Errata
“Black Lives in a Pandemic: Implications of Systemic Injustice for End‐of‐Life Care,” by Alan Elbaum, published in the May–June 2020 issue (Hastings Center Report 50, no. 3 [2020]: 58–60, doi:10.1002/hast.1135), contains several misstatements (on p. 59) about what is known as the “Pitt allocation framework” for allocating scarce critical care resources (“Allocation of Scarce Critical Care Resources during a Public Health Emergency,” published April 15, 2020, by the Department of Critical Care Medicine in the School of Medicine at the University of Pittsburgh).
Citing an account of the framework in the Journal of the American Medical Association article “A Framework for Rationing Ventilators and Critical Care Beds during the COVID‐19 Pandemic,” the essay describes the framework as adopting a utilitarian orientation that “optimizes life years saved.” The essay notes that “patients who have a life expectancy under five years are deemed less deserving of a ventilator.” In fact, by using five‐year survival instead of long‐term survival, the framework rejects a purely utilitarian framework. The framework (https://ccm.pitt.edu/sites/default/files/UnivPittsburgh_ModelHospitalResourcePolicy_2020_04_15.pdf) states that its primary ethical goal is “to achieve the most good for populations of patients,” a utilitarian goal, but that it also seeks “[t]o diminish the impact of social inequalities,” an equity goal that limits the utilitarian goal.
The essay asserts that the framework “do[es] not engage with the issue of the unjust disparity in life expectancy across racial groups.” In fact, the framework directly engages with the issue of unjust disparities in life expectancy across groups, stating the following: “The allocation framework does not incorporate long‐term life expectancy into priority scores. The reason is that doing so would unfairly disadvantage patients with a decreased long‐term life expectancy from disabilities or from diseases exacerbated by social inequalities.”
The essay asserts that the framework should be considered a “colorblind rationing scheme,” as it includes language stating that race is morally irrelevant. The essay further asserts that one outcome of the framework is that “black lives are sacrificed to preserve the lives of the more privileged.” Douglas B. White, the lead author of the framework, disputes both that it is colorblind and that it results in the sacrifice of black lives. Although the framework does not individually address racial inequity, its language about social inequities would normally be read as including racial inequities. One of the equity‐oriented measures in the framework is giving heightened treatment priority to workers who are “vital to the public health response” to the crisis, including the provision of health care and the maintenance of societal order. These workers, often referred to as “essential workers,” are often thought to be disproportionately persons of color. The framework also addresses social inequities by rejecting the use of judgments about social worth and quality of life in allocation decisions and by requiring that triage decisions be made by triage officers who have completed antidiscrimination and implicit‐bias training.
The essay asserts that the framework's authors “misrepresented an intensive community engagement study as finding ‘broad endorsement’ for their framework among people of diverse cultural and religious identities.” The phrase “broad endorsement” is from a University of Pittsburgh website that was not authored by the framework's authors, although the language of the website is ambiguous about authorship. A paper describing the community engagement study, which was conducted in Maryland, makes it clear that, on average, the study's participants supported the prioritization of near‐term survival and other key features of the Pitt framework (E. L. Daugherty Biddison et al., “Scarce Resource Allocation during Disasters: A Mixed‐Method Community Engagement Study,” Chest 153, no. 1 [2018]: 187–95). African American participants’ views diverged from the average; Elbaum and White draw different conclusions about what the study's multivariate analysis establishes about support for the Pitt allocation framework.