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Posted on April 13, 2020 at 9:00 AM

by Rosamond Rhodes, Ph.D.

In their timely article, “Fair Allocation of Scarce Medical Resources in the Time of Covid-19,” Ezekiel Emanuel and colleagues correctly note the need for guidance in making the difficult decisions that lie ahead.  They also identify “four fundamental values” for the “allocation of resources in pandemics and other settings of absolute scarcity.” The values that they identify — maximizing benefits, equality, rewarding instrumental value, and priority to the worst off — are, however, inconsistent with each other and reflect misunderstanding.  Consequently, their recommendations are inappropriate for directing the difficult decisions that will have to be made.  Allow me to explain.

Justice
Whenever we allocate a resource we should be attempting to achieve justice.  Justice requires treating similarly situated individuals similarly or “equally.”  The difficulty in achieving justice is that there are many competing principles for governing allocations. Discernment is required to identify the appropriate principle(s) for a particular allocation, and commitment is needed to pointedly set aside other, (i.e., irrelevant) considerations.  Equality then demands that the same principle(s) is employed in making each distribution decision for that circumstance.

For example, we allocate movie seats by first-come-first-served, seats at a holiday dinner go to family and friends, Nobel Prizes are awarded to individuals based on past performance, and places on the Olympic team go to those who are most likely to perform well and bring home medals.  These are fine principles for those particular allocations, but none of them is appropriate for allocating medical resources.  In many circumstances, medical professionals should allocate resources based on need rather than the randomness of first-come-first-served, and medicine’s commitment to non-judgmental regard means that neither fondness nor deservingness are relevant considerations in allocations. Thus, medical professionals are obliged to provide care for terrorist bombing’s victims as well as injured terrorists, for car accident victims and the drunk driver, for a friend and someone you don’t like.

Whereas medical allocations should eschew judgments of worthiness, different principles of justice are relevant in different domains of clinical care.  In well patient care, palliative, and hospice care, urgency and need are not particularly important.  But urgency and need are key issues for determining priority in the Emergency Room.  When administrators determine where to build a new clinic, they should consider those who would otherwise lack convenient access to medical facilities, that is, giving priority to the worse off.  And when allocating critically scarce transplant organs and ICU beds, medical professionals employ medical triage.

Art by Craig Klugman

Maximization vs. Triage
Emanuel et al. focus on utilitarian maximization when they should be focused on triage. Triage reflects the principle “avoid the worst outcome.” Triage is implemented by identifying those who are least likely to survive and withholding critically scarce resources from those few.  In contrast, maximizing benefits requires ranking all comers according to the amount of benefit they will receive (e.g., the number of life-years) and allocating resources so as to produce the greatest net amount of that benefit.  To appreciate the difference, recall the 2004 flu vaccine shortage.  Although the CDC was slow to offer guidance, health departments around the country quickly issued directives on how the limited supply should be prioritized, and the guidance was the same everywhere. Available vaccine was directed to:  healthcare providers, the immuno-compromised, the very young, pregnant women, and elderly.  Healthcare providers were allocated vaccine so they could continue to provide needed care for those who would become ill and thereby help to avoid avoidable deaths.  Others on the list had priority because they were most likely to die if they contracted the disease.  If the allocation principle had been utilitarian maximization rather than triage, the immuno-compromised and elderly would not have been eligible and everyone else would have been ranked based on life expectancy.  The young and otherwise healthy would have been given preference over individuals with shorter life expectancy because that allocation would maximize life years.

Instead of ranking everyone and working down the list, triage only identifies those who are least likely to have a significant benefit and excludes them from access to critically scarce resources. In other words, to avoid the most avoidable deaths triage excludes those at the bottom of the list and tries to provide for everyone else by first treating those with urgent need and then all of the rest.  The triage approach considers it better to allocate life-saving resources to someone with a relatively good chance of surviving than to someone who is likely to die regardless, thereby producing two deaths in a short period when instead there could be one death and one long-term survival.  Triage aims to minimize the number of deaths, whereas utilitarian maximization aims at maximizing life years.  I suggest that justice in the allocation of limited resources during the Covid-19 pandemic requires triage, not maximization, because, at this point, the scarcity of resources is not extreme enough to justify more speculative and fine-grained distinctions in the predicted amount of benefit.

Whereas maximization and triage may seem to point policy in the same direction, the difference in focus can be significant.  A maximization approach would count an allocation policy successful so long as the net number of life-years saved was greater than the alternative, even if some ventilators were left unused and awaiting the arrival of patients with a robust life expectancy.  A triage approach would, however, consider unused ventilators that allowed people to die to be a significant failure.

Furthermore, by pointing attention to the identification of those who are most likely to survive for the most life-years, maximization encourages decision makers to choose a high standard for justifying an allocation of life-preserving resources, for example, likelihood of at least one year survival.  A triage approach will instead identify a far lower allocation threshold, for example, survival to hospital discharge. Triage recognizes that small numerical differences may not be significant enough to make a moral difference and therefore aims at minimizing the distinctions that we make between different needy patients. Is a patient who is only expected to survive for eleven months significantly less deserving of access to a ventilator than one who is expected to survive for twelve months?  Certainly, when the shortfall of available resources is extreme, exclusion criteria will have to be more discriminating.  But when demand for the resource is only a bit greater than the supply, the exclusion criteria should reflect the predicted shortage and minimize grounds for discrimination between needy patients.

Inconsistency
This brings us to the authors’ problem of inconsistency in two different portions of their discussion.  First, there are blatant conceptual inconsistencies in their commitments to both maximizing outcomes and prioritizing the worst off.  In philosophical discussions of justice, theorists identify the worst off by comparing how individuals stand relative to one another and then aim at improving the condition of the worse off to make their situation comparable with those who are better off. On the one hand, prioritarians focus on how well-off one person is relative to another and try to improve the lot of the worse off.  Utilitarians, on the other hand, are not concerned with who receives the benefits, but focus only on maximizing the amount of benefit an allocation produces.  Emanuel and colleagues recommend both of these incompatible approaches apparently unaware of the inconsistency and their conflicting direction for resource allocation policy.

A second consistency problem with the authors’ position is that they offer two incompatible justifications for what they term “rewarding instrumental value” of medical professionals. One justification is consistent with medical triage: Prioritizing treatment for healthcare workers would enable them to continue providing clinical care that helps avoid the most avoidable deaths. When an effective treatment or vaccine is developed, this means health workers should be first in line to receive it. The authors’ other justification, however, is anathema to medical ethics: Prioritizing health care workers based on their past contributions violates both medicine’s longstanding commitments to non-judgmental regard and medicine’s fiduciary responsibility to put the good of patients before one’s own. Furthermore readers should notice that when a healthcare worker is likely to die regardless of treatment, allocating a critically scarce ventilator to that person would violate both utilitarian maximization and triage.

Conclusion
In sum, I endorse Emanuel and colleagues’ conclusion that we need “fair and consistent allocation procedures” for distributing scarce medical resources during this Covid-19 crisis. It is not too much to expect, however, that the guiding principles supporting those allocation decisions should be clear and coherent.  I therefore suggest that we limit guidance to just three principles of justice: avoid the worst outcome (triage), urgency, and equality.

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