photo by Alex Boyd for unsplash
One of the basic questions that many have confronted in the pandemic is: “How do we care for the least of these?” Some people are more vulnerable to the coronavirus than others: the elderly, those who live communally, those who have weakened immune systems, those without financial resources to get through months of little to no employment. For Christians, this recognition of vulnerability creates an imperative for extra care. We are called to feed the hungry and clothe and house the homeless, to take in the orphan and make sure the widow is taken care of. During the pandemic, we have had opportunities to act on this imperative in many areas.
Medical care is one important way we “care for the least of these.” People get sick and medicine restores their wholeness and health when it can. The vulnerabilities of illness do not define the person, but require that they receive extra care.
For Christians, this recognition of vulnerability creates an imperative for extra care.
In the places where the pandemic has raged out of control, resource scarcity has threatened our ability to give extra care to the vulnerable. To be fair, resource scarcity has many sides. You can have enough now to share with others, but fear that you will not have enough for yourself in the future. Caring for the least of these does not presume abundance, but it does presume enough. But the resource scarcity in this pandemic is literal and immediate. There is a finite number of ICU rooms and ventilators. Those numbers cannot be changed quickly. Five ventilators and two ICU rooms cannot treat 100 Covid-19 patients at the same time.
photo by Graham Ruttan for unsplash
As a hospital chaplain and ethicist, I’ve seen this resource scarcity lead to the creation of protocols, a set of guidelines to decide who gets access to care. I’ve been on organ allocation committees for transplant teams and I was on the hospital committee that developed protocols for access to care for Covid-19 patients. Several sets of protocols from other hospitals were released or leaked, and the public got a view of who would have access to high level care if they became sick. Protocols from New York, Detroit, and Seattle revealed that physical ailments that made one more vulnerable to Covid-19 could lead to less access to care. Instead of extra care, these preexisting conditions or morbidities would be used against patients as rationales for not being treated. Since Covid-19 hospitalizations started increasing in Arizona, Texas, Florida, and elsewhere, more hospital and state protocols have been made public, and charges of “This is eugenics!” and “These are death panels” echo across Twitter.
Despite their subtle differences, these protocols have much in common. They are utilitarian, meaning that the main guiding question is: “What is the greatest good for the greatest number?” Christianity has often positioned itself against utilitarianism due to the latter’s devaluation of individual life. When thinking about a problem from a utilitarian perspective, the needs of individuals are considered less than the good of the whole. Resource scarcity becomes the justification for in effect becoming utilitarian: we can’t treat everyone with our current resources, so we have to figure out how to maximize the usefulness of the resources we have. In turn, hospital ethics committees either prioritize saving the most lives or saving the most life years. Saving the most life years will mean prioritizing younger patients, while saving the most lives will mean prioritizing those patients with the greatest chances of survival. Generally, prioritizing numbers of lives over life years is seen to be the progressive move because it doesn’t as overtly disadvantage the elderly. But in both cases, one’s previous health is a factor in receiving care, with better health creating more access to care. The most vulnerable patients are pitted against the less vulnerable, and those with the best chances of survival are usually given the best care. In the end, the least of these are left behind.
Many bioethicists, members of the disability community, clergy, and others railed against this utilitarian rationing of healthcare. Alongside the charges of “death panels” were exasperated claims about unfairness; that we were not living up to our values by denying people lifesaving care; and that human life was being assessed according to a hierarchy of value.
The most vulnerable patients are pitted against the less vulnerable, and those with the best chances of survival are usually given the best care. In the end, the least of these are left behind.
Like so many aspects of the pandemic, these protocols reveal generally and institutionally held utilitarian social values that conflict with other commonly stated values and don’t line up with a Christian ethical perspective. We frequently hear the elderly valued for their life experience and wisdom, but the ethics of the healthcare protocols would deny them high-level care. That all human life is to be valued, and that there is an inherent dignity of each person is a view held by both the religious and non-religious. Yet many healthcare protocols create a hierarchy that places our disabled neighbors on a level beneath others.
That all human life is to be valued, and that there is an inherent dignity of each person is a view held by both the religious and non-religious.
I find it impossible to square these healthcare protocols with a Christian ethic that requires care for the vulnerable. And yet, to be fair, the protocols reveal that our ability to care for the least of these relies on material resources—there has to be enough. A Christian response to these protocols would involve admitting our failure as a nation to provide enough medical resources, and demanding an increase in medical capacity so that all who need medical intervention may be treated with equal levels of care. It is not enough to shift out of a scarcity mindset; the actual scarcity has to be addressed. Previous attempts to counter scarcity in healthcare have attempted to increase access to care. But the medical resources we have cannot stretch enough to cover everyone. If I have learned anything by being on these resource allocation committees, it is that we cannot simply think our way out of some kinds of scarcity. We must increase the available resources—ventilators, antivirals, tests, etc.—in order to avoid devaluing human life. A Christian response to the pandemic must include advocating for enough.
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“It is not enough to shift out of a scarcity mindset; the actual scarcity has to be addressed.” Utilitarianism and Christian ethics rhyme when “the greatest good ” means enough resources so that “the greatest number” CAN MEAN everyone. Thanks for this clear and compelling insight from your work on ethics committees.
Thanks, Patrick!
As an elderly person with a severe underlying condition that puts me into the high-risk-for-death-from-coronavirus category, I can relate to your analysis from personal experience.
When I suffered a sudden pneumothorax (lung collapse) about four months ago, I was treated as a potential Covid-19 patient during treatment in the ER and the ICU until my test result came up negative. Several times during my ICU stay, my primary hospital physician asked me whether I would accept intubation if/when needed.
Every time I told her that I would accept it, she tried to dissuade me by pointing out only the negative consequences of my decision, never the positive ones. I felt pressured to sign an affidavit rejecting what I viewed as necessary and reasonable treatment.
I never did sign it. While I subsequently recovered and am still Covid-19 negative, I am left with the lingering impression that I disappointed this doctor and the hospital’s protocols she was implementing.
I do not regret my decision. Am I selfish to feel this way?
Thomas: I don’t think you are selfish to feel that way. Not at all. I’m sorry that your hospital experience included feeling pressured to make decisions about your care that were not in line with your values.