Ethical decision making during a healthcare crisis: a resource allocation framework and tool

Abstract

The COVID-19 pandemic has strained healthcare resources the world over, requiring healthcare providers to make resource allocation decisions under extraordinary pressures. A year later, our understanding of COVID-19 has advanced, but our process for making ethical decisions surrounding resource allocation has not. During the first wave of the pandemic, our institution uniformly ramped-down clinical activity to accommodate the anticipated demands of COVID-19, resulting in resource waste and inefficiency. In preparation for the second wave, we sought to make such ramp down decisions more prudently and ethically. We report the development of a tool that can be used to make fair and ethical decisions in times of resource scarcity. We formed an interprofessional team to develop and use this tool to ensure that a diverse range of stakeholder perspectives were represented in this development process. This team, called the clinical activity recovery team, established institutional objectives that were combined with well-established procedural values, substantive ethical principles and decision-making criteria by using a variation on the well-known accountability for reasonableness ethical framework. The result of this is a stepwise, semiquantitative, ethical decision tool that can be applied to resource allocation challenges in order to reach fair and ethically defensible decisions. This ethical decision tool can be applied in various contexts and may prove useful at both the institutional and the departmental level; indeed this is how it is applied at our centre. As the second wave of COVID-19 strains healthcare resources, this tool can help clinical leaders to make fair decisions.

Development of decision-making considerations to support equitable patient selection in paediatric haemophilia trials

“…Iterative Step 1: Assessment of medical need Our first meeting identified medical need as one essential factor to consider in participant selection, as medical need is generally accepted as one of the most important benchmarks for clinical decisionmaking [15][16] . In this respect, we used standard indicators of severity in paediatric patients with haemophilia to assess this criteria, such as the effectiveness of the patient's current treatment, required frequency of infusions, and the severity and frequency of haemophilia-related complications such as breakthrough bleeding, joint damage, and previous bleeds (Table 1) [17][18][19] .…”

“…Of the strategies proposed and reviewed in the literature search, 'first come, first served' was a tactic that was generally not recommended, as it unfairly advantages those who can access or learn about treatments more quickly, and neither attempts to maximise benefits nor minimise harms with what limited resources are available [3,12,14] . Several of the articles reviewed explicitly stated the need to prioritise vulnerable patients or those with a medical need, indicating that protecting at-risk patients is a common priority [3,[11][12][13][14][15] . However, this may not necessarily be a consideration that carries over to clinical trials, as clinical trials have scientific aims to fulfil that scenarios involving resource allocation do not.…”

“…While random selection was lauded for its impartiality and received positive feedback for its usage in Dobra et al's algorithm for patient selection in competitive cystic fibrosis trials [6] , it has also been said to not meaningfully reduce morbidity or mortality, provide any economic or social benefit, or reduce health disparities [12] . In addition, many articles seem to lay out criteria or recommend selection processes that random chance is inadequate in fulfilling alone [3,8,9,[12][13][14][15] . Furthermore, although a considerable number of articles examined in the literature search made an effort to take into account the conflicts that may arise when attempting to satisfy multiple criteria during decision-making, each recommended a different order of priority [6,9,11,12,14,15] .…”

“…In addition, many articles seem to lay out criteria or recommend selection processes that random chance is inadequate in fulfilling alone [3,8,9,[12][13][14][15] . Furthermore, although a considerable number of articles examined in the literature search made an effort to take into account the conflicts that may arise when attempting to satisfy multiple criteria during decision-making, each recommended a different order of priority [6,9,11,12,14,15] . One article did not recommend that the interplay between criteria be taken into account at all, arguing that attempting to consider such complex interactions would make the processes too inconsistent or difficult to implement, and instead suggested following a linear, rigid sequence of priority [13] .…”

“…Lastly, in attempting to develop and implement a decision-making protocol that balances these competing priorities, four articles specifically recommended assembling a diverse team of stakeholders and using iterative deliberations to create a shared set of values and ethical principles to inform patient selection [3,6,14,15] . Of these articles, one recommended using a blinded scoring system to reduce bias and introduce a quantitative aspect to the selection process [3] ; one team came to the conclusion of using randomisation [6] ; one used a scoring system to develop solutions but left the relative weightings of each criterion up to individual judgement [15] ; and one suggested that multiple approaches should be used and that researchers' personal ethical and clinical reasoning would be required to evaluate trade-offs between conflicting priorities [14] .…”