The Issue of “Justice” During COVID-19 and the Leadership Failures

The COVID-19 pandemic remains one of the worst disasters in the history of humanity,
infecting over 623 million people and killing 6.5 million globally as of September 3, 2022
(Worldometer, n.d.). The US average death rate shot from 715 fatalities per 100,000 in 2019 to
roughly 835 per 100,000 in mid-2020 (Centers for Disease Control and Prevention, 2022). On
the worst end, COVID-19 accounted for the worst economic slump since the 2007-09 Great
Recession. America remains one of the worst hit countries globally, with more than 20.5 million
people losing their jobs in 2020 and the healthcare system incurring a record loss of $202.6
billion (American Hospital Association, 2020; Bauer et al., 2020). The government and
healthcare institutions have largely been blamed for poor leadership and inept decision-making.
However, for some, the pandemic exposed an array of ethical issues that choked decision-
making during critical times. Specifically, scarcity in resources like ventilators raised significant
ethical concerns, particularly concerning the equality of “justness” of the triaging methodology
hospitals and other authorities in the healthcare sector used to allocate ventilators and other
critical resources to patients (Zhu et al., 2022). The question of why and who gets resources
became a complex puzzle. This paper explores “justice” ethical concerns and the leadership
failures arising from the handling of the COVID-19 outbreak by the government and their
instrumentalities, as identified in the “Fairness and Quality During Coronavirus” case study and
other external sources.

The Issue of “Justice”

One of the ethical issues identified by Cacece (2020) in the case study focuses on
“justice” for COVID-19 patients, especially when triaging or allocating resources like ventilators
to patients. Typically, the principle of justice requires that resources, costs, risks, and benefits are
distributed equitably or evenly based on need, effort, contribution, and merit (Robert et al.,
2020). The surge of COVID-19 cases left many people infected and in need of urgent care, and
the sudden spike in new admissions left many hospitals and clinical facilities underprepared and
overwhelmed. Because of the colossal number of patients needing ventilators and other
emergency services and the low availability of this equipment and services, several healthcare
facilities can be left with the tricky question: who receives ventilators first and who does not?
Essentially, this question narrows down to who gets to die and who is saved (Tian, 201).
The most obvious answer to this question is that ‘adequate ventilators’ must be provided
to treat all patients effectively. Strong Memorial Hospital in Rochester, New York, is an example
of a facility that made available ventilators for all patients. Nonetheless, this can quickly become
unrealistic and a nightmare in case of a sudden spike in COVID-19 incidences, raising the ethical
question: What criteria can be used to determine who gets the ventilator? This is attributable to
the failure of the national government to provide countrywide rationing guidelines for the
COVID-19 pandemic.
Despite the evident lack of federal rationing guidelines, some states had proposed new
rules to guide hospitals in triaging patients. Others applied existing protocols established long
before the pandemic even struck. New York State is one of the states that applied the 2015
ventilator allocation guidelines, which were established to be used explicitly in case of a public
health emergency, such as COVID-19. The rules require hospitals and clinicians to “prioritize
patients whom ventilator intervention would most likely save,” meaning that people who are
“least” and “most” likely to live without a ventilator do not get one. The idea is to maximize
patient survival rates.

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As Cacece (2020) proposes, other professionals have had a different say on what criteria
should be standardized to allocate resources to patients when the demand overwhelms the
supply. For example, bioethicist Peter Singer of Princeton University proposes using Quality-
Adjusted Life-Year (QALY) to ration healthcare resources. This modality proposes giving
ventilators or lifesaving equipment/healthcare services to patients with more years to live. For
example, Singer would instead give a ventilator to a 20-year-old expected to live for 60 years
than an 80-year-old with less than nine years to live. For Singer, allowing a teenager to die is a
significant loss than an elderly patient. Additionally, Singer proposes prioritizing a person’s
quality of life, for example, giving a ventilator to an individual who can live ten perfect years
(without disability) rather than a person expected to live for 20 years as a person with
quadriplegia.
Triaging limited resources during COVID-19 has not been an ethical concern in the
United States but a global riddle. For example, the United Kingdom’s British Medical
Association has proposed guidelines that require hospitals or physicians to withhold life-support
services, especially when several patients require the same critical care services and the supply is
limited, for patients with poorer prognoses and prioritizing that likely to “benefit quickly’ from
the services. This approach also suggests withholding life-support care form stable or improving
patients whose “objective evaluation” shows a far worse prognosis than other patients requiring
the same resource (Liddell et al., 2020).
Regardless of the propositions for resource triaging, as discussed above, the issue that
remains unsolved is whether allocating life-support services to specific patients at the expense of
others is an injustice to others. The correct answer is that denying others lifesaving resources like
ventilators amounts to an injustice to them because everyone deserves to live and has a right to
access healthcare resources. Whatever criteria are used – the quality of life, remaining survival
years, or prognoses – the bottom line is that there is no just way of giving others life-support
resources and denying others. However, clear-cut rules guiding the triaging process can reduce
conflicts and improve the public’s trust in hospitals and healthcare facilities (Feinstein et al.,
2020).

Leadership Concerns

The most evident leadership gap identified in the case study is the lack of national
rationing guidelines for the coronavirus outbreak. The government failed to provide hospitals
and other healthcare facilities with clear-cut rules on what procedures or criteria to use in
selecting who gets resources/services like ventilators in case hundreds or thousands of patients
require the same equipment or services and there are not enough of them. Clear-cut rationing
guidelines can provide a standard framework, map, or criteria for triaging decisions (Moosa &
Luyckx, 201). New York State is an example of a state with an established set of guidelines that
hospitals and physicians leveraged to allocate resources to COVID-19 patients. The guidelines
require hospitals to ‘prioritize patients for whom ventilator therapy would potentially be
lifesaving.’ This implies that individuals with the least and highest survival chances to are
granted the lowest access level (Antommaria et al., 2020; Truog, Mitchell, & Daley, 2020).
The reasoning is that prioritizing people with the highest survival chance from ventilators
would optimize survivors with or without ventilatory therapy. For example, if a patient’s survival
chance is higher with pharmacotherapy (drugs), ventilator therapy might not be beneficial
enough to prevent their death or fasten their recovery. According to Cacece (2021), this
seemingly renders this issue black and white: individuals with high survival chance without
ventilators are not assigned, individuals with the lowest survival chance without ventilators are

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also left out, and people with the highest survival chance with the ventilator only get assigned.
For Cacece (2021), this optimizes the overall survival chances, keeping as many individuals
alive as possible. The biggest challenge is that no bioethical issues like COVID-19 are ever
apparent; multiple factors must be considered when making decisions. Usually, factors like age,
disability, and pre-existing conditions make decisions challenging.
Another governance issue identified in the case relates to the leadership’s competence to
make informed and sound decisions, especially concerning matters as sensitive as life and death
and patient welfare. There is also the issue with the government’s accountability to citizens,
especially its mandate to uphold the constitution by supporting the “rights of citizens,” especially
their right to healthcare access. Cacace (2020) defines a “legal right” as a reflection of what the
federal, state or local government is constitutionally obliged to render to its citizens, which in
this case is healthcare. To this end, Cacace describes “healthcare” as a positive human right
because it requires action (help) from the government (through appropriate policy and financing)
and social workers (physicians, nurses, nutritionists, and physiotherapists). Usually, the function
of healthcare is deeply rooted in keeping individuals functioning; that is, no avoidable or
controllable emotional/physical boundaries obstructing their day-to-day functioning.
Therefore, the “healthcare right” humans can lay the most substantial claim on is
healthcare that supports normal functioning in the most effective way possible by lowering the
effects of disability and disease. Therefore, by rationing critical COVID-19 treatment equipment
and medical supplies like ventilators, hospitals are undermining the constitutional human right to
a reduced disease impact. Nevertheless, during the COVID-19 outbreak, supplies ran
significantly low, with patient cases surging. This left medical workers and hospitals with no
option but to break some of these rules, including patients’ right to adequate and equal (just)
healthcare.

Conclusion

The primary ethical concern in the case study relates to “justice” for COVID-19 patients.
The principle of justice requires that resources, costs, risks, and benefits are distributed equitably
or evenly based on need, effort, contribution, and merit. Determining who receives ventilators
and COVID-19 emergency support services has been a nightmare for clinicians and institutions.
For those not triaged for emergency or specialized treatment, is disregarding their choices to
receive these services an injustice to them? Although different states have applied different rules
to find the best solution to the triaging issue, having federal or national rationing rules is a plus
because it standardizes the process, creating a more just model.

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