Influence of Community and Culture in the Ethical Allocation of Scarce Medical Resources in a Pandemic Situation: Deliberative Democracy Study

Abstract

Background Stark gaps exist between projected health needs in a pandemic situation and the current capacity of health care and medical countermeasure systems. Existing pandemic ethics discussions have advocated to engage the public in scarcity dilemmas and attend the local contexts and cultural perspectives that shape responses to a global health threat. This public engagement study thus considers the role of community and culture in the ethical apportionment of scarce health resources, specifically ventilators, during an influenza pandemic. It builds upon a previous exploration of the values and preferences of Maryland residents regarding how a finite supply of mechanical ventilators ought to be allocated during a severe global outbreak of influenza. An important finding of this earlier research was that local history and place within the state engendered different ways of thinking about scarcity. Objective Given the intrastate variation in the themes expressed by Maryland participants, the project team sought to examine interstate differences by implementing the same protocol elsewhere to answer the following questions. Does variation in ethical frames of reference exist within different regions of the United States? What practical implications does evidence of sameness and difference possess for pandemic planners and policymakers at local and national levels? Methods Research using the same deliberative democracy process from the Maryland study was conducted in Central Texas in March 2018 among 30 diverse participants, half of whom identified as Hispanic or Latino. Deliberative democracy provides a moderated process through which community members can learn facts about a public policy matter from experts and explore their own and others’ views. Results Participants proposed that by evenly distributing supplies of ventilators and applying clear eligibility criteria consistently, health authorities could enable fair allocation of scarce lifesaving equipment. The strong identification, attachment, and obligation of persons toward their nuclear and extended families emerged as a distinctive regional and ethnic core value that has practical implications for the substance, administration, and communication of allocation frameworks. Conclusions Maryland and Central Texas residents expressed a common, overriding concern about the fairness of allocation decisions. Central Texas deliberants, however, more readily expounded upon family as a central consideration. In Central Texas, family is a principal, culturally inflected lens through which life and death matters are often viewed. Conveners of other pandemic-related public engagement exercises in the United States have advocated the benefits of transparency and inclusivity in developing an ethical allocation framework; this study demonstrates cultural competence as a further advantage.

Which factors should be included in triage? An online survey of the attitudes of the UK general public to pandemic triage dilemmas

“…20 These same principles were recently endorsed by a similar deliberative process in Texas. 33 Our survey findings were somewhat different from another general public survey conducted during the COVID-19 pandemic. Buckwalter and Peterson conducted an online survey with US respondents.…”

Which factors should be included in triage? An online survey of the attitudes of the UK general public to pandemic triage dilemmas

“…[40] It is also consistent with community studies that mentioned maximizing numbers of life years saved, [19,31] as well as recent study using veil-of-ignorance reasoning in COVID-19 ventilator dilemmas. [39] While this latter study found older participants do not initially favour prioritizing the young, they do after imagining that they did not know if they would be the younger or older patient requiring a ventilator to survive.…”

“…[19] These same principles were recently endorsed by a similar deliberative process in Texas. [31] Study Description Key findings relevant to triage Ritvo et al 2010 [32] Canadian telephone survey administered in 2009 to a random sample of 500 Canadians to obtain opinions on key ethical issues in pandemic preparedness planning.…”

“…Concerns raised about withdrawal of a ventilator in order to benefit another patient. Schoch-Span et al 2020 [31] Texas-based public engagement initiative.…”

Mistrust and inconsistency during COVID-19: considerations for resource allocation guidelines that prioritise healthcare workers

“…So, the only way you can kind of say you're being fair is to be consistent'. 27 From the institutional perspective, however, consistent application of ethical principles is a procedural requisite to being trustworthy rather than merely earning trust 28 -a subtle distinction that has received much attention in recent years. 29 The following section thus explores the inconsistencies that arise when prioritising HCWs for scarce resources and the implications for public trust during the pandemic.…”