Internationales Zentrum für Ethik in den Wissenschaften (IZEW)

How the triage rules compound historical injustices against black communities in the USA

by Dr. Wulf Loh and Laura Schelenz

07 May 2020 · The United States has struggled with its response to the coronavirus. Reports of severe shortages in testing, protective gear, a crumbling health system in New York City, steep rising unemployment, and long lines at food banks. In the midst of this situation, marginalized communities most likely experience the harshest blow from the coronavirus pandemic. In this short article, we are interested in the way that structural discrimination materializes in the current crisis, provoking continued or compounding injustice. We argue that generations of discriminatory practices shape people’s socio-economic situations, which co-determine their chances of contracting and surviving the virus. If this is the case, these historic injustices are carried over into potential triage situations. In the second part, we explore whether this “compounds” prior injustices (Hellman 2018) and thereby may generate a moral duty to amend current triage rules.

Certainly, not all members of a marginalized community are (equally) oppressed and not all members of a privileged community are (equally) privileged. However, since we are looking at the structural level in this article, we make some generalizations that deserve differentiation in other contexts. One example is the situation of black and brown communities in the United States. Numerous reports have pointed to the disproportionate numbers of black people killed in the United States by Covid-19. “In Chicago, 72% of the people who have died from Covid-19 are black, though they make up 30% of the population”, reports CNN. Data from other cities and states suggest similar trends: the death rate among African-Americans is alarmingly higher than among white populations. Stakeholders call for more data on the ethnic make-up of Covid-19 patients and deaths. Understanding better why some populations are more affected than others is crucial. However, we should also consider the information we have about the continuing disadvantages of African American, Asian, Caribbean, Latinx, and other communities. Research on structural racism (e.g. project by Tricia Rose) provides a clear picture of how disadvantage through (everyday) racism is productive and performs across various areas of life: wealth, housing, education, media, and criminal justice. To understand how inequality materializes in the current pandemic, we may thus point to the legacy of interlocking systems of oppression. 

Looking more at the structural level, a report by ProPublica lays out some of the reasons why particularly African Americans may be disproportionately likely to contract the coronavirus and die from the corresponding illness. “Environmental, economic and political factors have compounded for generations, putting black people at higher risk of chronic conditions that leave lungs weak and immune systems vulnerable: asthma, heart disease, hypertension and diabetes.” Black people are likely to live in areas such as (big) cities that are more prone to air and water pollution. They are also disproportionately affected by poverty, lack of home ownership, and lack of health insurance. When resources are scarce, it may not be a priority or plain impossible to follow regular check-ups at the doctor’s office. Eating healthily or working out may also be harder on a tight budget, in a rented apartment, and with the stress of working several jobs to make ends meet. Plus, due to historical segregation, black neighborhoods have fewer quality supermarkets and health care provision in their vicinity. Finally, but significantly, stress itself may be a cause for high levels of diseases in black communities. That is not only economic hardship but also stress resulting from microaggression in the workplace and public transport, fears of police brutality, incarceration or the loss of a family member to the prison system. 

On top historically developed and continued inequalities, there are more immediate challenges that black communities face at the moment. Many African Americans work in jobs that are precluded from “stay at home” orders, e.g. the care sector, transportation, or supermarkets. These workers are therefore more exposed to the virus. They may further struggle with additional stress because schools and child care centers are closed. In different circumstances, African Americans and other minorities are also most affected by job loss in the course of the pandemic. Furthermore, patients who are visiting the doctor or even the emergency room may experience either overt racism or implicit bias. Some black women have been turned away from health centers because their complaints were not taken seriously. This again is a systemic experience of black women who seek medical advice. Testimony from black women, particularly on the issue of pain, has been dismissed throughout American history. 

Having established that structural discrimination amplifies struggles with the coronavirus itself or the effects of the corresponding health and economic crisis, we turn to the case of the triage rules, an extreme example, but nicely suited to illustrate how injustice may be compounding in the current situation. Triage is the process of deliberation over who receives treatment and in which order in a medical emergency (urgency). This translates roughly into decisions about who will have the best chances of survival with treatment. But while the triage decisions can be said to be fair in that they treat everyone in the ICU equally and differentiate only with respect to survival chance, they possibly “compound” prior injustices (Hellman 2018). A triage situation assumes that the ethical and legal basis for triage is the equality of human lives. This equality is fixed at the entrance of the Intensive Care Unit (ICU), in the sense that the probability of survival is assessed at this moment without regard to any other criteria, such as gender, race, religious affiliation, sexual preferences, and – hotly debated, but importantly also – age.

Since members of black and brown communities have an overall higher morbidity, their chances to be subjected to triage rules is higher compared to members of more privileged groups. Triage explicitly takes into account health factors (particularly survival chance) to determine priority care. Therefore, prior injustices (in this case a higher morbidity due to factors such as segregation, poverty, and stress) are compounded by triage decisions. An argument can be made that we have an obligation to not carry on, least further or exacerbate discrimination. Specifically, Deborah Hellman argues that we have a duty not to “compound” injustice by either exacerbating it or moving it to another “domain” (Hellmann 2018). According to her, this duty holds even when the person has nothing to do with the initial discrimination, and even if, without this initial discrimination, there would be nothing unjustified in the actions or policies. In line with this argument, hospital staff and ethics committees determining and enacting triage rules are not directly responsible for the original wrongs committed against marginalized communities. However, as the triage rules employ the selection variable “probability of survival” and thereby compound prior injustices, actors making triage decisions become implicated in the moral wrongdoing.

If this is true, then what? Change the triage rules? Doing so would upend the procedural fairness of those rules, i.e. the fact that they regard every patient equally with respect to their chance to survive Covid-19. Affirmative action or other mitigating effects within the ICU setting itself would require very complicated and often counterintuitive prioritization of different moral goods, rights, and values. As all kinds of historical injustices would have to be taken into account, it is unclear whether such a remodeling of the triage rules in the end will do more justice to all affected. If our argument is sound, however, it puts an obligation on doctors and other actors making triage decisions to not compound historical discrimination and other prior injustices. While there may be no final solution to this dilemma, we think that a way to at least mitigate it could be to put an emphasis on special relief measures for marginalized groups to ameliorate the historic injustices and soften the effects of the coronavirus pandemic on these communities. Finally, the lesson of this discussion should be to pay more attention to how discriminatory experiences and effects permeate our societies in all areas of life – and death. Making systemic changes to the way we allocate respect, recognition, and resources to members of society is crucial to avoid continuing the compounding of injustice in this crisis and the ones to come.

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