Governments everywhere are moving to a level of control over industry and civilian life normally seen only in wartime.
On a Wartime Footing
Comparisons to World War II and the “spirit of the Blitz” are common in Britain. It was a time when, in the national memory, Londoners withstood daily bombing with courage, determination, solidarity, and patriotism, and came to each other’s aid.Government control extended beyond providing health care for those serving in the greatly expanded armed services. It was also a matter of how the state needed to organize industry to meet critical health care needs, to apportion and ration health care resources, not least but not only for those wounded in combat.
The Dark Side of War Talk
For Irish writer John Waters, war talk is dangerous. From early on, as the disease engulfed northern Italy and swamped health care resources, physicians and policymakers spoke of the need to make hard choices in treating the sick, of “triaging in favor of younger, more ‘productive’ virus victims.”It is the language of prudent policy analysis, of making inescapable choices, and the common good. But it sounds reasonable, Waters argues, only because it reflects and reinforces a wider throwaway culture criticized by John Paul II and subsequent popes, a culture of death in which the weak and vulnerable are increasingly excluded from the human community.
The culture, in short, is desensitizing us “by ’training' us to see illness as a kind of luxury, treatment as a concession, and the old as a separate category of the human. Because the old are increasingly hidden away from everyday society in purpose-built nursing homes, when we happen upon the old we are already beginning to look away from their frailty, and therefore their, and our own, humanity,” writes Waters.
The language of combat triage to exclude from care and treatment whole categories of people misunderstands and misapplies the process. Military triage prioritizes for treatment those most likely to be capable of returning to the battlefield. It’s a dynamic process in which a soldier’s priority can change rapidly according to his health status.
Rationing Is Inevitable in Health Care
But are there not rational and just grounds for prioritizing measures like vaccination and testing of health care workers, who put themselves at higher risk and without whose work hospitals would collapse into centers of spreading infection?Or for giving lower priority in the use of scarce equipment to those who are very frail and in rapidly declining health? Are these not indeed the kind of prudential choices that a plague, like a war, forces on our attention, however firm our commitment to doing no harm and to healing the sick?
The important objection to Italy’s response is not that physicians had to choose whom to provide with the best available care. That is true in all health care systems. We have deluded ourselves into thinking that health care is an unquestioned right in the sense of an open-ended claim on the state.
Resources are limited, so the question remains, what better way might exist for allocating them? By treating age as the determining criterion, the Italian system laid itself open to the kind of criticism it has received. It excludes the most vulnerable, a whole category of the population, from the protection of the community.
The UK’s National Health Service (NHS) has long experience of providing a universal health care system within a constraining budget. It has always had to ration health care, albeit through long waits rather than copays, deductibles, and caps. It regards rationing—denying a potentially beneficial treatment to a patient on the grounds of scarcity—as inescapable. But the UK, like Italy, has a universal health care system. The two countries provide an instructive contrast.
Faced with even fewer critical care beds, relative to population, the NHS has developed official guidance for physicians on how to decide whether patients suffering from the COVID-19 disease should be admitted to critical care or not. It has done so without mentioning age. The new NHS guidance is a dynamic triage system that relies on a Clinical Frailty Scale (CFS) and “algorithm” or decision tree for choosing a treatment plan. It takes into account patient wishes, underlying pathologies, comorbidities, and severity of acute illness. All without mentioning age.