Structural Ableism: Defining Standards of Care Amid Crisis and Inequity

Abstract

Health care delivered during a pandemic instantiates medicine's perspectives on the value of human life in clinical scenarios where resource allocation is limited. The COVID-19 pandemic has fostered dialogue and debate around the ethical principles that underly such resource allocation, which generally balance utilitarian optimization of resources, equality or equity in health access, the instrumental value of individuals as agents in society, and prioritizing the "worst off" in their natural history of disease.' State legislatures and health systems have responded to the challeges posed by COVID-19 by considering both the scarcity of intensive care resources, such as mechanical ventilation and hemodialysis, and the clinical criteria to be used for determining which patients should receive said resources. These crisis guidelines have yielded several concerning themes vis-a-vis equitable distribution of health care resources, particularly when the disability status of patients is considered alongside life-expectancy or quality of life. Crisis standards of care (CSQ prioritize population-level health under a utilitarian paradigm, explicitly maximizing "life-years'' within a population of patients rather than the life of any individual patient.· Debated during initial COVID surges, these CSC guidelines have recently been enacted at the state level in several settings, including Alaska and Idaho.