The era of replacing human organs and their functions began with chronic dialysis and renal transplantation in the 1960s. These significant medical advances brought unprecedented problems. Among these, the selection of patients for a scarce resource was most troubling. In Seattle, where dialysis originated, a “God Committee” selected which patients would live and die. The debates over such a committee stimulated the origins of bioethics.

Withholding or withdrawing life-saving ventilators can become necessary when resources are insufficient. In the USA, such rationing has unique social justice dimensions. Structural elements of dominant allocation frameworks simultaneously advantage white communities, and disadvantage Black communities—who already experience a disproportionate burden of COVID-19-related job losses, hospitalisations and mortality. Using the example of New Jersey’s Crisis Standard of Care policy, we describe how dominant rationing guidance compounds for many Black patients prior unfair structural disadvantage, chiefly due to the way creatinine and (...) life expectancy are typically considered.We outline six possible policy options towards a more just approach: improving diversity in decision processes, adjusting creatinine scores, replacing creatinine, dropping creatinine, finding alternative measures, adding equity weights and rejecting the dominant model altogether. We also contrast these options with making no changes, which is not a neutral default, but in separate need of justification, despite a prominent claim that it is simply based on ‘objective medical knowledge’. In the regrettable absence of fair federal guidance, hospital and state-level policymakers should reflect on which of these, or further options, seem feasible and justifiable.Irrespective of which approach is taken, all guidance should be supplemented with a monitoring and reporting requirement on possible disparate impacts. The hope that we will be able to continue to avoid rationing ventilators must not stand in the way of revising guidance in a way that better promotes health equity and racial justice, both to be prepared, and given the significant expressive value of ventilator guidance. (shrink)

In a recent JME article, Joona Räsänen makes the case for allowing legal age change. We identify three problems with his argument and, on that basis, propose an improved version thereof. Unfortunately, even the improved argument is vulnerable to the objection that chronological age is a better proxy for justice in health than both legal and what we shall call official age.