Trauma and Critical Care Surgeon
Assistant Professor and Director
Center for Humanism
and Ethics in Surgical Specialties
Washington University
in Saint Louis School of Medicine
Saint Louis, MO
This is part of our series, Flattened By the Curve, which features the voices of doctors, nurses, healthcare workers, and others on the front lines against COVID-19. For information on how to submit, click here.
Long before I ever practiced medicine in the US, I was first a patient and then a volunteer at the surgical ward of a hospital in Budapest, Hungary. I know my parents had purchased many luxury gifts to ensure the medical team’s attention while I was sick. And much later, when I was a member of the medical team, impoverished older women begged me to accept their bribes as tokens of promise that I would care for them. In the US, we shudder at the very thought that such corruption shapes our healthcare system; and yet, if you look carefully, what we are doing may lead to far greater injustices than what I experienced in Budapest.
The COVID-19 pandemic has pushed to the forefront an unprecedented focus on how to ethically allocate finite resources such as personal protective equipment, ventilators, and intensive care unit beds. The death toll to date has surpassed 100,000. While many hospitals are still running below full capacity, at many others, patients are turned away and sent home with life-threatening illnesses, both COVID-related and otherwise. And still, healthcare facilities have chosen to hold back on implementing strict triaging guidelines for the allocation of finite and scarce resources.
I serve on my institution’s task force for defining steps and guidelines for triaging throughout our hospital system as the escalating pandemic surge threatens to exhaust our diminishing resources. A fellow ethicist has constructed an ethically sound and clinically practical set of guidelines for this situation. However, the decision to implement the set of guidelines could not get past legal and administrative roadblocks. The systematic, transparent, and ethically compelling triaging algorithm has not been employed.
If a society can be described as having cognitive dissonance, then the United States Society certainly has it. The story we tell ourselves is that we didn’t need to use these protocols because, as always in tales of triumph and the American legend, we simply overcame the obstacles without having to resort to any compromises. There are enough tests available, we tell ourselves; enough ventilators have materialized from all of us pulling together, and the nation’s economic sacrifice was all worth it. We never had to decide who lives and who dies. What a marvelous outcome, what a heroic achievement on all accounts!
The trouble is that this is just the story we tell, and it is not the truth. The truth is that triaging happens every day by every physician and every hospital. I recently operated on a 19-year old young woman with acute appendicitis who had been turned away from no less than three healthcare facilities. She was turned away, not because they misdiagnosed her, but because they refused to even examine her. Not having any COVID symptoms, she was simply not the priority. A few more days without treatment, and she could have died.
The most dangerous feature of our society’s cognitive dissonance is that it is a self-fulfilling prophecy. The more our resources diminish, the more we practice bedside rationing in order to free up resources, creating the impression there is no need for systematic triaging. We are winning against ourselves, convincing ourselves with our escape from reality.
Injustice has many shapes. Having to bribe the surgeon to operate on your child is a clear and readily apparent variation, as is slipping a larger bill into a white coat’s pocket. Although the entire system is negatively affected in these scenarios, the actions are clearly traceable to each individual. The injustice we have in the US is different. It is systematic, much like family secrets we do not talk about. Bedside rationing decisions are made by well-intentioned individuals who are either “doing the best for their patient” or “are exercising stewardship of resources.” But since these two imperatives are often at odds with each other, the end result is unsystematic, non-transparent, wholly variable bedside rationing. The victims are those who are already suffering the most from one discrimination or another. The more acute the driving force behind securing public health, the more marginalized these individuals become. In short, it is not the individuals, but the system that is unjust.
I wish we dared to look in the mirror and see.
Piroska Kopar is a trauma surgeon, intensivist, and assistant professor of surgery at Washington University School of Medicine in Saint Louis, MO, where she directs both the Center for Humanism and Ethics in Surgical Specialties (CHESS) and its Surgical Ethics Fellowship.