© 2022 SAHAKYAN Hayarpi
2022 – № 1(23)
Saakyan A. (2022) Spravedlivoe raspredelenie ogranichennykh meditsinskikh resursov [Fair Allocation of Scarce Medical Resources]. Meditsinskaya antropologiya i bioetika [Medical Anthropology and Bioethics], № 1(23).
Teacher of bioethics and philosophy
Yerevan State Medical University,
Faculty of Social Sciences;
Faculty of Philosophy and Psychology
Yerevan State University
(Yerevan, Republic of Armenia)
Keywords: ethical dilemmas, fair allocation, scarce resources, Covid-19, pandemic, ethical principles, multivalue ethical framework
Abstract: During and after Covid-19 pandemic, a number of bioethical issues were significantly addressed in many publications in popular media and by academics. However, most of the discussions are new twists on an old theme. In this article, we will consider the ethical issues related to fair allocation of scarce medical resources during and after Covid-19 pandemic. We will try to understand if there are exact principles to be followed to protect fairness while allocating medical resources in such situations. Considering the hardships of such situations, multiple studies attempted to ease this burden by constructing an exact ethical framework for prioritizing patients in the setting of resource scarcity.
Since the pandemic is an emergency, it requires specific measurements and estimation. In other words, specific ethical guidelines should be considered, in order to best apply distributive justice in the proper allocation of resources. Nevertheless, even with these standards the context and circumstances matter when making such decisions. In addition, recommendations from high-income countries about fair allocation during Covid-19 should not be copied into low-income settings. We would like to highlight that context, mindset and country conditions more than matter while making such decisions.
Anyway, ethical values and principles that guide individual relationships in emergency situations, such as respect for autonomy, informed consent, individual care centered values, preferences and needs, and ethical values based on the needs of specific groups, should be carefully considered. Health promotion should be accessible for the majority of the population, in order to minimize morbidity and mortality with wise use of scarce resources.
Indeed, ethical dilemmas are not new in medical practice and are deeply rooted in it. Although there is a belief that the right to all possible healthcare should never be compromised, however, under certain circumstances, like the shortage of medical resources during crises like pandemic, war or natural disasters, when the demand for healthcare services exceeds the supply, this right might be waived. Pandemics, conflicts, wars, and natural disasters are all settings where medical resources can become scarce, causing various challenges. These challenges often are multidimensional, multivector and complex, so they cannot be solved without jeopardizing the ethical framework of fairness, equity, and equality. Even though after a while due to Covid-19 there were some guidelines that lead healthcare workers during and after, still the essence of fairness is not clear. Sicker patients in need of more intensive treatment will likely be in the same boat as most patients with chronic disease in economically deprived settings—out of luck. This may be what “fair allocation” will look like, though that might not be the best choice of words. However, as this is not the purpose of this article we will not go deep into this question. We should just accept that fairness could have different bases depending on the situation and circumstances.
Let’s consider the “unfairness” of fairness in some small examples. For instance, a multitude of bioethics frameworks turning out from high income countries endorse the idea that scarce medical resources should be allocated in ways that maximize benefits. In short, the greatest amount of good for the greatest number of people. In this context, it means to expand the number of saved lives and improvements in patients’ years of post-treatment life. Some insist that there is considerable agreement on these criteria among experts and that they can be defended on both utilitarian (best overall outcomes) and non utilitarian (value of human life) grounds. What does this mean in practice? Actually practicing these criteria means to prioritize patients that are most likely to get better with a reasonable life expectancy. These criteria look impartial and neutral. As Harald Schmidt states this is not true on closer inspection. Taking into account the social determinants of health, people who are disadvantaged and need emergency care are less likely to recover and less likely to have a reasonable likelihood of life after treatment. These criteria are not disinteresting. In low and middle income countries, if we consider those social determinants of health, those who are more indigent may be least likely to access necessary care, which will make social injustice and discrimination deeper and more complicated. Moreover, the high society or rich people from those societies, avoiding their own health care system can dishonorably go abroad when they get sick and again be on top for care access.
In addition, bioethicists insist that allocating scarce medical resources during Covid-19 in high income countries can favor youth over the aged ones. It is interesting and complicated to think about the age question from the perspective of different countries: in low, middle, and high income countries. It is unclear what “reasonable life expectancy post treatment” would even mean. Does it refer to “locally reasonable”? Is “reasonable” the right word?
Another important question in this context is equally treating Covid-19 and non-Covid-19 patients. While this principle may be suitable for well-resourced health care settings, it is not clear how it could be implemented in low-income settings faced with an acute public health emergency while already barely able to meet non-Covid medical requirements. What is more likely to happen, but will have an ethical cost, is the prioritization of Covid-19 patients over non-Covid-19 patients who have chronic, potentially less reversible conditions. This shift in care priorities and human resources in health care institutions can be ethically defended in the short term as a response to an acute public health emergency in which there are many unknowns. The ethical indirect damage of such a move is contempt of patients with significant non-Covid health conditions, along with the complicated problem of when and how to bring the resources back again.
Most of the prioritization structures suggest to give priority to frontline health care workers for two reasons: first, they put themselves at risk while helping others (a matter of mutuality) and second, because they will continue to assist other members of society during and after a pandemic (a matter of utility). Another unclear question can arise in this context as well: do by medical workers we mean the whole personnel, including cleaners, administrative people too, because they are the ones who make patient care possible and also they are at high risk as well compared with the other population.
Therefore, as it turned out during Covid-19 pandemic, limited hospital beds and ventilators, medical supplement, medicine etc. brought many ethical dilemmas and issues. This shortage of equipment and supplements made healthcare workers face tough decisions. Considering the toughness of such situations, multiple studies attempted to ease this burden via the construction of an ethical framework for prioritizing patients in the setting of resource scarcity.
Nine ethical principles can be highlighted to stratify patients in order of priority; sickest first, waiting list, prognosis, youngest first, instrumental values, lottery, monetary contribution, reciprocity, and individual behavior. Note that these principles are emphasized conditionally, because they can appear with different combinations and priorities:
- sickest first: sick individuals will be prioritized;
- waiting list: according to the order of registration;
- service: subsidy the past for common good;
- youngest first: young individuals will be prioritized;
- instrumental values: priority will be given to those who are going to keep society functioning (ex. Healthcare workers);
- lottery: random selection, ex via lottery;
- monetary contribution: meaningful supplement in the costs of medical treatments;
- reciprocity: mutuality and contribution for common good;
- individual behavior: priority will be given to those who became ill not by their own fault.
Usually, in different countries and in different medical institutions, the above mentioned nine moral principles are arranged in different ways, but mostly they all emphasize these points even if with different arrangements. Overall, these principles are usually prioritized.
Moreover, even if there are these nine common ethical principles, as we have already mentioned, there are still a multitude of varying opinions on how to rank them according to priority in different countries and different medical institutions.
One should also take into consideration the following: maximizing gains; prioritizing healthcare providers; not allocating on a first-come, first-served basis; being responsive to evidence; and applying the same principles to all Covid-19 and non–Covid-19 patients. It would be a huge mitigation to decision-makers if there was a definite consensus regarding how to distribute scarce medical resources. The criteria for patient selection and the allocation of resources should be straightforward, yet a clear-cut approach to the cultivation of such guidelines might not be easily achieved.
In the context of Covid-19 maximizing gains is the most portentous value to be sought. The most important consideration for restricted resources should be objective both at saving the most lives and at maximizing enhancements in post-treatment length of life of individuals. The consensus value across the reports of experts in this sense is saving more lives and more years of life. It is persistent both with utilitarian ethical perspectives that accentuate population outcomes and with non-utilitarian views that accentuate the utter value of each human life. There are many judgmental methods of stabilizing ‘saving more lives’ against ‘saving more years of life’; whatever balance between lives and life-years is picked out must be applied invariably.
In addition, as we know maximizing the benefits is a key value during the pandemics. Some experts think that removing ventilators or ICU beds for providing them to the others is ethical and legally justified, they should just be informed about it at admission. No doubt that withdrawing ventilators or ICU beds are psychologically hard especially for medical workers and we are sure there were many clinical workers who refused to do this, but still according to Covid-19 pandemic protocols it is justified and well-argued. Nevertheless, we agree that on the other hand this act is far from being called killing.
The quality-adjusted life-year (QAYL) method should also be considered while talking about fair allocation of medical resources. Even though the QAYL method in many cases was against what we underline above, it is an important method to discuss in the context of scarce allocation of resources during and after pandemic. QAYL is a specific type of measurement that healthcare workers were following while treating patients during the pandemic. QAYL became a preferred tool for healthcare providers in many countries by including both the quality and the quantity of life lived, though there were studies that criticized QAYL for having the potential to be “ageist”. However, with QAYL they usually increase health benefits and social welfare when allocating scarce medical resources.
As we said the international associations argue that, since the pandemic is an extraordinary situation, it must be managed as an emergency situation, which assumes best apply to distributive justice in the appropriate allocation of scarce medical resources. All these guidelines agreed on prioritizing front-line health care providers. As they are essential during pandemics, they should be taken care of first for the sake of society and its own benefits.
First-come first-served principle should be handled in the case of pandemic. For example, patients who live near hospitals or clinics will have priorities and it can encourage crowding and even violence during a period when social distancing has the utmost importance. For patients with analogous prognosis service should be provided equally through contingent allocation. Especially, to my knowledge one of the most important principles is that there should be no difference in allocating scarce resources between patients with Covid-19 and those with other medical conditions.
So, as we have mentioned, fair allocation assumes an ethical scope involving multiple values that can be adjusted and revised, depending on the resources and context at issue.
In literature multiple criteria decision analysis is yet another oftentimes used way to make decisions for prioritizing and allocating scarce resources during crises. In this case the healthcare workers should make their choice based on not one but at least two or more criteria while choosing who should be treated first, who should be hospitalized etc.
Distribution of scarce resources during and after pandemic is built on four basic values: maximizing the gains fabricated by scarce resources, nursing people equally, upgrading and rewarding instrumental value, and giving priority to the worst off. There is a unity among the stakeholders that says that an individual person’s wealth should not determine who lives or dies. We all understand that no single value is sufficient alone to determine which patients should get scarce resources. Hence, fair allocation requires a multi principal ethical framework or allocation system.
Each of these values can be implemented in different ways. For example, maximization of benefits can be understood as saving the most individual lives or as saving the most life-years by giving priority to patients likely to survive longest after treatment. Treating people equally could be understood via random selection, such as a lottery, or by a first-come, first-served allocation or anything else. The proposals for allocation discussed above also recognize that all these ethical values and ways to implement them are compelling.
In conclusion, we can just add that surely governments and policy makers must do their best to stop the scarcity of medical resources. However, if resources do become scarce, we believe that above-mentioned fundamentals and ethical values should be used to manifest guidelines that can be applied fairly and consistently across cases. Such guidelines can ensure that individual healthcare providers are never tasked with deciding unaided which patients receive life-saving care and which ones do not. Instead, we believe guidelines should be regulated at a higher level of authority, both to lessen medical worker burden and to guarantee equal treatment.
В заключение можно только добавить, что, безусловно, правительства и политики должны сделать все возможное, чтобы предотвратить нехватку медицинских ресурсов. Однако, если ресурсов действительно станет недостаточно, то вышеупомянутые принципы и этические ценности следует использовать для разработки руководящих этических установок, которые могут применяться справедливо и последовательно во всех случаях. Такие руководящие принципы могут гарантировать, что отдельным поставщикам медицинских услуг никогда не придется самостоятельно решать, какие пациенты получают жизненно необходимую помощь, а какие нет. Руководящие принципы должны регулироваться на более высоком уровне власти, как для уменьшения нагрузки на медицинских работников, так и для обеспечения равного обращения с пациентами.
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