After initially emerging in China, the coronavirus (COVID-19) outbreak has advanced rapidly. The World Health Organization (WHO) has recently declared it a pandemic, with Europe becoming its new epicentre. Italy has so far been the most severely hit European country and demand for critical care in the northern region currently exceeds its supply. This raises significant ethical concerns, among which is the allocation of scarce resources. Professionals are considering the prioritisation of patients most likely to survive over those (...) with remote chances, and this news has triggered an intense debate about the right of every individual to access healthcare. The proposed analysis suggests that the national emergency framework in which prioritisation criteria are currently enforced should not lead us to perceive scarce resources allocation as something new. From an ethical perspective, the novelty of the current emergency is not grounded in the devastating effects of scarce resources allocation, which is rife in recent and present clinical practice. Rather, it has to do with the extraordinarily high number of people who find themselves personally affected by the implications of scarce resources allocation and who suddenly realise that the principle of ‘equals should be treated equally’ may no longer be applicable. Along with the need to allocate appropriate additional financial resources to support the healthcare system, and thus to mitigate the scarcity of resources, the analysis insists on the relevance of a medical ethics perspective that does not place the burden of care and choice solely on physicians. (shrink)

The coronavirus disease (COVID-19) crisis provoked an organizational ethics dilemma: how to develop ethical pandemic policy while upholding our organizational mission to deliver relationship- and patient-centered care. Tasked with producing a recommendation about whether healthcare workers and essential personnel should receive priority access to limited medical resources during the pandemic, the bioethics department and survey and interview methodologists at our institution implemented a deliberative approach that included the perspectives of healthcare professionals and patient stakeholders in the policy development process. Involving (...) the community more, not less, during a crisis required balancing the need to act quickly to garner stakeholder perspectives, uncertainty about the extent and duration of the pandemic, and disagreement among ethicists about the most ethically supportable way to allocate scarce resources. This article explains the process undertaken to garner stakeholder input as it relates to organizational ethics, recounts the stakeholder perspectives shared and how they informed the triage policy developed, and offers suggestions for how other organizations may integrate stakeholder involvement in ethical decision-making as well as directions for future research and public health work. (shrink)

Objective: A deep understanding of the relationship between a scarce drug's dose and clinical response is necessary to appropriately distribute a supply-constrained drug along these lines. Summary of key data: The vast majority of drug development and repurposing during the COVID-19 pandemic – an event that has made clear the ever-present scarcity in healthcare systems –has been ignorant of scarcity and dose optimisation's ability to help address it. Conclusions: Future pandemic clinical trials systems should obtain dose optimisation data, as (...) these appear necessary to enable appropriate scarce resource allocation according to societal values. (shrink)

Crisis standards of care are a significant change in the standard level of medical care that can be given compared to normal healthcare operations. CSC are implemented when a healthcare facility is overrun due to catastrophic events like earthquakes, or in the case of SARS-CoV-2, a global pandemic. Especially in disasters, resources like hospital beds, pharmaceuticals, and staff become stretched thin, and facilities must adapt their allocation strategies for distributing scarce resources. Inevitably, a question arises: How do we (...) allocate scarce resources justly? During the coronavirus pandemic, bioethicists, healthcare practitioners, and policymakers have asked this question. A recurring worry among them... (shrink)

Ruth Tallman has recently offered a defense of the modified youngest first principle of scarce resource allocation [1]. According to Tallman, this principle calls for prioritizing adolescents and young adults between 15–40 years of age. In this article, I argue that Tallman’s defense of the modified youngest first principle is vulnerable to important objections, and that it is thus unsuitable as a basis for allocating resources. Moreover, Tallman makes claims about the badness of death for individuals at (...) different ages, but she lacks an account of the loss involved in dying to support her claims. To fill this gap in Tallman’s account, I propose a view on the badness of death that I call ‘Deprivationism’. I argue that this view explains why death is bad for those who die, and that it has some advantages over Tallman’s complete lives view in the context of scarce resource allocation. Finally, I consider some objections to the relevance of Deprivationism to resource allocation, and offer my responses. (shrink)

In infectious disease outbreaks, demand for certain medical resources often outstrips supply, necessitating frameworks to fairly allocate these now-scarce resources. Vaccination, meanwhile, can oft...

In the Canadian health care system, the Government is responsible for allocating scarce resources in a fair and equitable manner. A proposal to implement managed care as a method of reimbursing physicians in Alberta, Canada, needs careful ethical consideration, because physicians are not well prepared, and should not be asked, to make the resulting difficult allocation decisions. The Government must continue to be held responsible for ensuring that all citizens have equal access to necessary medical services, and we (...) must find ways to encourage the public to become more involved in deciding how resources are best allocated. Health professionals other than physicians must take an interest and enter into this debate. (shrink)

The novel COVID-19 pandemic has placed medical triage decision-making in the spotlight. As life-saving ventilators become scarce, clinicians are being forced to allocate scarce resources in even the wealthiest countries. The pervasiveness of air travel and high rate of transmission has caused this pandemic to spread swiftly throughout the world. Ethical triage decisions are commonly based on the utilitarian approach of maximising total benefits and life expectancy. We present triage guidelines from Italy, USA and the UK as well (...) as the Jewish ethical prospective on medical triage. The Jewish tradition also recognises the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making. (shrink)

The COVID-19 pandemic brought unprecedented strain on hospitals and, in particular, critical care settings. Early in the pandemic, multiple plans were developed to ration ventilators in anticipatio...

This article considers the possible relation between the idea of parity and some past work on the allocation of scarce resources. Parity of value is first connected with the idea of some goods being irrelevant in interpersonal comparisons. The notion of moral parity is introduced to describe the recognition that people who are moral equals (even when they are not on a par in terms of value) as not substitutable. The relation between a Separability Test and nonsubstitutability of (...) persons is considered. These ideas are then used to discuss various cases in which one must choose to whom to provide medical assistance, including whether and when to distinguish morally between a disabled and a nondisabled person. (shrink)

Although rationing of scarce health-care resources is inevitable in clinical practice, there is still limited and scattered information about how physicians perceive and execute this bedside rationing (BSR) and how it can be performed in an ethically fair way. This review gives a systematic overview on physicians’ perspectives on influences, strategies, and consequences of health-care rationing. Relevant references as identified by systematically screening major electronic databases and manuscript references were synthesized by thematic analysis. Retrieved studies focused on themes that (...) fell under three major headings: (i) conditions and influences of BSR, (ii) strategies of BSR, and (iii) consequences of BSR. The range of themes indicates that physicians’ rationing behavior is highly variable, strongly influenced by context-related factors, and consists mainly of implicit rationing strategies. Torn between patient advocacy and the obligation to contain costs, physicians experience various role conflicts. The development of explicit rationing strategies seems necessary to avoid arbitrary BSR and allow a fair allocation of health-care resources. (shrink)

In this article, I first compare positions I have taken in the past and those taken by Peter Singer on how the allocation of life-saving resources should be affected by the aggregation of expected quality of life, quantity of life, and need, both within the life of a person and across persons . I then reexamine the specific issue of whether and why differences in expected years of life and quality of life that a scarce resource can (...) provide a disabled and a nondisabled person should affect our allocation decisions. I attend to how the use of the veil of ignorance bears on this issue and also how the conclusions I reach differ in certain ways from my past positions. (shrink)

The COVID‐19 pandemic has raised important universal public health challenges. Conceiving ethical responses to these challenges is a public health imperative but must take context into account. This is particularly important in sub‐Saharan Africa (SSA). In this paper, we examine how some of the ethical recommendations offered so far in high‐income countries might appear from a SSA perspective. We also reflect on some of the key ethical challenges raised by the COVID‐19 pandemic in low‐income countries suffering from chronic shortages in (...) health care resources, and chronic high morbidity and mortality from non‐COVID‐19 causes. A parallel is drawn between the distribution of severity of COVID‐19 disease and the classic “Fortune at the bottom of the pyramid” model that is relevant in SSA. Focusing allocation of resources during COVID‐19 on the ‘thick’ part of the pyramid in Low‐to‐Middle Income Countries (LMICs) could be ethically justified on utilitarian and social justice grounds, since it prioritizes a large number of persons who have been economically and socially marginalized. During the pandemic, importing allocation frameworks focused on the apex of the pyramid from the global north may therefore not always be appropriate. In a post‐COVID‐19 world, we need to think strategically about how health care systems can be financed and structured to ensure broad access to adequate health care for all who need it. The root problems underlying health inequity, exposed by COVID‐19, must be addressed, not just to prepare for the next pandemic, but to care for people in resource poor settings in non‐pandemic times. (shrink)

COVID‐19 caused an imbalance between medical resources and the number of patients in Türkiye like in many countries. There was not pandemic‐triage system, and this situation led to decision making based on experience, intuition, and judgment of allocation of scarce resources. The research explains the guiding criteria that healthcare professionals used to prioritize the distribution of scarce medical resources during the COVID‐19 pandemic. The criteria preferred by 928 healthcare professionals were evaluated when preventive measures for COVID‐19 were (...) reduced and so the number of cases increased rapidly. The results indicate that Turkish healthcare professionals largely support the utilitarian approach, which focuses on medical benefit in pandemic. The main problem was that some criteria not approved in COVID‐19 triage guidelines were considered important by healthcare professionals. These criteria, which cause discrimination by preventing the provision of fair and equal medical care to patients, are a prominent issue in the study. (shrink)

Scarce resource allocation policies vary across the United States. Little is known about regional variation in resource allocation protocols and variation in their application. We sought to evaluat...

In a much cited phrase in the famous English ‘Child B’ case, Mr Justice Laws intimated that in life and death cases of scarce resources it is not sufficient for health care decision-makers to ‘toll the bell of tight resources’: they must also explain the system of priorities they are using. Although overturned in the Court of Appeal, the important question remains of the extent to which health-care decision-makers have a duty to give reasons for their decisions. In this (...) paper, I examine the philosophical foundations of the legal obligation to give reasons in English law. Why are judges sometimes supportive of the imposition of a duty to give reasons and sometimes not? What is it about the context of life and death health care allocation problems that makes it unsuitable in their view for such a duty; and is this stance justified? What is it to give a reason for a decision? I examine Frederick Schauer’s account of reason-giving in terms of generalisation and commitment and I suggest that it provides an overstated account of what giving a reason commits one to. I go on to examine an idea of judicial creation: that where value judgements are “inexpressible” there is a strong reason not to impose a duty to give reasons on to public bodies. The strongest case for a duty to give reasons is in terms of the value of respect for citizens. I argue that there is nothing in the very nature of reason-giving that ought to preclude the imposition of such a duty in this context, but concede that there is a serious danger of legalism that could result in a hamstringing of health care decision-making. It is up to judges and lawyers to seek to avoid this danger. (shrink)

In this paper, I argue that the ‘modified youngest first’ principle provides a morally appropriate criterion for making decisions regarding the distribution of scarce medical resources, and that it is morally preferable to the simple ‘youngest first’ principle. Based on the complete lives system's goal of maximizing complete lives rather than individual life episodes, I argue that essential to the value we see in complete lives is the first person value attributed by the experiencer of that life. For a (...) life to be ‘complete’ or ‘incomplete,’ the subject of that life must be able to understand the concept of a complete life, to have started goals and projects, and to know what it would be for that life to be complete. As the very young are not able to do this, it can reasonably be said that their characteristically human lives have not yet begun, giving those accepting a complete lives approach good reason to accept the modified youngest first principle over a simple ‘youngest first’ approach. (shrink)

This response to a commentary on “Allocation of scarce resources, disability, and parity” considers whether a difference that would be morally relevant when choosing which of two people to save retains its relevance if this would affect other people’s chances of being saved.

A patient’s age serves as a very useful guide to physicians in deciding what disease manifestations to anticipate, what treatment to offer for certain conditions, and how to prepare for possible emergencies. In the context of the COVID-19 pandemic, determining treatment options on the basis of a patient’s chronological age can easily give rise to unjustified discrimination. This is of particular significance in situations where the allocation of scarce critical care resources could have a direct impact on who (...) will live and who will die. This paper examines the fairness of recommendations contained in resource allocation guidelines in the Philippines that have implications for the way elderly patients could be treated or excluded from some forms of critical care treatment in the context of the ongoing Corona virus emergency. (shrink)

Objective To compare the perspectives of medical students in the preclinical and clinical phases of medical training on the issue of rationing scarce medical resources in times of crisis. Methods Questionnaire-based cross-sectional study. Results A total of 201 participants took part in the study, with 100 participants in the preclinical phase group, and 101 in the clinical phase group. A multivariable analysis found that just 14.9% (n = 34) of the clinical phase students were willing to give a short-supplied (...) blood unit to the first-arrived patient to the emergency department when more patients are expected compared to 63.9% in the preclinical group (n = 62) ( p < 0.001, OR = 0.75 95% CI: 0.029−0.192). Seventy-four percent (n = 74) of the clinical phase students were found to be willing to remove a patient from a respirator to allocate it to an ill child compared to 35.7% (n = 35) in the preclinical phase group ( p < 0.001, OR = 4.168 95% CI: 1.931−8.998). Of the clinical phase group, 46.6% (n = 41) were willing to allocate a short supplied flu medicine to a patient with poor prognosis compared to 57.7% (n = 56) in the preclinical phase group ( p = 0.04, OR = 0.457 95% CI: 0.216−0.966). Conclusion Clinical exposure during training may affect the way medical students make ethical decisions, independent of age, sex, as well as marital and parental status. (shrink)

Park and Davies (2024) discuss the allocation of scarce resources during a pandemic—primarily ventilators and healthcare staff—and assess the ethical concepts that are used in arguments for and aga...

In lieu of an abstract, here is a brief excerpt of the content:Catholic Social Teaching and the Allocation of Scarce ResourcesJohn Langan S.J. (bio)I shall approach the issue of justice in the allocation of scarce resources from the viewpoint of Catholic social teaching, as developed over the last century. This teaching is found primarily in the social encyclicals issued by popes from Leo XIII (1878–1903) to John Paul II (1978- ), but also in the pastoral letters (...) of the various bishops’ conferences, especially in the United States and in Latin America. These documents, which enjoy a high standing in Catholic teaching but which are not taken as binding in all their particulars, form part of a tradition of moral and social theorizing that a contemporary American would regard as “communitarian.” On social questions, this tradition also has shown itself to be historicist in that it is capable of modifying itself in significant ways in response to changing political and economic situations. It normally approaches issues from a universalist perspective, though it has shifted from a preoccupation with the concerns of the industrial societies of Europe to an advocacy of much of the reform agenda of the Third World.Rooted in classical and biblical sources and modified in the course of the last [End Page 401] century to include a principled acceptance of religious freedom, of human rights, and of democratic political institutions, the Catholic social tradition proposes a number of ideas that can serve as the basis for significant criticism of currently dominant liberal modes of organizing and interpreting advanced industrial societies. These ideas do not form a countertheory to liberalism so much as they indicate ways in which a religious organization that includes both hierarchical and egalitarian elements in its structure and that has both moral commitments and practical responsibilities with regard to health care can draw on its intellectual resources to develop alternative strategies for the reform of health care.I shall survey six ideas that figure prominently in Catholic social teaching and that are relevant to the allocation of scare resources in American health care. Space constraints require that I present them in a very condensed fashion, without tracing the complex development they have undergone in the internal Catholic debate or subjecting them to much criticism.First, Catholic social teaching, especially the great encyclical of John XXIII, Pacem In Terris (PT 1963), affirms the full range of human rights recognized in such modern documents as the Universal Declaration of Human Rights (1949). In addition to the civil and political rights enumerated in the Bill of Rights added to the original U.S. Constitution (1791), the Universal Declaration includes rights “to life, to bodily integrity, and to the means which are suitable for the proper development of life; these are primarily food, clothing, shelter, rest, medical care, and finally the necessary social services” (PT 11). Catholic social teaching has not committed itself to one particular way of institutionalizing these rights, but it effectively endorses the comprehensive West European welfare states that the Christian Democratic political parties helped to construct in the period after 1945.Second, Catholic social teaching has accorded a central organizing role to the notion of the common good, the realization of which “is the whole reason for the existence of civil authorities” (PT 54). The common good, however, is not to be understood as identical with the interest or the power of the state; rather, it “embraces the sum total of those conditions of social living whereby men are enabled to achieve their own integral perfection more fully and more easily” (PT 58; quoting Mater et Magistra). John XXIII is particularly anxious to affirm that the common good cannot be construed so as to exclude some groups or to violate the rights of individuals and that it must include both physical and spiritual goods (PT 55–61). The notion of the common good has both an inherent attractiveness and a vagueness that cries out for specification and clarification. But in the contemporary situation it serves to remind us that “individual citizens and intermediate groups are obliged to make their specific contributions to the common welfare” (PT 53).Third, while an insistence on the primacy of the common good and on the [End Page 402... (shrink)

Using a fair allocation approach, this paper identifies and examines important concerns arising from the Philippines’ COVID‐19 response while focusing on difficulties encountered by various sectors in gaining fair access to needed societal resources. The effectiveness of different response measures is anchored on addressing inequities that have permeated Philippine society for a long time. Since most measures that are in place as part of the COVID‐19 response are meant to be temporary, these are unable to resolve the inequities that (...) have led to the magnitude of morbidity and mortality associated with the pandemic. These cannot improve the country’s readiness to deal with pandemics and other emergencies in the future.Transition to a new normal recognizes the possibility that other infectious diseases could come and endanger our health security. Our pandemic experiences are proving that having an egalitarian society will serve the interests not only of disadvantaged sectors but also of everybody else, including the privileged. Response measures should thus take the opportunity to promote equity by giving importance to the concerns of the underprivileged and vulnerable while giving preference to initiatives that can be sustained beyond the period of the current pandemic. (shrink)

Severe staffing shortages have emerged as a prominent threat to maintaining usual standards of care during the COVID-2019 pandemic. In dire settings of crisis capacity, healthcare systems assume the ethical duty to maximise aggregate population-level benefit of existing resources. To this end, existing plans for rationing mechanical ventilators and intensive care unit beds in crisis capacity focus on selecting individual patients who are most likely to survive and prioritising these patients to receive scarce resources. However, staffing capacity is conceptually (...) different from availability of these types of discrete resources, and the existing strategy of identifying and prioritising patients with the best prognosis cannot be readily adapted to fit this real-world scenario. We propose that two alternative approaches to staffing resource allocation offer a better conceptual fit: (1)prioritise the worst off: restrict access to acute care services and hospital admission for patients at relatively low clinical risk and (2)prioritise staff interventions with high near-term value: universally restrict selected interventions and treatments that require substantial staff time and/or energy but offer minimal near-term patient benefit. These strategies—while potentially resulting in care that deviates from usual standards–support the goal of maximising the aggregate benefit of scarce resources in crisis capacity settings triggered by staffing shortages. This ethical framework offers a foundation to support institutional leaders in developing operationalisable crisis capacity policies that promote fairness and support healthcare workers. (shrink)

This article is about the potential justification for deploying some form of affirmative action (AA) in the context of healthcare, and in particular in relation to the pandemic. We call this Affirmative Action in healthcare Resource Allocation (AARA). Specifically, we aim to investigate whether the rationale and justifications for using prioritization policies based on race in education and employment apply in a healthcare setting, and in particular to the COVID-19 pandemic. We concentrate in this article on vaccines and (...) ventilators because these are both highly scarce resources in the pandemic, and there has been a need to develop policies for allocating them. However, as will become clear, the ethical considerations relating to them may diverge. We first set out two rationales for AAs and what they might entail in a healthcare setting. We then consider some disanalogies between AA and AARA, as well as the different implications of AARA for allocating ventilators as opposed to vaccines. Finally, we consider some of the practical ways in which AARA could be implemented, and conclude by responding to some key objections. (shrink)

Summary Background The principle of maximization, which roughly means that we should save more lives and more years of life, is usually taken for granted by the health community. This principle is even more forceful in crises like the COVID-19 pandemic, where we have scarce resources which can be allocated only to some patients. However, the standard consequentialist version of this principle can be challenging particularly when we have to reallocate a resource that has already been given to (...) a patient. -/- Methodology Engaging in thought experiments, conceptual analysis, providing counterexamples, and appealing to moral intuitions, we challenge the standard consequentialist version of the maximization principle and make a case for adopting an alternative deontological version. -/- Discussion In certain cases, the standard consequentialist version of the maximization principle is shown to yield intuitively immoral results. The deontological version of this principle is preferable because it can retain the merits of the standard consequentialist version without falling prey to its problems. -/- Conclusion Compared to the standard consequentialist version, the deontological version of the maximization principle can better guide the ethical decisions of the health community, even in cases where we face a scarcity of resources. (shrink)

Issues of resource allocationResource allocation, triageTriage, and rationingRationing decisions are common in the context of disasters and public healthPublic health emergencies, such as pandemics. However, to date, the majorityMajority of the literature focuses on an adult population with very little attention given to a pediatric population or to a population that may be mixed: adults and children. Furthermore, decisions of rationingRationing scarce resources do not only occur during disasters and other wide-scale emergencies. Such decisions are commonplace in (...) pediatric organ transplantation and can creep into areas of experimental medicine, such as xenotransplantation. This chapter explicates differences between pediatric and adult triageTriage decisions by first looking at the trifold issues of resource allocationResource allocation, triageTriage, and rationingRationing decisions mainly in the context of a disaster situation or public healthPublic health emergency. However, the issues of pediatric organ transplantation, health disparitiesHealth disparities, and experimental medicine will also be covered. (shrink)

The authors report and comment on student reactions to a clinical example of moral choice in the microallocation of scarce resources. Four patients require dialysis simultaneously, but only one kidney machine is available. What moral, as opposed to clinical, criteria are available to determine who should have priority?

Various models have been used to “emplot” our collective experience of the COVID-19 pandemic, including the epidemiological curve, threshold models, and narrative. Drawing on a threshold model that was designed to frame resource-allocation decisions in clinical care, I offer an ethical justification for taking caring responsibilities into consideration in such decisions during pandemics. My basic argument is that we should prioritize the survival of patients with caring responsibilities for similar reasons we should prioritize the survival of healthcare professionals. (...) More generally, the pandemic reveals the fundamental importance of informal care and affords an opportunity to raise questions of justice relating to it. (shrink)

The literature on the ethics of machine learning in healthcare contains a great deal of work on algorithmic fairness. But a focus on fairness has not been matched with sufficient attention to the relationship between machine learning and distributive justice in healthcare. A significant number of clinical prediction models have been developed which could be used to inform the allocation of scarce healthcare resources. As such, philosophical theories of distributive justice are relevant when considering the ethics of their (...) design and implementation. This paper considers the relationship between machine learning in healthcare and distributive justice with a focus on four aspects of algorithmic design and deployment: the choice of target variable, the model's socio-technical context, the choice of input variables, and the membership of the datasets that models are trained and validated on. Procedural recommendations for how these considerations should be accounted for in the design and implementation of such models follow. (shrink)

As resources in health care are scarce, managers and clinicians must make difficult choices about what to fund and what not to fund. At the level of a regional health authority, limited approaches to aid decision makers in shifting resources across major service portfolios exist. A participatory action research project was conducted in the Calgary Health Region. Through five phases of action, including observation of senior management meetings, as well as two sets of one-on-one interviews and two focus groups, (...) an approach to priority setting at the macro level within the health region was developed and implemented. The resulting macro level approach builds on the program budgeting and marginal analysis (PBMA) framework. Using a multi-disciplinary expert panel, about $45M (CAN) was released for the 2002/03 fiscal year and made available for re-allocation to service growth areas and the deficit. Important qualitative themes from the managers and clinicians informed both process development and refinement. The approach developed here not only facilitated re-allocation of resources, but also drew in both clinicians and managers to work together on this challenging task. The approach is pragmatic, transparent and evidence based, and should have application elsewhere. (shrink)

Four ethical values — maximizing benefits, treating equally, promoting and rewarding instrumental value, and giving priority to the worst off — yield six specific recommendations for allocating medical resources in the Covid-19 pandemic: maximize benefits; prioritize health workers; do not allocate on a first-come, first-served basis; be responsive to evidence; recognize research participation; and apply the same principles to all Covid-19 and non–Covid-19 patients.

In healthcare, a tension sometimes arises between the injunction to do as much good as possible with scarce resources and the injunction to rescue identifiable individuals in immediate peril, regardless of cost (the “Rule of Rescue”). This tension can generate serious ethical and political difficulties for public policy makers faced with making explicit decisions about the public funding of controversial health technologies, such as costly new cancer drugs. In this paper we explore the appropriate role of the Rule of (...) Rescue in public resource allocation decisions by health technology funding advisory bodies such as the National Institute for Health and Clinical Excellence. We consider practical approaches to operationalising the Rule of Rescue from Australia and the UK before examining the relevance of individual moral imperatives to public policy making. We conclude that that whilst public policy makers in a humane society should facilitate exceptional departures from a cost effectiveness norm in clinical decisions about identified individuals, it is not so obvious that they should, as a matter of national public policy, exempt any one group of unidentified individuals within society from the rules of opportunity cost at the expense of all others. (shrink)

Patients with insufficient financial resources place physicians in a conflict of interest between the patients' needs and the financial interests of the physician, other patients, and society. Not only must physicians act ethically, but they must avoid liability for violating their legal duties to their patients. The traditional rules of contract and malpractice law that govern the patient-physician relationship do not provide satisfactory guidelines. Better answers are found in the rules of fiduciary law, but only with regard to direct conflicts (...) between patients and physicians and only at the risk of reducing patient access to care. Certain types of legislative action can resolve these conflicts by altering the traditional legal rules, but care must be taken to preserve patient-physician trust, which the legal rules were designed to enhance. (shrink)

Ruth Macklin argued that dignity is nothing more than respect for persons or their autonomy. During the COVID-19 pandemic, difficult decisions are being made about the allocation of scarce resources. Respect for autonomy cannot justify rationing decisions. Justice can be invoked to justify rationing. However, this leaves an uncomfortable tension between the principles. Dignity is not a useless concept because it is able to account for why we respect autonomy and for why it can be legitimate to override (...) autonomy in times of critical care resource shortages. Dignity affirms the worth of the human individual as a meaning-making embodied subject, who is always in relationship to others, the world, time, and transcendence, and who realizes their dignity through their moral behaviour. Such an understanding means people should be helped to make morally right decisions about their own treatment, which may include forgoing potentially beneficial treatment for the good of others. Respect for dignity does not require fulfilling the morally wrong choices of one who insists on treatment at the expense of others. Dignity also protects the discretion of clinicians to make decisions appropriate to their competence by prohibiting the application of broad-based criteria such as age. (shrink)

The question of how to allocate scarce medical resources has become an important public policy issue in recent decades. Cost-Utility Analysis is the most commonly used method for determining the allocation of these resources, but this book counters the argument that overcoming its inherent imbalances is simply a question of implementing methodological changes. The Economics of Resource-Allocation in Healthcare represents the first comprehensive analysis of equity weighting in health care resource allocation that offers a (...) fundamental critique of its basic framework. It offers a heterodox account of health economics, putting the discourse on economic evaluation into it broader socio-political context. Such an approach broadens the debate on fairness in health economics and ties it in with deeper rooted problems in moral philosophy. Ultimately, this interdisciplinary study calls for the adoption of a fundamentally different paradigm to address the distribution of scarce medical resources. This book will be of interest to policy makers, health care professionals or Post-Graduate students looking to broaden their understanding of the economics of the healthcare system. (shrink)

This book addresses the problem of how to make democratically-legitimate public policy on issues of contentious bioethical debate. It focuses on ethical contests about research and their legitimate resolution, while addressing questions of political legitimacy. How should states make public policy on issues where there is ethical disagreement, not only about appropriate outcomes, but even what values are at stake? What constitutes justified, democratic policy in such conflicted domains? Case studies from Canada and Australia demonstrate that two countries sharing historical (...) and institutional characteristics can reach different policy responses. This book is of interest to policymakers, bioethicists, and philosophers, and will deepen our understanding of the interactions between large-scale socio-political forces and detailed policy problems in bioethics. (shrink)

A new word has recently entered the British medical vocabulary. What it stands for is neither a disease nor a cure. At least, it is not a cure for a disease in the medical sense. But it could, perhaps, be thought of as an intended cure for a medicosociological disease: namely that of haphazard or otherwise ethically inappropriate allocation of scarce medical resources. What I have in mind is the term ‘QALY’, which is an acronym standing for quality (...) adjusted life year. Just what this means and what it is intended to do I shall explain in due course. Let me first, however, set the scene. (shrink)

The COVID-19 pandemic has forced clinicians, policy-makers and the public to wrestle with stark choices about who should receive potentially life-saving interventions such as ventilators, ICU beds and dialysis machines if demand overwhelms capacity. Many allocation schemes face the question of whether to consider age. We offer two underdiscussed arguments for prioritising younger patients in allocation policies, which are grounded in prudence and fairness rather than purely in maximising benefits: prioritising one’s younger self for lifesaving treatments is prudent (...) from an individual perspective, and prioritising younger patients works to narrow health disparities by giving priority to patients at risk of dying earlier in life, who are more likely to be subject to systemic disadvantage. We then identify some confusions in recent arguments against considering age. (shrink)

When hospitals face surges of patients with COVID-19, fair allocation of scarce medical resources remains a challenge. Scarcity has at times encompassed not only hospital and intensive care unit beds—often reflecting staffing shortages—but also therapies and intensive treatments. Safe, highly effective COVID-19 vaccines have been free and widely available since mid-2021, yet many Americans remain unvaccinated by choice. Should their decision to forgo vaccination be considered when allocating scarce resources? Some have suggested it should, while others disagree. (...) We offer a framework for evaluating when it is ethical and briefly discuss its legality in American law. (shrink)

For a long time discussion about scarce health care resource allocation was limited to allocation of medical resources, with the paradigmatic case being kidney transplants. However, a narrow focus on medical resources prevents us from seeing that there are many cases-- perhaps the majority-- in which less dramatic but equally important issues of rationing occur. The allocation of nurses' time is one such issue.

The purpose of this paper is to discuss the accountability for reasonableness and its four conditions. This explains the priority setting and resource allocation for scarce resources. In this article it is discussed that how the scarce resources in a developing country like Pakistan be allocated in health care. This is explained with the help of case scenario.

The Infectious Diseases Act entered into force officially on 14 November 2018 in Bangladesh. The Act is designed to raise awareness of, prevent, control, and eradicate infectious or communicable diseases to address public health emergencies and reduce health risks. A novel coronavirus disease was first identified in Bangladesh on 8 March 2020, and the Ministry of Health and Family Welfare issued a gazette on 23 March, listing COVID-19 as an infectious disease and addressing COVID-19 as a public health emergency. The (...) gazette empowers the government to monitor the spread of infection. Despite there being an infrastructure of research ethics committees in almost all hospitals in Bangladesh, a lack of such committees in the clinical setting often forces healthcare professionals to allocate scarce healthcare resources to the task. These personnel are often either influenced by materialistic matters or guided by the emergency policies, without reaching a consensus on how to allocate scarce resources in times of need, especially in the time of the COVID-19 pandemic. Ethical dilemmas often arise when a number of patients with COVID-19, especially in poor and middle-class areas, are denied care while elites are prioritized to receive such scarce resources. Resource allocation in healthcare during the COVID-19 pandemic in Bangladesh appears to be unethical and in direct conflict with the biomedical principles of non-maleficence and procedural justice. The findings of this study suggest that the Act needs substantive changes in the stipulation of policy directing hospitals in the provision of resource allocation framework. Furthermore, parliament should produce guidance outlining how to successfully implement the law with the aim of protecting public health in times of emergency, especially the COVID-19 pandemic. (shrink)

When the demand for a medical resource exceeds the supply, we have a problem of scarcity. There are many instantiations of this issue. The time of health care providers during an emergency, organs for transplantation, a bed in an intensive care unit, and a slot in a research protocol can all be scarce resources. Interest in this issue has been renewed because of recent concerns about a pandemic and shortages of vaccines. In each of these cases there is (...) a problem of distributive justice. If the resource is lifesaving, then the question is especially poignant: Who shall be saved when not all can be? This was the problem faced by Sir Dr. Colenso Ridgeon in Bernard Shaw's 'The Doctor's Dilemma', a play first performed a century ago. (shrink)