Who Should Receive Life Support During a Public Health Emergency? Using Ethical Principles to Improve Allocation Decisions

Abstract

A public health emergency such as an influenza pandemic will lead to shortages of mechanical ventilators, critical care beds, and other potentially life saving treatments. This will raise difficult decisions about who will and will not receive these scarce resources. Existing recommendations reflect a narrow utilitarian perspective in which allocation decisions are based primarily on patients' chances of survival to hospital discharge. Certain patient groups, such as the elderly and those with functional impairment, are denied access to potentially life saving treatments based on selective application of additional allocation criteria. We analyze the ethical principles that could guide allocation and propose an allocation strategy that incorporates and balances multiple morally relevant considerations, including saving the most lives, maximizing the number of "life-years" saved, and prioritizing those who have had the least chance to live through life's stages. We also argue that these principles are relevant to all patients and that justice requires that these principles be applied evenly, rather than selectively to the aged, functionally impaired, and those with certain chronic conditions. We discuss strategies to genuinely engage the public in setting the priorities that will guide allocation of scarce life sustaining treatments during a public health emergency.

The Ethics and Reality of Rationing in Medicine

“…This type of objection points to the possibility that multiprinciple allocation strategies may better account for the complex moral considerations at play in such decisions compared with single-principle allocation strategies. 34 …”

“…In surveys of physicians, citizens, and economists about how to balance such trade-offs, people generally prioritize treatment that can be made available to everyone, but this view is tempered by impulses to maximize usefulness 34,45,46 and to rescue those in need. 42,[48][49][50][51][52] Finding an acceptable balance between these competing ethical goals remains a serious challenge for the development of explicit rationing policies.…”

“…33 For example, a prioritarian might preferentially allocate medical resources to the young over the old because the young have had the least chance to live through life's stages. 33,34 This "life cycle principle"-which is one example of a prioritarian allocation strategy-has been advocated as a way to allocate scarce organs for transplantation and mechanical ventilators during an infl uenza pandemic. 34,45 The justifi cation for this principle does not rely on considerations of one's intrinsic worth or social usefulness.…”

“…33,34 This "life cycle principle"-which is one example of a prioritarian allocation strategy-has been advocated as a way to allocate scarce organs for transplantation and mechanical ventilators during an infl uenza pandemic. 34,45 The justifi cation for this principle does not rely on considerations of one's intrinsic worth or social usefulness. Rather, the goal is to give all individuals equal opportunity to live a normal life span.…”

“…22 A more comprehensive description of the principles-and how they might be combined into multiprinciple allocation strategies-can be found elsewhere. 22,33,34 A foundational debate about distributive justice is how to navigate the confl icting impulses to maximize effi ciency (making decisions so as to produce the most good with the least expenditure), equity (treating individuals equally), and prioritarian conceptions of justice (favoring the worst off). Therefore, we briefl y discuss three approaches to allocating scarce resources grounded in these radically different philosophical notions of justice: utilitarianism, egalitarianism, and prioritarianism.…”