By Harleen Kaur Johal, Rachel Prout, Marianne Tinkler.

Although the COVID-19 pandemic has challenged all communities, increasing evidence has emerged that certain sectors have been disproportionately affected. A Public Health England report identified individuals from Black ethnic groups as most likely to be diagnosed with COVID-19. The risk of mortality was also estimated as being between 10 and 50% higher among people from Black and Asian ethnic groups, compared to White people.

The pandemic has not created disparities in health and healthcare, but it has highlighted and exacerbated long-standing inequalities affecting Black, Asian, and Minority Ethnic (BAME) groups. These racial inequities are largely attributed to economic disadvantage among BAME populations; however, the situation is likely to be more nuanced. Low socioeconomic status is strongly associated with risk factors for severe COVID-19 infection, such as cardiometabolic disease and smoking. BAME groups are more likely to live in crowded housing conditions in areas with higher population densities, and more likely to use public transportation. They also face a greater risk of occupational exposure to COVID-19, as they are overly represented in professions which maintain critical infrastructure. This includes workers in health and social care, public transport and food supply. Of the United Kingdom (UK) healthcare workers who died because of COVID-19 infection, an overwhelming majority were from a BAME background. Research suggests that historic marginalisation and racial discrimination within the health service may prevent BAME healthcare workers from raising concerns about inadequate personal protective equipment or testing.

Globally, this is already a taxing time for the Black community. Centuries of racial inequity have surfaced with the resurgence of the Black Lives Matter movement, and inherent racial biases are being exposed throughout society. Racial inequity can be considered in three layers: individual, institutional, and structural. The individual level describes prejudgements and generalisations about a person or group of people, based on their race. Institutionally, this refers to policies and practices within an establishment that benefit White people. This could be a failure to provide healthcare advice or health information leaflets in languages other than English, to non-English-speaking service users. Structural racism refers to the interchange of policies and practices between institutions which, in the context of historical and cultural conditions, propagate the position of White communities and deprive BAME communities.

Throughout the pandemic, there have been concerns about the distribution of finite healthcare resources. This has led to the development of ethical frameworks for critical care triage. Although previous moral imperatives were to minimise harm to patients and involve patients in their treatment planning to maximise their autonomy, decisions are now prioritising the safety of the patient, healthcare team, and general population. This shift arises from the ethical theory of utilitarianism, which proposes that the moral choice is that which will provide the most benefit for the greatest number. Utilitarianism appears to be dominant in pandemic guidance, but alternative theories exist. Rawls’ difference principle, for example, suggests that policies should most benefit the least-advantaged members of society.

Emanuel and colleagues argue that “limited time and information in a COVID-19 pandemic make it justifiable to give priority to maximising the number of patients that survive treatment with a reasonable life expectancy”. The British Medical Association similarly advises that “capacity to benefit quickly” is an important consideration. Whilst this may result in indirect discrimination against certain groups, this might be lawful in a pandemic as it would amount to a “a proportionate means of achieving a legitimate aim”. Thus far, there has been acknowledgement of how these recommendations might unfairly disadvantage the elderly, disabled or cognitively impaired. However, there has been no suggestion within the quoted guidance of how these recommendations might indirectly discriminate against BAME communities.

In the UK, the senior critical care physician on duty decides who is admitted to an Intensive Care Unit (ICU). The number of beds per 100,000 inhabitants is 6.6, compared to 34.7 in the United States (US). Hence, critical care beds are a scarce resource and supply is limited at times of high demand. When guidelines have scope to be left open to interpretation, the subjectivity of the decision-making authority will also influence the decision. This raises questions around the conscious and unconscious biases of the decision-maker.

Of particular concern is whether members of BAME communities may be perceived as less likely to benefit from scarce life-sustaining treatments, following the revelation that they are more likely to die from COVID-19. Publicly available data in England, Wales and Northern Ireland offers some insight. The Intensive Care National Audit & Research Centre (ICNARC) report on COVID-19 in critical care until July 2020 observed higher BAME representation amongst patients admitted for critical care, as compared to the general population. However, these patients had lower dependency prior to admission and lower incidence of severe comorbidity (excluding renal pathology) than White patients. As White patients with more severe comorbidities were admitted to ICU, this could suggest that, in a few marginal cases, patients from BAME groups were denied admission where a White patient with similar comorbidities or higher dependency was admitted. Furthermore, although patients from BAME groups admitted for critical care had lower prevalence of severe comorbidities and were consequently more likely to have a survival advantage, they still had excess deaths compared to White patients.

Ethical recommendations have been framed in such a way that indirect discrimination against certain groups is justified, on the basis that “more lives and more years of life” are saved. This corresponds with the utilitarian view, which emphasises population outcomes, and nonutilitarian views, which stress the intrinsic value of human life. When considering fair allocation of critical care resources, John Harris’s ‘fair innings’ argument has historically been used as a reason to deny elderly patients treatment, when they are in competition with younger patients. Whether this claim is right is in itself contentious, but there appears to be no mainstream, reasoned argument which similarly supports indirect discrimination against BAME groups. If the incidence of COVID-19 grew and healthcare systems were strained, would it be fair to give White patients treatment because they have the “capacity to benefit quickly” whereas BAME patients do not? It is an uncomfortable idea and our answer is instinctively no, but it is worrying that guidelines have been left open to interpretation in this way. Professional guidelines which justify indirect discrimination could, by definition, be construed as institutionally racist.

At an individual level, racial biases exist amongst healthcare professionals. In an international systematic review, implicit racial/ethnic bias was found among healthcare professionals at similar levels to the general population. Although the included studies were predominantly conducted in the US, there were several studies from the UK and other European countries. These implicit biases were significantly related to treatment decisions. As healthcare professionals have been found to have positive attitudes towards White people and negative attitudes towards BAME individuals, this presents further concerns of how COVID-19 ethical guidelines could be applied.

The purpose of ethical guidance is to guide healthcare professionals towards the ‘right’ or ‘moral’ course of action. Yet accumulated White privilege has acted in this pandemic to protect already advantaged individuals in our societies. We must develop ethical frameworks that recognise racial inequity at all levels – individual, institutional, and structural – to ensure that we do not undervalue BAME lives when making resource allocation decisions.

Authors: Harleen Kaur Johal^l1,2, Rachel Prout², and Marianne Tinkler²

Affiliations:

1. Centre for Ethics in Medicine, University of Bristol, Bristol, UK
2. Great Western Hospital NHS Foundation Trust, Swindon, UK

Competing interests: HKJ is a BAME junior doctor and PhD student at the Centre for Ethics in Medicine at the University of Bristol, currently working in an Intensive Care Unit. RP is a Consultant in Anaesthetics & Intensive Care Medicine. MT is a Consultant in Respiratory Medicine.

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