Disclaimer: The views expressed are that of the individual author. All rights are reserved to the original authors of the materials consulted, which are identified in the footnotes below.
By Danielle Mitchell
the ICU ward at the NHS Nightingale Hospital in the North-East
Introduction
One of the myriad of concerns plaguing the NHS during the COVID-19 pandemic is the issue of resource allocation. This is a problem which presents itself in a number of guises, from how vaccines ought to be distributed, to who has a stronger claim to medical interventions. Of particular concern is the rationing of ventilators. When the need for ventilation arises, it is usually a matter of life-or-death, and deciding who gets use of the limited ventilators available raises serious ethical dilemmas. Although some may argue differently,[1] there is no way to determine allocation scenarios based purely on medical need; ‘responding to [medical] facts requires ethical, value-based judgments’.[2] The focus of this article will be on allocation principles deriving from egalitarianism and utilitarianism, ultimately advocating for a combined approach.
Egalitarianism
The NHS is founded on the idea of egalitarianism, meaning that every person should be treated equally.[3] In a healthcare context, this requires that every person should have equal opportunity to access the treatment they need, regardless of any other factors such as the probability of a positive outcome, or subsequent quality of life.
According to this view, one option for allocating limited resources would be a lottery. This would give each patient an equal chance of obtaining the treatment they require. Since ‘each person’s desire to stay alive should be regarded as of the same importance and deserving the same respect as that of anyone else’, this approach gains much support.[4] Moreover, it offers the benefits of simplicity and the ability to resist corruption, since additional factors are not relevant to selection.[5] However, as noted by Stein, a lottery ignores a plethora of factors that are arguably central to allocation decisions.[6] For example, one person might gain 50 years of life if ventilated while another might remain unconscious even if ventilated; surely the vast difference in benefits attainable from ventilation ought to be a relevant consideration here, though it would not be factored in under a lottery system.
An alternative egalitarian allocation system would be ‘first come, first served’. This is the approach generally taken by the NHS in relation to ventilation. It allows doctors to utilise the available resources until they are gone, without having to make choices between patients. However, whilst this approach may not seem to value one patient over another, in practice it permits a number of irrelevant factors to influence allocation. As argued by Daniels, this method fails to consider the various factors affecting when a person seeks treatment; it favours those who gain knowledge of their condition first, who can afford to take time off work to seek treatment, who do not have children to care for, etc. [7] Resultantly, the system is open to claims of discrimination, therefore failing as a valid ethical basis for resource allocation.
Thus, while in principle an egalitarian approach seems desirable, the inability to consider a variety of arguably relevant factors makes the system unjust in practice. Consequently, an alternative approach which allows for the consideration of other factors, might produce preferable outcomes.
Utilitarianism
One such alternative is utilitarianism; according to this view, decisions that produce ‘the greatest good for the greatest number’ ought to be taken. Whilst the NHS is theoretically centred on the idea of equality, in practice utilitarian considerations often come into play.
There are numerous approaches which come under the banner of utilitarianism. Firstly, the approach which saves the most lives. For instance, if a single ventilator could be used to save five lives in succession, in the same time that it could be used to save just one life, then utilitarianism dictates that you save the five lives. Alternatively, allocation based on saving the most years of life is also utilitarian in nature. Here, ventilating someone who would gain 30 years is preferable to ventilating someone who would gain only one year. This embodies the idea that younger people deserve to be given priority because they have had less opportunity to live out their lives; however it is not based solely on treating the youngest patient first. If an 80-year-old would gain 10 years from ventilation, and a 10-year-old would gain only one year, then utilitarianism would dictate that you ventilate the 80-year-old, even though they have already enjoyed 70 more years than the 10-year-old. Consequently, utilitarianism can advance the desire to save the youngest first, as they will generally have a greater life expectancy, without arbitrarily discriminating on the basis of age.
Quality of life considerations are also relevant to utilitarian decisions. This is the notion that priority should be given to those who would have a ‘better’ quality of life following treatment. Such an idea is embodied in the quality-adjusted life year (QALY) judgments made by Clinical Commissioning Groups, which determine whether treatment should be given on the basis of expected life years gained, discounting years due to poor quality of life.[8] However, the ethical acceptability of such an objective consideration is contested. [9] There is significant potential for discrimination, particularly as it relates to disability and age; when compared to a younger or non-disabled person, an older or disabled person would likely be deemed to be expected to have a worse quality of life and therefore not be chosen for ventilation.[10] Thus, this approach may constitute indirect discrimination.[11]
Moreover, prioritising those who are socially valuable may also be relevant. This might mean, for example, prioritising healthcare workers who would be able to return to work and consequently save more lives. This approach has been incorporated into the COVID-19 vaccine distribution, which includes health and social care workers in the high priority groups, aiming to ensure that they do not contract COVID-19 and are able to keep working.[12] Since these people are being given priority in order to benefit the wider community, it is argued that this approach is successful in recognising the moral value of every person, not just those who are prioritised for treatment.[13] Nevertheless, there are problems with this approach since debates on who is considered socially valuable in a given situation will inevitably arise.
Conclusion
Both the egalitarian and utilitarian approaches offer some appeal in answering the problem of resource allocation. However, due to the issues highlighted, neither camp provides an adequate response to limited resources. Consequently, a combined approach might be more suitable. Whilst ‘combining principles into systems increases complexity and controversy, [it] is inevitable if allocations are to incorporate the complexity of our moral values’. [14] Such an approach might look like that of ‘precautionary utilitarianism’, as advocated by Savulescu et al.[15] This would entail allocating resources to patients with significantly higher life expectancies or chances of survival, thereby largely acting for the greatest good, but adopting a lottery-style approach where differences between patients are insignificant in order to avoid arbitrary discrimination. Such a system would require extensive guidance on which factors are to be considered, their relative weight, and how to conclude where differences in cases are minimal. Nonetheless, it is maintained that a complex system that balances a range of considerations is necessary to achieve an ethically acceptable outcome.
Image: https://www.theguardian.com/society/2020/may/28/porters-story-hospital-reminds-me-disaster-movie-covid-19
Source: https://www.theguardian.com/society/2020/may/28/porters-story-hospital-reminds-me-disaster-movie-covid-19 [1] Michael Langford, ‘Who Should get the Kidney Machine?’ (1992) 18 J Med Ethics 12. [2] Govind Persad et al, ‘Principles for Allocation of Scarce Medical Interventions’ (2009) 373 The Lancet 423, 423. [3] Julian Savulescu et al, ‘Equality or Utility? Ethics and Law of Rationing Ventilators’ (2020) 125 BJA 10, 10. [4] John Harris, The Value of Life: An Introduction to Medical Ethics (Routledge 1985) 101. [5] (n2) 423. [6] Mark Stein, ‘The Distribution of Life-Saving Medical Resources: Equality, Life-Expectancy, and choice Behind the Veil’ (2002) 19 Social Philosophy and Policy 212. [7] Norman Daniels, ‘Fair Process in Patient Selection for Antiretroviral Treatment in WHO’s Goal of 3 by 5’ (2005) 366 The Lancet 169, 170. [8] Shaun Pattinson, Medical Law and Ethics (5th edn, Sweet and Maxwell 2017) 45. [9] Julia Savulescu et al, ‘An Ethical Algorithm for Rationing Life-Sustaining Treatment During the COVID-19 Pandemic’ (2020) 125 BJA 253, 257. [10] See John Harris, ‘Double Jeopardy and the Veil of Ignorance – A Reply’ (1995) 21 J Med Ethics 151. [11] (n3) 13. [12] Joint Committee on Vaccination and Immunisation (6 January 2021) <https://www.gov.uk/government/publications/priority-groups-for-coronavirus-covid-19-vaccination-advice-from-the-jcvi-30-december-2020/joint-committee-on-vaccination-and-immunisation-advice-on-priority-groups-for-covid-19-vaccination-30-december-2020#vaccine-priority-groups-advice-on-30-december-2020> accessed 15 February 2021. [13] (n2) 426. [14] (n2) 426. [15] (n3) 13.
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