Standard Racism: Trying to Use “Crisis Standards of Care” in the COVID-19 Pandemic

Abstract

Lowering the standard of care in a pandemic is a recipe for inferior care and discrimination. Wealthy white patients will continue to get “standard of care” medicine, while the poor and racial minorities (especially black and brown people) will get what is openly described as substandard care rationalized by the assertion that substandard care is all that we can deliver to them in a crisis. (IOM 2009) Paul Farmer’s experience in responding to the Ebola outbreak in West Africa is a shocking, if extreme, example of how dangerous to patients this practice is. White patients were treated with the US standard of care, including transfer to the US for treatment, black (local) patients were often given little no medical care at all (on the premise that it was too dangerous for caregivers to touch them or to place IVs to hydrate them). The standard of care for the local population, in Farmer’s words, “in many cases didn’t resemble care at all.” (Farmer 2020) As COVID-19 has taught us, structural racism in healthcare is not just a problem in West Africa, and does not just manifest itself in a pandemic. Modifying the standard of care downward in a pandemic is unnecessary and dangerous to patients (Schultz and Annas 2012). Since shortages are much more likely to affect safety net hospitals that serve poor and minority communities, lowered standards of care are also most likely to be applied to these hospitals (e.g., as witnessed in Queens and Los Angeles) and primarily adversely affect minority patients (Fink 2021; Rosenthal et al 2020). In this way, lowering care standards in a pandemic can dramatically expose structural racism in the US. (Maxmen 2021; Manchanda et al. 2020a, 2020b) Because it is exceedingly unlikely that minority communities would voluntarily consent to second class treatment, even in a pandemic, a core element of the “crisis standard of care” (CSC) mantra is eliminating or curtailing informed consent, including sidelining advance directives, health care agents, palliative care, and even visitor access to hospitalized patients, and replacing conversation with Sequential Organ Failure Assessment (SOFA) scores and triage teams (Annas 2020).