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The ethics of allocating scarce medical resources during a pandemic

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A pandemic such as COVID-19 places huge strains on health systems and there may not be sufficient resources to protect or treat everyone. Ethicists describe the different factors that need to be considered in making decisions over scarce resources, which include issues of health science as well as value judgements. An important goal is to provide clear guidelines to clinicians and public health specialists making hard decisions in stressful circumstances.

Medical resource allocation

During this pandemic of COVID-19, many difficult decisions have to be made quickly about how to allocate limited resources. Questions range from the care of patients in hospitals to the health of whole populations. They include which patients should have access to limited treatments (such as access to ventilators or new drugs); who should be eligible to receive the first doses of a new vaccine; and who should have priority access to limited personal protective equipment (PPE). Making choices in such circumstances is unavoidable and doing nothing is as much a decision as actively intervening.

In clinics and hospitals, “triage” is the term used for rationing or allocating scarce resources under critical or emergency conditions, when decisions about who should receive treatment must be made immediately because more individuals have life-threatening conditions than can be treated at once.[1] Under triage, priority will ordinarily be given to those whose conditions are the most urgent, the least complex, and who are likely to live the longest, thereby maximising overall benefit in terms of reduced illness and death.[1]

Medical ethicists are now studying the particular issues presented by the COVID-19 pandemic. Some of the principles that can be used to guide the allocation of limited resources are: maximise benefits in relation to costs; reward the value to society of key workers; and treat people equally, fairly and consistently.[2]

Maximise benefits

One view of resource allocation is that limited funds, staff and materials should be distributed to those who would benefit from them most; in other words, the goal should be to maximise the benefits obtained from rationed resources. In a disease such as COVID-19, one clear definition of benefit is the chance of surviving. Another metric is the number of healthy years a patient is likely to enjoy after recovery. Other things being equal, a young person might then be prioritised for access to ventilation over an older person, or a previously healthy patient who is less likely to suffer major ill effects of such a traumatic intervention might be given priority. In contrast, limited stocks of a vaccine might be allocated to older people who are more likely to benefit from its protection than young people, most of whom will develop only mild COVID-19 disease.

One difficult issue is the decision to take patients off interventions such as ventilators; this is only considered when the clinical team judges that there is no realistic chance of their survival. Guidelines have been developed to help clinicians in making such choices. Key considerations include: respect for the patients themselves (autonomy), placing the interests of patients ahead of those of medical staff and medical institutions (beneficence), and the fair and consistent allocation of resources to people who need them (justice).[3]

The benefits of interventions to control COVID-19 should be evaluated, not only for individuals, but for whole populations. For instance, immunisation against COVID-19, if a vaccine can be developed, would protect vaccinated individuals through personal immunity and everyone else through population or “herd” immunity. Vaccines have benefits in protecting individuals and populations, and in preserving the functioning of societies.

During the pandemic, health services must care not only for patients with COVID-19, but for those suffering from other illnesses too. Their requirements for access to limited resources need to be treated under the same framework of maximising benefits. Unintended indirect health effects of COVID-19, such as discouraging people with other potentially serious conditions from seeking medical attention, subtract from the benefits, or add to the costs, of managing the pandemic.

Prioritise health care workers and other key workers

Health care workers are considered a priority because, when they are protected from illness or have recovered, they are able to help other people recover from COVID-19 and other illnesses. A further consideration is that ready access to treatment helps health workers accept the significantly higher infection risk to which they are exposed.

Key workers are any individuals whose absence leads to societal harms. They include those who work in health and social care, but also those responsible for education and child care, local and national government, food production and distribution, and public safety, among other functions.[4]

Clarity, transparency, consistency

Ethical decisions about resource allocations at a time of pandemic inevitably involve value judgements.[5] Not everyone in society will come to the same conclusion based on the same evidence. Clarity, transparency and consistency can help to build trust in decision making when consensus is difficult to achieve. Ensuring that frontline doctors and public health officials operating under immense pressure have guidelines that are as easy as possible to interpret and implement, will both maximise beneficial outcomes and reduce the emotional toll on those who have to make hard decisions.[2]

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References

  1. COVID-19 – ethical issues. A guidance note. from BMA Guidance: COVID-19: ethical issues. BMA. 2020 Apr.

  2. Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. The New England Journal of Medicine. 2020 Mar. DOI: 10.1056/nejmsb2005114.

  3. Bayer R, Berenheim RG, Crawley LM, et al. Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators during a Severe Influenza Pandemicor Other Public Health Emergency. Centers for Disease Control and Prevention. 2011 Jul.

  4. UK Cabinet Office, UK Department for Education. Guidance for schools, childcare providers, colleges and local authorities in England on maintaining educational provision. UK.GOV. 2020 Mar.

  5. Bloom DE, Cadarette D, Ferranna M, Seligman B. Point of View: A Matter of Life and Death. Finance & Development. 2020 Apr.

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