsylvania's crisis plan does take into account preexisting medical conditions. It does not discriminate against disabled people.

David Oxman of Thomas Jefferson Hospital is treating several flu victims.
David Oxman of Thomas Jefferson Hospital is treating several flu victims.Read more

COVID-19 is sweeping the region and filling hospitals with patients, many of whom need critical care. Images of packed intensive care units in Italy and New York City have led to open discussion of doomsday scenarios where hospitals run out of resources, and doctors are forced to make excruciating decisions about which patients get lifesaving treatments — and which do not. Fortunately, while the regions’ hospitals are being stretched, we are currently nowhere near approaching these doomsday scenarios. Hospital staffs are working under tremendous pressure, but there are still plenty of resources for all that need them.

However, in an abundance of caution, the Pennsylvania Department of Health recently released an emergency plan for just such a scenario and gives guidance to hospitals on how to make these unprecedented and agonizing decisions.

Last week, Disability Rights Pennsylvania filed a lawsuit claiming the plan discriminates against persons with intellectual or physical disabilities. They argue that the plan punishes people with disabilities and values their lives less. This contention is untrue. While the plan does take into account preexisting medical conditions, it does not discriminate against disabled people.

In a crisis situation, doctors would have to decide how to allocate resources when there are not enough for everyone. One approach is to borrow a strategy from the battlefield. Here the goal is to save the most lives possible, and not waste resources on those unlikely to survive. Allocation decisions only consider the severity of immediate injuries and how likely an individual is to survive in the short term. But in this pandemic, people needing critical care are not all previously healthy people wounded on the battlefield. Instead, many patients will have serious preexisting conditions with limited life expectancy well before they became sick with COVID-19.

The goal of the Pennsylvania crisis plan is to maximize not just the health of individuals, but the entire population.

David Oxman

Imagine you ran a hospital with one ventilator left and there were two patients who needed it: one is a previously healthy woman with respiratory failure; the second is a slightly younger man who has the same short-term risk of death but also has untreatable cancer and a 12-month life expectancy. Shouldn’t the hospital take the man’s cancer into account when deciding who should receive the ventilator? Sadly, some disability rights advocates have conflated these considerations of preexisting medical conditions with discrimination.

To understand how misguided this argument is, consider another two people. One suffers from advanced heart failure, and one is physically healthy apart from a spinal cord injury. Both are unable to walk. But should their disabilities be thought of in the same way? The person with heart failure has a severely decreased life expectancy, but the person with the spinal cord injury does not. While both people may be considered “disabled” by their conditions, it is only the heart failure that would be considered in crisis triage decisions.

Disability advocates also argue the crisis plan discriminates against people with intellectual impairment. This is based on the inclusion of advanced dementia on a list of severe life-limiting co-morbidities to be considered in triage decisions. They suggest this signals that the plan values the lives of those with intellectual impairment less. But advanced dementia is considered in triage decisions because it is associated with medical complications that severely limit life expectancy. It is not a value judgment on the intrinsic worth of a person with dementia. Rather, it is a recognition of the biological reality that people with advanced dementia have a severely reduced life span.

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The goal of the Pennsylvania crisis plan is to maximize not just the health of individuals, but the entire population — or “to do the greatest good for the greatest number.” It advises the allocation of resources in a way that doesn’t just save the greatest number of lives, but saves the greatest number of “life-years.” To do this, hospitals must consider not only short-term life expectancy but long-term life expectancy as well.

Disability rights advocates are understandably suspicious of the medical establishment. There is, unfortunately, a history of discrimination in organized medicine against people living with disability. But considering preexisting medical conditions in a crisis allocation plan does not equal discrimination. As an intensive care physician in the region, I can attest to the extraordinary measures being taken to increase capacity and ensure these plans never see the light of day. But in the event that they have to, it is critical the public understand them for what they are, and not be misled about what they are not.

David Oxman is an intensive care physician and medical ethicist living and working in Philadelphia.