Allocating Scarce Medical Resources During the Covid-19 Pandemic
Zachariah A. Philip
Covid-19 has brought light to the issue of allocating scarce medical resources during a pandemic. Resource shortages have already forced decisions about which patients should receive lifesaving medical resources. While it remains a challenging issue, major ethical frameworks provide us with different ways of answering these allocation questions.
In their New England Journal of Medicine article “Fair Allocation of Scarce Medical Resources in the Time of Covid-19,” Emanuel et. al. introduce a utilitarian approach to fair medical resource allocation (Emanuel et. al.). They offer four principles rooted in utilitarian theory: (1) maximizing benefits produced by scarce resources, (2) treating people equally, (3) promoting and rewarding instrumental value, and (4) giving priority to the worst off.
The first principle would include not only saving the most lives but also the most life years. Because utilitarians do not see life as an inherent good, they prioritize saving a younger person with more life-years ahead of them. The second principle leads to random allocation among patients with similar prognoses. The third principle might sound like an extreme utilitarian position that gives priority to those with higher “social worth.” However, the authors claim that it is a reaffirmation of the equality of each person because those with higher instrumental value (e.g. healthcare workers) are necessary to help others. At the same time, this can be a slippery slope, given that the authors say they would give "priority to those who have saved others in the past." It is understandable to want to reward those who have saved others in the past, but it is a violation of the equality of all persons to offer preference based on good deeds patients have done in the past. The fourth principle involves prioritizing the worst off, which they define as including the sickest and youngest. Younger patients are worse off because they have more potential life years ahead of them than an older patient. This relates to the first principle, where it would lead to a higher benefit to save a younger person than an older person because of the utilitarian stance on life.
Based on these four principles, the authors offer six recommendations: (1) prioritize “maximizing benefits” above other values, (2) offer interventions to healthcare workers first, (3) use random allocation in patients with similar prognoses, (4) prioritize vaccines for older people and ventilators or ICU beds to younger patients (those more likely to recover), (5) prioritize research participants, (6) treat all patients equally (Covid-19 and non-Covid-19).
Because healthcare workers and the public make sacrifices during a pandemic, it is the obligation of the healthcare system to maximize the benefits from scarce resources. This includes removing a patient from a ventilator or ICU bed to provide it to others with a better prognosis because it follows from the principle of “maximizing benefits.” The second recommendation reflects the third value (“promoting and rewarding instrumental value”) because it gives preference to healthcare workers, not because they are inherently more valuable, but because they are necessary to the health of future patients. At the same time, this seems to be a clear violation of distributive justice.
Mark A. Rothstein holds to his position, stating that the three defenses for giving treatment priority to health care workers are all flawed (Rothstein). The first argument is that they deserve priority for their specific social worth and service during a pandemic. However, this violates distributive justice, giving priority to certain people and downplaying the social worth of others. While others argue that it encourages them to serve during a pandemic, Rothstein insists that this is a form of “unprofessional inducement,” even violating informed consent. The most common argument in favor is that giving priority ensures that they are well enough to treat others. Still, Rothstein claims that this argument is problematic. We do not know whether prioritizing healthcare workers will actually decrease the time from illness to treating patients again. It also seems to violate distributive justice, using social (and not medical) criteria to make rationing decisions. One may still object that if prioritizing healthcare workers during the Covid-19 pandemic will get them to work sooner, it will be for the good of all patients.
Returning to the original article, the third recommendation is to use random allocation for patients with similar prognoses, affirming the equality and value of each person while prioritizing those with higher medical needs. The fourth recommendation states that different interventions should have different prioritization guidelines. Vaccines should be given to older people because contracting Covid-19 as an older person leads to poorer outcomes. On the other hand, ICU beds and ventilators should be given to younger and healthier patients who have both a higher chance of recovering and living more years than an older patient (based on the first value). The fifth recommendation is to offer some priority to vaccine or therapeutic research participants to reward them for their risk and encourage others to participate in clinical trials. However, this is a very similar case as with the healthcare workers not being entitled to priority because of its violation of distributive justice. Giving priority could even cloud proper informed consent. Finally, the authors state that there should be no difference in allocating scarce resources between Covid-19 patients and others. Fair allocation ought to apply to all patients, not just those suffering from one particular disease.
“Guidelines for Rationing Treatment During the COVID-19 Crisis: A Catholic Approach” offers a counter-perspective rooted in Catholic and natural law values (Daly). While the recommendations are similar, the author holds to four unique values: (1) human dignity, (2) preferential option for the poor, (3) common good, and (4) stewardship of resources. Human dignity includes both the (1) inherent (God-given value of each person) and (2) normative dignity, where each person must be treated as transcendentally valuable. The preferential option for the poor is the Catholic view that in order to attain the common good, there must be a universal love that prioritizes the “least of these,” including the poor, the elderly, refugees, and others. The common good exists where each person in a society has access to goods they need to live a life suitable to a human person. Finally, responsible stewardship defends the right of every person to basic health care, while providing equitable access to the poor and vulnerable (while also accounting for treatment burdens on the community).
These four values lead to the following recommendations: (1) uphold the Christian mission of showing mercy to the sick, (2) prioritize healthcare workers, (3) exercise the preferential option for the poor, (4) distribute solely on medical factors, (5) prefer patients who will experience the same benefit for longer, (6) withdrawing a treatment for reallocation to a patient who will experience greater benefit is acceptable, and (7) rationing of care should be done on a case-by-case basis.
The first guideline is in line with Catholic values, but that since these guidelines appeal to Christian values and faith, some may argue that they should not be applied to non-Christian hospitals. The second guideline is in line with the NEJM recommendations, but conflicts with Rothstein’s argument. The third guideline may also face similar objections as the first, because the idea of a “preferential option for the poor” is not as defensible from a utilitarian perspective. The fourth guideline seems to conflict with the third, which prioritizes the poor, not necessarily based on medical need. While an extreme utilitarian perspective might give preference to those with high “social worth,” this Catholic approach works with those who are not. But still, prioritizing them on social factors still occurs and seems to conflict with the fourth value. The fifth and sixth guidelines are in line with both the utilitarian and natural law views, maximizing benefits from scarce resources, to the point of removing a ventilator when greater benefit could be yielded in another patient. The final guideline supports the formation of an ethics committee that makes decisions based on individual patients, rather than based on the groups they belong to (as the NEJM article supports).
While the Catholic approach holds unique fundamental values (namely its emphasis on Christian charity and the “preferential option for the poor”), it shares many similar recommendations as the utilitarian approach outlined earlier.
The authors of “An Ethical Framework for Allocating Scarce Inpatient Medications for COVID-19 in the US” take a utilitarian approach and argue that evidence-based, fair, transparent guidelines can help physicians make the difficult decisions in allocating scarce Covid-19 drugs (Dejong et al.). They hold similar ethical values such as reducing mortality, fairly allocating medications (avoiding social factors and discrimination based on age or quality of life), and allocation proccess transparency. To achieve these goals during the Covid-19 pandemic, the authors suggest that hospitals stay evidence-based, only use medical criteria to make decisions, use random allocation (while prioritizing essential workers).
Finally, British Medical Journal article “Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective” compares two Jewish approaches to resource allocation (Solnica et al.). The authors begin by comparing deontologist and consequentialist theory. Deontologists argue that actions are moral ends in themselves and have innate moral properties. Paul Ramsey, Protestant theologian and ethicist, holds to this view, stating that random allocation of resources affirms equality of worth, protecting us from playing God. Of the major ethical theories previously discussed, this theory seems to coincide closer with natural law ethics. Consequentialists state that moral rightness exists only based on the consequences of actions. Unlike deontologists, who would leave resource allocation to chance, consequentialists would argue that no matter how painful, it does more good to take responsibility for allocating resources beyond pure random chance. Overall, these two Jewish perspectives reflect the larger discussion: on whether we should take a deontological or consequentialist approach, focusing on the actions themselves or the consequences of them.
The Covid-19 pandemic has required ethicists to consider hard questions about which patients should receive which treatments. While the natural law and deontological approaches favor random allocation and medical criteria as sole criteria, consequentialist and utilitarian theories allow for prioritization based on age, quality of life, or instrumental value. However, the borders between each theory are not always clear; even the Catholic natural law approach allows for re-allocation of ventilators to younger or healthier patients and some utilitarians also reject the use of non-medical criteria in allocation decisions. Overall, it provides a clear example of how the fundamental values of any ethical theory lead to different conclusions about how scarce resources should be allocated.
Works Cited
Daly, Daniel J. “Guidelines for Rationing Treatment During the COVID-19 Crisis: A Catholic Approach.” Health Progress, Catholic Health Association of America, 2020, https://www.chausa.org/publications/health-progress/article/pandemic-coverage/guidelines-for-rationing-treatment-during-the-covid-19-crisis-a-catholic-approach.
Dejong, Colette, et al. “An Ethical Framework for Allocating Scarce Inpatient Medications for COVID-19 in the US.” Jama, vol. 323, no. 23, 2020, p. 2367., doi:10.1001/jama.2020.8914.
Emanuel, Ezekiel J., et al. “Fair Allocation of Scarce Medical Resources in the Time of Covid-19.” New England Journal of Medicine, vol. 382, no. 21, 2020, pp. 2049–2055., doi:10.1056/nejmsb2005114.
Rothstein, Mark A. “Currents in contemporary ethics. Should health care providers get treatment priority in an influenza pandemic?.” The Journal of Law, Medicine & Ethics, vol. 38,2 (2010): 412-9. doi:10.1111/j.1748-720X.2010.00499.x
Solnica, Amy, et al. “Allocation of Scarce Resources during the COVID-19 Pandemic: a Jewish Ethical Perspective.” Journal of Medical Ethics, vol. 46, no. 7, 2020, pp. 444–446., doi:10.1136/medethics-2020-106242.