This section will discuss the ethical arguments around scarce resource distribution with a focus on various scenarios that may arise in the COVID-19 pandemic. Briefly, we consider two broad forms of resource allocation: macroallocation and microallocation. Macroallocation determine how a particular society allocates funding and issues policies across areas such as defense, education, infrastructure, public health, and health care. It focuses on the healthcare needs of a population as an aggregate, with distributive justice as the underlying principle. In contrast, microallocation relies on context and individual judgment in the distribution of scarce supplies, such as ventilators and face masks. It uses ethical principles such as those discussed in Principles of Allocation to make decisions among individual cases. In short, macroallocation decisions affect statistical and hypothetical lives, while microallocation decisions affect identified lives.
In this section, we first consider issues of macroallocation involving resource distribution between hospitals, states, and nations that may have differential access to resources or ability to produce them independently. We then turn to various scenarios involving microallocation of personal protective equipment (PPE), testing for SARS-CoV-2, and ventilators, all of which may be preferentially directed to certain individuals.
It is never easy for clinicians to allocate resources, yet we do it all the time. We make choices as to how we spend our time, attention, and energy, the expertise of our specialists and subspecialists, and who we believe can be saved with or without heroic measures. The unfortunate reality is that any scarcity of resources is exacerbated in a time of crisis. Resources are more limited in a time of crisis, requiring decisions that would not ordinarily be made. The scarcity questions that arise in a crisis may be the same as in non-crisis situations but to a greater degree (e.g. patients competing for limited clinician attention), or they may be different in kind (e.g. ventilators supply for sick patients is not entertained in normal times). Furthermore, there are unique features of the COVID-19 pandemic that exacerbate resource shortages. Many of the masks, testing kits, and ventilators in short supply are produced on a regional or even global scale and are affected by stockpiling, supply chain issues, and politics. Since the pandemic is predicted to be limited to a relatively short time period, governments and suppliers face the economic question of whether it is worthwhile to buy or produce more resources if the investment or infrastructure will not be needed in the future.
It is important to note that any discussion of resource allocation is incomplete without the appropriate historical, political, and geographical context. A truly just distribution would allocate resources according to some agreed-upon criterion, such as need or potential improvement in well-being and would strike a fair bargain between various countries and regions. In reality, resources are not distributed this way. Economic and political interests, in the context of long-standing imbalances of power, drive preferential access in times of scarcity. We therefore concern ourselves here with the non- ideal world in which we live; this is the world in which allocation decisions operate in times of crisis.
Macroallocation centers on the larger dimension of healthcare needs across a society or multiple societies. Disparities in critical infrastructure and government functions are exacerbated in a pandemic in a way that raises questions of key moral importance. For instance, the rapidly increasing number of confirmed COVID-19 cases in countries like Morocco, Nigeria, and Armenia raises concerns about how each country will manage the impact COVID-19 will have on its health systems. Because the COVID-19 pandemic has already demonstrated the need for a highly interdependent global response, a widespread outbreak in low-to-middle income countries (LMIC) will not only impact their populations and health systems, but will also exacerbate problems with the interdigitated health and economic systems of the world. Thus, macroallocation considers how scarce resources can be provided to safeguard the well-being of countries with more constraints and fewer resources.
Macroallocation places particular emphasis on priority setting across a population, with a focus on distributive justice as the underlying moral aim. Distributive justice is concerned with the equal distribution of goods across or between societies. Principles of distributive justice, such as various forms of Egalitarianism, are “therefore best thought of as providing moral guidance for the political processes and structures that affect the distribution of benefits and burdens in societies” (SEP). In practice, these processes are operationalized by governments or the relevant authorities in the hopes of achieving the statistically best outcome with the underlying principles as guidance. It is critical to note that these principles do not exist on their own but should be consistent with societal norms and values to be effective.
In response to COVID-19, a number of organizations and institutions have established recommendations about priority-setting in various contexts. Some of these focus on the international setting. The Center for Disaster Philanthropy (CDP) addresses questions regarding the distribution of general funding, such as philanthropic and high-GDP country support for low- and middle-income countries (LMICs) as they try to afford critical treatments. USAid states that funds directed to the WHO will help governments in developing countries prepare for large-scale testing, implement public health emergency plans, and equip rapid response teams. What are the roles of high-income governments in supporting LMICs during a global pandemic, if the outcome would be orders of magnitude worse in LMICs? How much funding should well-off countries divert from their own domestic efforts to fight the spread of disease overseas?
There are also questions of differential access. The WHO has explored the question of whether countries will have differential access to a vaccine in the early days after development, before it is made in large enough quantities for all. Such actions can spark global controversies, as evidenced by reports of President Donald Trump’s attempt to buy exclusive rights to a German vaccine (BMJ). Thus, we must question: Who will receive vaccines first? Does that distributive strategy prioritize fairness or power differentials?
Domestically, the United States Congress passed legislation that allocates funding for state and local health departments, pharmaceutical interventions, the NIH, and hospital reimbursement, as well as non-health needs such as educational and economic stabilization. These relative contributions to various sectors entail value-laden choices about how to prioritize, for instance, economic recovery or early disease control.
Individual values can influence how participants in macroallocation agreements view proceedings. The relative prioritization of values differs around the world. Unaddressed differences in ethical perspectives amongst participants can cause conflict and a failure to successfully implement policies. Macroallocation and the equitable distribution of resources therefore depends on a contract between stakeholders - to negotiate in good faith and seek to understand each other’s priorities and perspectives - in agree on fair resource allocation resources.
What are our responsibilities within our own country? Should we feel responsible for the rest of the world? If so, how could we be of assistance?
Here we present three situations necessitating microallocation, all of which seek to obtain more of the resource, use less of it, or stretch available resources further. These allocation questions involve direct trade-offs and require choosing who from among various identifiable individuals will receive scarce resources. At a certain point, the available resources, no matter how agilely managed, will dissipate. How should these cases be managed? In much of the conversation here, we draw from the Principles of Allocation.
As the case burden of COVID-19 continues to grow, supply shortages of PPE such as gowns, gloves, and masks have become increasingly acute. Governments and hospitals worldwide must ration scarce PPE reserves. In some cases, healthcare workers are being trained to reuse PPE, improvise their own gear, and sterilize or re-sanitize masks after completing shifts. If resource shortages continue to worsen, these individuals may be faced with a harrowing decision - do they work with substandard PPE, without PPE, or not at all? These decisions directly impact their own well-being as well as that of their patients.
Where there is still adequate PPE, who should have priority access? Many sources, including WHO, Strategic National Stockpile, Ranney et al., 2020 believe that frontline healthcare workers and first responders should have priority . These individuals assume the critical mantle of treating patients and keeping the medical infrastructure intact and arguably the most instrumental value during a pandemic (Emanuel et al. 2020). A utilitarian approach also supports conservation of PPE for these personnel. Medical personnel, if infected, may transmit the virus and infect others. If they fall ill or succumb to the disease, many patients - both with and without COVID-19 - will receive insufficient care with increases in morbidity and mortality. Prioritizing PPE for frontline workers mitigates their own health risks and avoids asking them to treat patients with COVID-19 at a potentially tremendous personal cost.
There is some debate over how far the definition of “frontline” worker should extend. For example, Partners Healthcare and Beth Israel Lahey Health, both in Boston, have mandated that all hospital personnel wear surgical masks on the premises, regardless of whether they directly interact with COVID-19 patients. One argument in support of this approach is that various staff who do not have direct patient care responsibilities (e.g. hospital cleaning staff) perform vital services in a pandemic by keeping hospitals running smoothly. Outside of the hospital, there is disagreement over whether “essential” workers such as grocery store employees should wear PPE. The CDC has stated that the general public, including supermarket employees, do not need to wear masks, though various locales in Massachusetts and elsewhere have encouraged all grocery store workers to do so. This is in part a disagreement over who constitutes “essential” personnel and how far available resources can be stretched.
More on the allocation of PPE can be found in the supplemental materials here.
Do healthcare providers who lack adequate access to PPE have an obligation to care for patients?
Should governments compel individuals and businesses to donate PPE to “frontline” efforts? What ethical principles or other circumstances might factor into that decision?
Demand for COVID-19 diagnostic testing outpaces supply in many countries. Worldwide, efforts to mass-produce test kits and augment testing volume have been stymied by shortages in collection swabs and testing reagents, as well as limitations in laboratory processing capabilities. In the U.S., testing has also been handicapped by multiple missteps in the initial government response, including costly technical and regulatory delays in deploying working tests. Confronted with significant testing shortages, hospitals and public health agencies have devised guidelines stipulating which individuals merit access to testing over others (examples: WHO, CDC, Beth Israel Lahey Health, Brigham/Mass General - access credentials required). These guidelines aim to use available testing kits in the most efficacious manner by triaging testing.
Two groups consistently emerge as top priorities for testing: patients with COVID-19 symptoms who require hospitalization and healthcare workers who are directly caring for them. Patients hospitalized for presumptive COVID-19 tend to be the sickest and often have significant medical comorbidities. From a prioritarian perspective, these individuals should be tested first because they face the highest risk of morbidity and mortality from the disease and are thus considered to be the worst off (Emanuel et al. 2020). Ascertaining a diagnosis is paramount in guiding the next steps of care, whereas it is far less critical for someone with mild disease recovering at home. According to many guidelines, members of the general public who are asymptomatic or who exhibit mild symptoms are lower priority for testing (CDC), particularly in areas where existing testing capacity is inundated by cases from hospitalized patients. In these settings, it has become difficult to test suspected cases of mild community-acquired COVID-19, to preemptively test close contacts, or to monitor local spread of the virus, all of which are important public health goals (Emanuel et al., 2020). The current approach to prioritize testing of high-acuity patients over lower-acuity ones achieves certain valuable goals at the expense of others. These tradeoffs are inherent in resource allocation and highlight the importance of developing broad testing.
A different rationale guides preferential testing of frontline healthcare workers, who are at elevated risk of contracting and transmitting the virus yet have instrumental value in the response to a pandemic. Therefore, they require frequent testing in order to function effectively and avoid viral spread. Some have argued that this approach should extend personnel such as first responders, who have assumed similarly indispensable duties and risks during the pandemic. It is less clear how to optimally balance the testing of hospitalized patients with that of essential personnel in the setting of test kit shortages. If many hospitalized patients remain untested, this may affect appropriate triaging of care and cause unnecessary PPE use. Alternatively, if many essential personnel remain untested, they may be unnecessarily sidelined by mandatory quarantining or serve as vectors for infection, exacerbating healthcare and first responder staffing shortages.
It is unclear how consistently testing allocation schemes are being observed. In the U.S., a number of prominent figures, including members of Congress and NBA players, have been tested for COVID-19 despite being asymptomatic. One could argue that these individuals possess instrumental value (such as leadership or media influence during a pandemic) or associated risk factors (such as essential travel and extensive close contacts) that necessitate testing. However, if “instrumental value” is broadened to this extent, this could privilege the interests of the powerful and well-connected over those of the general public.
Given the current scarcity of diagnostic tests, communities will likely have differential access to early testing. How might disparities in access to early tests shape how the pandemic affects these communities in the long run?
At the crux of resource allocation in a pandemic is who has access to lifesaving interventions when they are in limited supply. This reality is most acute when it comes to life-saving interventions such as ventilators and extra-corporeal membrane oxygenation (ECMO), as allocation decisions directly save certain lives at the expense of others. The current pandemic casts these choices into the sharpest relief. In what follows, we review several situations that could conceivably arise during the current pandemic, in which the allocation of life-saving interventions is necessary. Our goal is not to reach conclusions about the “right” choices to make in these cases. Rather, by highlighting various allocation issues that may arise, we hope to prepare readers for the possibility that they will be called on to make those decisions.
There is a critical need for ventilators in the current pandemic. Why is that the case? It is a result of two key features of the disease: patients with COVID-19 require intubation early and for long periods of time. Usually, when a patient’s respiratory status is declining, there is a stepwise approach that gradually increases the invasiveness of the interventions used. Several intermediate steps in that pathway - the use of nebulizer treatments, humidified oxygen therapy (e.g., high-flow nasal cannula) and BIPAP machines - are felt to be unsafe, as they are aerosolize SARS-CoV-2 particles, placing healthcare workers at risk. Many hospitals therefore skip directly to intubation of any and all patients with COVID-19 in respiratory distress. Patients requiring mechanical ventilation need that support for an unusually long period of time - an average of two weeks, in contrast to the clinical course for most, in which many patients’ clinical status improves after several days. Thus, ventilators cannot be repurposed easily or after short periods.
A number of important ethical questions arise around the question of who receives a ventilator. First, should ventilators be shared? New York has started to share or ‘split’ ventilators between patients. The downside to this approach is that a ventilator can only be set to one setting, whereas patients usually require highly individualized settings fine-tuned by trial-and-error in the ICU to deliver optimal pulmonary support. The aim is to find patients who require similar settings, so both receive appropriate car, however, this practice has not been rigorously tested in humans and is primarily a theoretical idea. The advantage of this approach is that it may save more lives. The disadvantage is that a larger number of patients may have worse outcomes if they all receive treatments that are less efficacious compared to typical standard of care. Do the benefits of this approach outweigh the risks? The principle of non-maleficence suggests that clinicians should avoid harming patients. A corollary is that care is inappropriate if provided below a certain accepted standard. Non-maleficence opposes the splitting of ventilators, as it means that some patients - who might survive if they were the only one on a ventilator - might experience worse outcomes. This value is in tension with the idea of beneficence, which supports any attempt to save more lives. How should this tension be resolved? A common strategy is to turn to consequentialist approaches such as QALYs or DALYs to see which strategy has the greater expected net benefit. Other approaches argue that certain moral principles, such as nonmaleficence, carry greater moral weight given their relative centrality in the medical profession’s canon (e.g. ‘do no harm’ supersedes an affirmative obligation to heal).
Second, should some patients not be considered for a ventilator? Some patients may arrive extremely sick, and a triage decision is made that they have a low likelihood of survival due to comorbidities or clinical status. Once ICU-level care with a ventilator is offered, it is difficult to revoke. Withdrawing life-sustaining care is typically done at a patient or family’s request, or for medical futility. In contrast, during a pandemic, rationing may require withdrawal of care in order to provide ventilators to patients who are given higher priority, a reason foreign to many front-line clinicians (Truog et al, NEJM 2020) This raises the question of when to initiate that decision. If it is apparent to ED clinicians that a particular patient, if intubated, would be removed from a ventilator in the near future because they are of lower priority, should they offer mechanical ventilation? If some patients will not be offered the option of aggressive care, when is that decision made, and who conveys it? These questions are likely to arise as an increasing number of precipitously ill patients arrive at the hospital.
Third, who gets a ventilator? If there are not enough ventilators for all patients, some patients will receive them, while others will not. This will require tough decisions as to which patients may be saved. These allocation decisions can be made with a variety of ethical frameworks and principles. An excellent approach to thinking through allocation decisions is provided above (Principles of Allocation). While these decisions are often not standardized across institutions and may reflect local context, the principles on which these decisions are based are felt to be universal.
Finally, who decides who gets a ventilator? There are various options. Some have suggested that clinicians intimately involved in the care of the patients in question should make those decisions - an approach known as ‘bedside rationing.’ Such decisions can be fraught with bias and emotional entanglements with patients (e.g. ‘this patient reminds me of so-and-so’), and can inflict a toll on clinical staff. In an effort to standardize allocation decisions and obviate the distress to frontline staff, there is a move for hospital committees to make allocation decisions (Truog, et al NEJM 2020). Hospital committees consisting of doctors, various other clinical staff, and administrator, would meet and review cases. One clear advantage of this approach is that it allows for involvement of various stakeholder views including that of ‘community representatives.’ It may obviate the distress of bedside clinicians but may also make them feel that life-or- death decisions about their patients have been taken out of their hands.
If you had to allocate ventilator spots to a panel of patients, how would you decide? What criteria would you consider important, and why?
When have you seen life-saving care rationed in the hospital on clinical rotations?
On April 7, 2020, the Commonwealth of Massachusetts released Crisis Standards of Care recommendations. These guidelines are primarily grounded in utilitarian principles: they seek to save the most lives and life-years. They do so by using clinical scoring criteria to identify patients most likely to benefit from critical care services.
In the days after the release of these recommendations, public servants and providers taking a more prioritarian view pushed back, arguing that, "giving priority to those without serious comorbid illness, will disproportionately discriminate against vulnerable populations by serving as a proxy for race, ethnicity, immigration status, serious mental illness, and other sociodemographic characteristics."
Some of these concerns are addressed in this video recording of Surgical Grand Rounds at April 15, 2020, at the Beth Israel Deaconess Medical Center. What do you make of Dr. Kristin Raven’s assessment at 44:16 that “unfortunately in a time of crisis, we can’t also make up for those longstanding disparities in care... certainly an important thing that needs to be taken into consideration after crisis standards”?
In addition to Massachusetts, several other states. have released Crisis Standards of Care (CSC) guidelines for the allocation of scarce critical care resources. Most guidelines use the Sequential Organ Failure Assessment (SOFA) scores to predict short-term survival and maximize lives saved. However, different states have adopted different stances on whether to account for patient co-morbidities as a measurement of incorporating long-term survival into the consideration. In the future, it is important that physicians, wherever they practice, have an easy way to access and understand their own state guidelines, since another surge could arise before a vaccine is found. This information will also be useful for future pandemics. A table in our supplementary section compares and contrasts four state guidelines: Maryland, Pennsylvania, New York, and Colorado. For more information about how these state guidelines compare in terms of outcomes, please visit the paper published in medRXiv: https://www.medrxiv.org/content/10.1101/2020.05.16.20098657v1. Of note, Massachussetts's guidelines was originally similar to that of Pennsylvania, but has now been addended extensively.