The importance of citizenship for deserving COVID-19 treatment

Intense political debates across Western Europe surround access to public resources, particularly for non-citizen immigrants. This study investigates the presence of "healthcare chauvinism," examining whether citizenship status influences perceptions of deservingness for life-saving COVID-19 treatment. The COVID-19 pandemic created a scenario of limited healthcare resources, forcing difficult allocation decisions. This research utilizes original online survey data from Germany to analyze opinions regarding who should receive priority access to life-saving care. The study's main hypothesis posits that non-citizen immigrants will be considered less deserving of COVID-19 treatment compared to citizens. A secondary hypothesis proposes that citizens and non-citizens will be viewed equally deserving. The context of healthcare allocation, where everyone is potentially vulnerable to illness, is considered a 'least likely case' for detecting discrimination, contrasting with welfare benefits where responsibility and social status play larger roles. The study also considers utilitarian factors, such as the chance of survival and societal contribution, as additional benchmarks for evaluating deservingness, contrasting them with the citizenship boundary. The trolley problem is referenced as a less realistic and abstract method of evaluating value of life compared to the real-world context of COVID-19 resource allocation.

The study acknowledges existing evidence of widespread bias against immigrants in various sectors, including labor markets, housing, politics, and everyday interactions. This discrimination is often justified by the perception that immigrants are insufficiently invested in the national community. Concerns arose in Germany about potential discrimination against immigrants in accessing healthcare during the pandemic. Previous studies documented similar trends in Denmark and Switzerland, demonstrating a willingness to discriminate against immigrants for access to COVID-19 treatment. This research differentiates itself by comparing the citizenship divide against various patient characteristics to explore nuances and by utilizing 23 cross-sectional waves to test for temporal fluctuations in public opinion.

A preregistered paired between-subject conjoint experiment was conducted using a nationally representative online survey (approximately 17,000 respondents across 23 waves from April 2020 to March 2021). Participants were presented with pairs of hypothetical COVID-19 patients and asked to choose which patient deserved priority treatment. Patient profiles included seven attributes: chance of survival, age, occupation, presence of school-aged children, criminal record, gender, and citizenship status (German citizen vs. immigrant with a residence permit). Average marginal component effects (AMCEs) were calculated to determine the influence of each attribute on treatment prioritization decisions. Standard errors were clustered on survey waves, and analysis involved unweighted data with listwise deletion of missing values. The study acknowledges that the attributes were randomized differently across waves 1-13 and waves 14-23, and that this design difference did not affect the findings. Additionally, the study considered respondent characteristics such as feeling of closeness toward Germans and attitudes towards immigration to assess variation in bias.

The results show that the chance of survival was the strongest predictor of deservingness, followed by the presence of school-aged children and criminal record. Crucially, non-citizen immigrants were 10 percentage points less likely to be chosen for treatment than German citizens, a penalty larger than those associated with occupation and age. This penalty remained consistent across all survey waves, although the magnitude decreased slightly in later waves (waves 14-23). Analyses across respondent subgroups revealed that the bias against non-citizen immigrants was most pronounced among those who felt close to Germans and were critical of immigration. However, the bias was not universal; it was absent among respondents who were not German citizens themselves. This suggests that healthcare chauvinism, while prevalent, is not a uniform characteristic across the entire population.

The findings provide strong evidence of healthcare chauvinism in Germany, demonstrating that citizenship status is a significant factor in determining deservingness for life-saving healthcare, even surpassing some utilitarian considerations. This persists despite the increasing integration of immigrants into German society. The consistent bias across different time periods underscores the robustness of the finding, although the slight attenuation in later waves merits further investigation, possibly linked to changing pandemic contexts or respondent composition. The observed variation in bias across subgroups highlights the complexity of the issue, but confirms that healthcare chauvinism is a significant and widespread phenomenon among German citizens.

This study provides robust evidence of healthcare chauvinism in Germany, indicating that citizenship remains a significant barrier to equitable access to life-saving healthcare. The findings have substantial implications for policy debates about resource allocation and social integration in Western Europe. Future research should investigate the underlying mechanisms driving this bias and explore interventions to promote more equitable access to healthcare for all.

While the study utilized a large, nationally representative sample and a robust experimental design, some limitations exist. The online survey setting might introduce selection bias, and the hypothetical nature of the scenarios could influence responses. Further research could explore the potential impact of specific cultural or ethnic backgrounds of immigrants and the effect of varying levels of integration into society on attitudes towards deservingness.