Only a lottery will avoid ventilator rationing by privilege

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Jerome Adams MD, U. S. Surgeon General

Deborah Birx MD, Coordinator for the White House Coronavirus Task Force

Anthony Fauci MD, Director National Institute on Allergies and Infectious Disease


We, the undersigned physicians of color and supporters, strongly urge the medical system not to ration care during the COVID-19 pandemic on the basis of prior health, who has more years of life left, and if they are health care workers.


The fairest form of rationing, should hospitals become overwhelmed, is by lottery.


Advisories on rationing that seem ethical and fair by judging who is most likely to survive COVID-19 are in fact neither. Not when centuries of systemic medical racism, corporate targeting of tobacco and unhealthy food products and the siting of toxic industries have fueled highly disproportionate levels of disease that might disqualify many people of color from lifesaving treatment such as ventilator access. Using prior health conditions and years of life left when white Americans normally live longer lives ignores the nation’s history of oppression. It represents a sanitized version of genocide of disadvantaged groups, including people of color, the disabled, and the old.


These advisories also fail to factor in that because of structural economic inequality, African Americans, Latinx, Native Americans and members of some Asian American groups are disproportionately represented in jobs that are considered essential, such as grocery store cashiers, bus drivers and sanitation workers and other service and farming occupations. Many of those jobs come with a high risk of coronavirus infection, but do not come with the level of protection afforded health care workers. Prioritizing health care workers over other essential workers is class privilege, pure and simple.


As our society remains rife with implicit bias, no rationing scheme can be considered trustworthy, particularly for African Americans, haunted by the Tuskegee Experiment, Puerto Ricans who remember birth control and cancer experiments and Native Americans and disabled people who were sterilized. We also live in a society where discounting of old people is the last acceptable “ism.” We are ALL ruled by implicit bias, any rationing that claims to ignore our medical and political history will only perpetuate the status quo of the ladder of privilege.

Michelle D. Holmes, MD, DrPH

Brigham & Women's Hospital, Harvard Medical School, Harvard School of Public Health