Dr Dinesh Palipana OAM says healthcare rationing disproportionately affects people with disabilities but the disparity is often quietly swept under the rug.
COVID-19 has put a well overdue spotlight on the issue, says Dr Palipana, a Griffith University researcher and doctor in emergency medicine at GCUH who was paralysed after an horrific car accident part way through medical school at Griffith.
“One of my bosses said it best recently; these are politically unpleasant issues, but we need to talk about them,” he said.
“Difficult questions about disability are nothing new for me. When I returned to medical school, my abilities were often doubted outside the school. I was asked by doctors if I could ‘even type’, whether patients would take me seriously or if their colleagues would want me treating their family.”
To be criticized for your physical being was demoralising.
“When I graduated and was registered to practice, the employing state health organization was reluctant to give me an otherwise guaranteed internship,” Dr Palipana said.
“Eventually they did, and in 2018, I was awarded Junior Doctor of the Year at GCUH before becoming senior resident in the busiest Australian emergency department.
“What really gave meaning to all the challenges I overcame was when a patient with a significant disability told me he was glad I was treating him, because he knew I would understand his issues.”
COVID-19 uncovered more prejudices
Dr Palipana says COVID-19 has uncovered more prejudices about people with underlying conditions and disabilities.
“We realised there are swathes of vulnerable populations who identify with disabilities and have compromised physiologies,” he said.
“Society grappled with questions about how ventilators could be rationed between people with disabilities and those without.
“In Australia and the U.S. relevant authorities maintain that access to intensive care should not be based on “irrelevant and discriminatory considerations,” including disability.”
However, Dr Palipana says while the guidelines and materials discourage discriminating against people with disabilities broadly, they don’t help in weighing the physiological vulnerabilities caused by many disabilities that affect likelihood of survival.
“How do you decide access to intensive care between a person who has a pre-existing issue causing a disability and one who doesn’t?” he asked.
Dr Palipana cites an extreme but not far-fetched circumstance in which only one intensive care bed is available in a hospital in a COVID-19 hotspot.
“Imagine that the medical team has to decide who gets that bed: a healthy 35-year-old man with no significant medical history, or myself. This is a sobering scenario. I’d rather not die, but I also know that the other guy would have a better chance of survival.”
Palipana is happy to use his own circumstances to make an uncomfortable case.
“A physician friend said that realistically, we need to choose people who can make it out of the intensive care unit, which is sad to hear but a view that’s in line with guidelines from National Institute for Health and Care Excellence (NICE).
“That guidance also argues that clinicians should consider a clinical frailty scale of 5 or more as a reason to exclude intensive care admission in these scenarios. Although that scale is typically applied to elderly people, my score is more than 5 but I don’t feel frail. I’m a doctor actively working to care for those who are affected by the pandemic.”
He poses a critical question: should he automatically be disqualified from intensive care if he gets sick?
“This is the problem with objective measures without context as they don’t take into account anything about a person’s life other than their physicality.”
Dr Palipana says as a disabled doctor who studied a degree in law before medicine, he understands the complexities of resource allocation but insists guidelines must be strengthened to protect the interests of those with disabilities and all vulnerable populations.
“Guidance that tells doctors not to discriminate on the basis of disability is useful, but providing specifics about how to do that is more useful,” he said.
“For example, if a person with multiple sclerosis and a person without that condition both need the last remaining ventilator, one approach would be to take multiple sclerosis completely out of the equation.
“Another approach, controversial though it may be, would be to give the most vulnerable person priority to the resource. After all, isn’t that how we triage patients in emergencies?
“Another underexplored avenue is involving patients. If possible, we could include their opinions and wishes after informing them of the scenario. Either one may suggest giving the other life-saving treatment. The world is full of heroes hiding in plain sight.”
The state’s first quadriplegic medical graduate, Dr Palipana writes more on this issue in Medscape. He is currently leading the Biospine research project with co-lead Dr Claudio Pizzolato.
Location with ADaPT on Griffith’s Gold Coast campus, Biospine brings together some of the most promising advances in human history for spinal cord injury, using thought control, electrical simulation, and drug therapy in an attempt to restore function in paralysis.