In their paper, “Ethical Challenges Arising in the COVID-19 Pandemic: An Overview from the Association of Bioethics Program Directors (ABPD) Task Force” the authors address (1) how to engage communities and (2) how to mitigate concerns of discrimination and the effects of structural inequities (McGuire et al. 2020). Specifically, the authors note that “community engagement has long been integral to public health and specifically integral to planning for pandemics and addressing such controversial issues as allocating limited resources” and that engagement plans should reflect an understanding of the community. In this commentary, we address two issues: (1) The ordering of engaging communities first and mitigating disparities second itself reflects structural bias and may undermine trust among marginalized communities and (2) Local community engagement, although purposeful and however well intentioned, ultimately may produce the writing of multiple triage protocols which itself may undermine trust in the health system.

Structural bias and racism in health care and its relationship to health disparities is well established (Williams and Wyatt 2015; Yearby 2018) and this forms a basis for marginalized communities to view the health system as less than highly trustworthy. The authors state that included among the ethical challenges are “…how to engage communities in these difficult decisions, and how to mitigate concerns of discrimination and the effects of structural inequities.” First, what is primarily in need of mitigation is not the concerns of discrimination but discrimination itself. These concerns are held by its victims above others, and the proposition that concerns are in need of mitigation externalizes the issue from within the health system and places focus on the “other”. Second, structural inequity (e.g., wealth distribution, access to healthcare, etc.) itself, and not merely its effects, is in need of remedy because structural inequity often exists in both explicit and inexplicit forms and these insidiously undermine the trustworthiness of the health system.

The suggestion that leaders should first engage communities then address their concerns of discrimination is again an “othering” of the victim. The existing substantial data on implicit and structural bias in health care has long demanded a vigorous, comprehensive effort and broad reductions in disparities. Recognition of, and serious attention to, known discrimination and structural inequities should be a precondition for engaging communities in discussions of resource allocation which itself is inherently fraught with values, framing, and with bias of one sort or another. If the health system more effectively confronted discrimination and reduced structural inequities, this would move toward remediating its deficiencies in trustworthiness, and may strengthen the basis for productive interchange between health system leaders and the public.

The authors suggest that community engagement serves to provide formative input for protocol development, gauge community reactions, and demonstrate transparency and that engagement plans should be based on “…an informed context, grounded in knowledge of the community–its history, its demographic composition, and customs–and with heightened concern for disenfranchised and vulnerable populations.” The very need to engage these communities is a product of entrenched social and health-related structural differentials. These concerns notwithstanding, there is certainly value to community engagement and we agree that it is important to clarify the purpose and the role of community engagement. It is also important to understand its full implications and its potential to exacerbate mistrust.

Community engagement (often with a particularly motivated segment of the community) without subsequent initiatives to educate all of the community about allocation policies does little to promote transparency. New York, the pandemic epicenter, had no formal allocation policy to share with the public, although the New York State Task force on Life and the Law, in drafting its 2015 guidance document on ventilator allocation, purposefully sought community input. Nevertheless, during the COVID-19 surge, each hospital in the New York State was free to develop its own triage policy and criteria and left to create its own implementation strategy. Its public hospitals, primarily serving poor and immigrant populations in New York City, were less heavily resourced than private hospitals located in the same borough and even in the same neighborhood (Caress 2020; Mahler and Montgomery 2020). Due to these differences, thresholds for activating triage protocols could not be expected to be uniform. Similarly, a survey of hospitals across the United States, published elsewhere by these authors, found heterogeneity in allocation and triage policies for pandemic (Antommaria et al. 2020). The authors note “Some states have uniform policy, while some systems and states have no policies at all.” During the pandemic, New York’s Governor centralized ventilators in order to allocate it from less afflicted hospitals to more heavily affected ones. New York State also received ventilators from Oregon and later loaned ventilators to Michigan and Maryland (Mastrangelo 2020; West 2020). Different allocation schema governed the use of what became a shared critical resource within the state and between states.

Resource inequity and health policy variability within and between communities does little to engender trust. Fairness requires that one’s opportunity to receive life-supporting measures under conditions of triage is not dependent on which hospital happens to be the destination of one’s ambulance, whether one lives in an affluent or impoverished part of one’s state, or an affluent or impoverished state. The ethical implications of a provincial approach to resource availability and resource sharing and for allocation policy is clear as is the need for a national standard for triage and allocation. To bolster the trustworthiness of the health system for all disadvantaged communities, communities not only must be provided with the opportunity for input but must also be assured of resource equity integral to a single national standard for triage and allocation.

The authors observe that hospitals in the United States “…generally function as businesses…but the services that they provide are considered essential.” The authors also note that “facing a pandemic, the healthcare system cannot remedy the structural inequalities of the social system in the United States, but it should not contribute to them.” We agree that adjusting for these preexisting disparities during pandemic is particularly fraught. Moreover, the competitive business model in which health care organizations operate makes its role in mitigating health disparities a challenging proposition with a relatively low priority. However, there is no bright-line between either healthcare inequities and social inequities or the structural racism embedded in society and its manifestations in health care. One Ohio county Board of Commissions recently resolved that “racism is a public health crisis…” (Franklin County 2020). The Board is correct. The total U.S. mortality from COVID-19 is less than the annual excess mortality from socio-structural disparities (Galea et al. 2011). These organizational deficits in U.S. health care contribute to ethical ones and, while affecting disadvantaged groups disproportionately, leaves us, as a larger community, less well off.

The health care system must move well beyond acknowledging inequities, bias, and disparities and addressing concerns and engaging communities. The spirit of ventilator sharing seen during pandemic must be codified into a national moral imperative for resource-leveling across communities. This imperative to remediate structurally-based social and health disparities has existed long before pandemic and must be addressed before the next one. COVID-19 presents a stark opportunity to reassess the moral progress we have made as a national community.