Justice, rationing, and resource allocation

Emanuel EJ, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. NEJM. Published online March 23, 2020.

Zeke Emanuel is a physician and eminent bioethicist at the University of Pennsylvania, and this piece in the New England Journal of Medicine is a comprehensive but concise overview of the how to approach the question of allocation of scarce resources during this pandemic. This is a nice “Ethics 101”-type piece for the current situation, though there's ample room for debate. The authors cover the basic numbers of the pandemic, including the best available large-scale modeling data and health system capacity. They give a brief nod to emerging diagnostic and therapeutic interventions, and then they delineate the ethical values at play in determining how to ration health resources in a crisis like this.

The authors suggest that four underlying principles emerge: “Maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.”

• By “maximizing the benefits,” they’re referring to saving a) the largest number of lives, and b) the largest number of life-years - that is, giving priority to those projected to survive the longest if treatment is given.

• With “treating people equally,” they argue that random allocation should be performed among people with equivalent prognosis, and that “first come first serve” approaches are not permissible.

• “Instrumental value” refers to giving priority to people who have or are expected to contribute to the saving of lives - such as healthcare workers and research participants.

• Finally, the authors use “priority to the worst off” to describe the idea of allocating resources either to the sickest, if it aligns with maximizing benefit, or to the youngest, who would have lived the shortest lives if they do not receive treatment and die.

The piece ends with six recommendations:

1. First, benefits should be maximized. What does this look like in practice? They suggest giving priority to those who are young and sick and more likely to recover with treatment over those less likely to recover with treatment. There’s another ethical maxim that states that withdrawing an intervention is ethically equivalent to withholding it in the first place, but for families and clinicians alike, it often feels much harder to withdraw an intervention that’s been started; the authors touch on some ideas for how to address this.

2. Critical interventions, including testing, PPE, and treatment, should go to front-line healthcare workers and critical infrastructure employees, not because they’re more “worthy” but because they carry instrumental value.

3. Random allocation should be used to determine resource allocation among patients with similar prognoses

4. Guidelines for how to prioritize should be unique for different aspects of the situation - for example, older individuals and those with chronic medical conditions should be prioritized to receive a vaccine when available, because illness has been more severe in these groups.

5. Participants in Covid-19-related research should receive some priority, but this should only factor in as a “tie-breaker” compared to someone with an otherwise similar prognosis.

6. Finally, rationing should occur in the same way for non-Covid-19 related illness.

Eman Mubarak, a medical student in her second year, offers summaries of two articles on the topic of research ethics in the setting of emerging epidemics/pandemics. The global race for a cure or prevention for the novel coronavirus has begun, and with it, a host of questions about how to conduct such research in a manner that is both expeditious and ethical. The first article outlines some common fallacies that may lead to problematic “research exceptionalism,” while the second looks back to lessons learned during the HIV/AIDS and Ebola epidemics, and suggests some core scientific and ethical principles to guide clinical research in similar outbreak settings.

Persad G, Wertheimer A, Emanuel EJ. Principles for allocation of scarce medical interventions. Lancet. 2009;373(9661):423-431. doi:10.1016/S0140-6736(09)60137-9

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60137-9/fulltext

This article explores the rationale behind different approaches to allocation of scarce medical resources in general (not specific to COVID-19); the article describes the advantages and disadvantages of existing allocation schemes and clinical situations in which they are routinely employed. – Stephanie Kukora, MD

In this 2009 article, professor at the University of Denver Sturm College of Law, Govind Persad PhD, JD and co-authors explore approaches to allocation of resources applied across different medical situations of scarcity. Though not specific to resource allocation for the COVID-19 pandemic, this paper describes the ethical rationale supporting various schemes along with advantages and disadvantages of each.

The authors note that decisions of allocation cannot be based exclusively on clinical or scientific facts, and are always value-based judgements. While many principles are utilized in practice across different healthcare settings many may be insufficient, meaning they ignore morally relevant considerations, while others may be flawed, meaning the recognize morally irrelevant considerations.

Four main categories:

Treating People Equally (Equality):

· Includes Lottery and First-Come-First Served approaches

· Advantages: little information is needed about the patient’s history, diagnosis, or prognosis; difficult to corrupt and protects doctor/patient relationships; quick to enact

· Disadvantages: Blind to many relevant factors, resulting in random decisions that do not optimize resources

· Example situation: ICU beds

Favoring the Worst Off (Prioritarianism):

· Includes Sickest First/Prognosis and Youngest First approaches

· Advantages: Aids those acutely suffering or with the most to lose; applicable in situations of temporary scarcity

· Disadvantages: May result in modest gains at high cost; fails to consider post-treatment prognosis

· Example Situation: Emergency Room Triage

Maximizing Benefits (Utilitarianism)

· Includes Most Lives Saved and Most Life-Years Saved approaches

· Advantages: Attempts to allocate resources to do the most good

· Disadvantages: Decision must be made on which benefits to maximize (is it better to save 4 adults or one infant?); requires system-wide buy-in, difficult to make decisions for individual patients

· Types of Situations: Large-Scale Disasters, Bioterrorism

Promoting and Rewarding Social Utility

· Includes Instrumental Value and Reciprocity approaches

· Advantages: Helps promote or reward important values

· Disadvantages: Decision must be made on which values to prioritize/how to measure social utility (should government officials decide that they themselves have very high social utility and deserve to be prioritized?); requires system-wide buy-in, difficult to make decisions for individual patients

· Types of Situations: Prioritizing healthcare workers first for vaccines

The article concludes by discussing how multiple approaches can be used together to address complex situations of scarcity; for example, organ donation through the United Network for Organ Sharing (UNOS) is based on a combination of sickest first (current condition), first-come-first-served (wait time), and maximizing benefits (antigen/antibody/blood type matching to ensure best prognosis). There are still challenges to implementing such systems fairly. The authors also discuss advantages and disadvantages of systems to address quality of life considerations when making allocation decisions (Quality-adjusted life years and Disability-adjusted life-years). The authors propose a model for allocation they term the “complete lives system” which combines principles from the youngest-first, prognosis, lottery, and most lives saved approaches.