Over the last few days, many analysts in the US have been arguing that what’s happening in Italy today, vis-à-vis the spread of the SARS-CoV-2 coronavirus, is a good estimate of where many states in the US might be in a week or two.
In this respect, perhaps the most terrifying scenario is the one playing out in Italy’s ICUs, following a remarkable report published by the country’s College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). As Yascha Mounk wrote in The Atlantic,
“Instead of providing intensive care to all patients who need it, it may become necessary to follow the most widely shared criteria regarding distributive justice and the appropriate allocation of limited health resources… [Following such criteria would mean that] those who are too old to have a high likelihood of recovery, or who have too low a number of ‘life-years’ left even if they should survive, will be left to die. This sounds cruel, but the alternative [according to SIAARTI] is no better.”
We don’t know for sure if India will face a similar situation in the coming weeks. But what is certain is that if it does happen, our healthcare system will experience a total collapse. It is common knowledge how dysfunctional many of our clinics and hospitals are, how little we spend on — or even care about — providing good quality healthcare services to people, and how cavalier we are about our rampant and embarrassing undernutrition. Apart from such infrastructural and logistical under-preparedness, however, there is an equally damaging challenge we face: of moral under-preparedness.
Experts describe the dilemma facing doctors in Italy today as challenges of rationing, or triaging. Every hospital, society, district and country has a finite amount of resources, such as medical equipment, professionals, beds, etc. Triaging is one way to decide which patients to prioritise when the number of patients is too high for the capacity available to treat them. In the Italian case, for example, there are too many patients but too few ventilators (used to treat critically ill patients of the new coronavirus), so someone “too old to have a high likelihood for recovery” will have to be denied or taken off of their life support system. When a crisis intensifies, healthcare professionals on the frontline often need the option and then the power to decide who is more deserving of being saved.
This of course is a lot of power, and we can’t say if such power will always be exercised responsibly and humanely in a society as messy as in India. It’s more likely that professionals will abide by a set of well-formulated, bioethics-based rules on paper but in reality follow entrenched biases or well-lobbied-for orders.
For example, according to the generally accepted utilitarian criteria for triage, a 46-year-old working woman with two children is more important, so to speak, than a 72-year-old man with advanced kidney disease. However, this example is more suited to making a point. Doctors have to choose more often between, say, a woman working as a house-maid and a father of the local bank manager, or a woman working in the IT sector and a man related to the local MLA. In a country with a history of spinning female foeticide and hysterectomies of young women into money-making enterprises, it’s painful to imagine what cottage industries could pop up in the event of a severe COVID-19 crisis.
Additionally, most doctors and other healthcare professionals in India aren’t exposed to rational solutions to such ethical issues during their college education (e.g. through classes in medical ethics, which only a few medical colleges in India take seriously). Not only are our doctors generally under-prepared for such crises, they’re also ill-prepared. The hidden curricula of our medical education system teach students many ‘truths’ that are actually glorified biases, and rarely expose them to concepts like structural violence in any meaningful way.
One of the ideas I remember learning in medical college was that it is okay to yell at low-income patients: since they were ‘freeloaders’, a heartless attitude was ostensibly necessary to prevent them from taking “too much” advantage of the government’s “largesse”. Apart from such acquired prejudices, many healthcare professionals often harbour awful personal biases that they refuse to rein in when dealing with patients. The most recent example of this was the highly problematic ways in which some doctors responded to the victims of religious violence in Delhi in February.
If this is how we are in peacetime, how will we be like at war? It’s a difficult question to answer but it’s possible that while our systems – and many of their leaders – will miserably fail, there will be exceptional examples of individuals and small groups rising to the occasion, arguably the general trend in independent India. While folks I interacted with in my medical college had little empathy for low-income patients, there were also those whose kindness and sweetness often lit up the wards. Some doctors constantly yelled at patients but others went out of their way to help patients, including by spontaneously donating money. Such striking stories of ordinary professionals’ medical and moral heroics are not uncommon in India.
However, scattered and essentially random instances of kindness won’t suffice when we’re faced with a beast like the pandemic. We need robust systems but that seems to be an idea best pursued once the pandemic slows. One thing we could do right now is to enhance the moral response of healthcare professionals. The Indian Medical Association could make a positive contribution to the country, as against their recent ill-advised plea to classify COVID-19 data, on this count: by using their influence to appeal to medical workers that, while epidemics are known to bring out the worst in people, today is a good opportunity for doctors to regain public trust and goodwill by bringing out the best and the kindest in themselves.
Kiran Kumbhar is currently studying the history of science at Harvard University, focusing on the history of medicine in modern India. He is also a physician and a health policy graduate.