Fair allocation of scarce medical resources in the time of Covid-19

These ethical values ​​— maximizing benefits, treating as equals, enhancing and rewarding automated value, and prioritizing the worst — yield six specific recommendations for allocating medical resources in the Covid-19 pandemic: maximizing benefits; give priority to health workers; not allocate on a first-come-first-served basis; respond to evidence; Getting to know the research participation; And apply the same principles to all Covid-19 patients and non-Covid-19 patients.

Recommendation 1: In the context of a pandemic, the value of maximizing benefits is most important.3,26,28,29,31-33 This value reflects the importance of responsible stewardship of resources: it is hard to justify asking health care workers and the public to take risks and make sacrifices if the promise that their efforts will save and prolong lives is an illusion.29 The priority for limited resources should aim to save the most lives and maximize improvements in people’s lifespan after treatment. Saving more lives and more years of life is a value agreed upon by expert reports.26,28,29 It is consistent with both utilitarian moral perspectives that emphasize demographic outcomes and with non-utilitarian views that emphasize the ultimate value of every human life.34 There are many reasonable ways to strike a balance between saving more lives and saving more years of life30; Any balance chosen between life and years of life must be applied consistently.

Time and information limitations in the Covid-19 pandemic make it justifiable to prioritize maximizing the number of patients who survive treatment with a reasonable life expectancy and to consider maximizing improvements in longevity as a secondary goal. The latter becomes important only in comparing patients with similar survival prospects. Also, limited time and information during an emergency situation advises against integrating future quality of life for patients and high quality-adjusted life-years into maximizing benefits. Doing so would require time-consuming information gathering and would pose ethical and legal problems.28,34 However, encouraging all patients, especially those facing the prospect of intensive care, to document in their advance care guidance what future quality of life they may consider acceptable and when to refuse ventilators or other life-sustaining interventions may be appropriate.

Activating the value of maximizing benefits means that patients who could recover if treated give priority to those who are unlikely to recover even if treated and those who are likely to recover without treatment. Since critically ill young patients often include many patients but can recover from treatment, this operation also has the effect of prioritizing those who are worse off in that they are at risk of dying at an earlier age and are not at risk of dying. whole life.25,29,30

Because maximizing benefits is critical in the event of a pandemic, we believe that removing the patient from a ventilator or ICU bed to provide them to others in need is also warranted and that patients should be made aware of this possibility upon admission.3,28,29,33,35 To be sure, withdrawing ventilators or ICU support from patients who arrived early to save those with a better prognosis would be extremely distressing for clinicians — and some clinicians may refuse to do so. However, many guidelines agree that the decision to withdraw scarce resources to save others is not an act of murder and does not require patient consent.26,28,29,33,35 We agree with these guidelines as an ethical thing to do.26 Initially, customizing beds and ventilators according to the value of maximizing benefits can help reduce the need for withdrawal.

Recommendation 2: Critical interventions for Covid-19 — testing, personal protective equipment, intensive care beds, ventilators, therapies, and vaccines — must go first to frontline health care workers and others who care for patients and who keep critical infrastructure working, especially Workers who face a high risk of infection and whose training makes replacement difficult.27 These workers should be prioritized not because they are somehow more meritorious, but because of their tool value: they are essential to the pandemic response.27,28 If doctors and nurses are powerless, all patients – not just those with Covid-19 – will suffer greater deaths and years of life lost. Whether health workers who need ventilators will be able to return to work is uncertain, but prioritizing ventilators recognizes their assumption of the high-risk work of saving others, and may also discourage absenteeism.28,36 Priority for critical workers should not be abused by prioritizing wealthy, famous or politically influential people over first responders and medical staff — as the test has already done.37 Such violations will undermine confidence in the allocation framework.

Recommendation 3: For patients with similar prognosis, equality should be invoked and run through random assignment, such as a lottery, rather than a first-come, first-served assignment process. First-come, first-served resources are used in resources such as transplantable kidneys, where scarcity is long-term and patients can survive without the scarce resources. On the contrary, coronavirus treatments meet the urgent need, which means that a first-come, first-served approach would unfairly benefit patients who live close to health facilities. Distributing first-come, first-served medicines or vaccines will encourage crowding and even violence during a period when social distancing is critical. Finally, first-come, first-served approaches mean that people who happen to fall ill later, possibly due to strict adherence to recommended public health measures, are excluded from treatment, deteriorating outcomes without improving equity.33 In the face of time pressures and limited information, randomization is also preferable to attempting to make accurate predictive judgments within a group of roughly similar patients.

Recommendation 4: Guidelines for prioritizing should vary by intervention and should respond to changing scientific evidence. For example, younger patients should not be prioritized for Covid-19 vaccines, which prevent rather than treat the disease, or for empirical prophylaxis after or before exposure. Covid-19 outcomes have been much worse in the elderly and those with chronic conditions.8 Invoking the value of maximizing saving lives justifies older people’s prioritization of vaccines right behind health care workers and first responders. If the vaccine supply is insufficient for patients in the highest-risk groups—those over 60 years of age or with coexisting conditions—equality supports the use of random selection, such as a lottery, to allocate a vaccine.24,28 The invocation of mechanistic value justifies prioritizing vaccines for younger patients only if epidemiological modeling shows that this would be the best way to reduce the spread of the virus and the risks to others.

Epidemiological modeling is even more important in prioritizing coronavirus testing. Federal guidance currently prioritizes health care workers and older patients,38 But reserving some tests for public health monitoring (as some states are doing) could improve knowledge about Covid-19 transmission and help researchers target other treatments to maximize benefits.39

Conversely, intensive care beds and ventilators are curative, not preventative. Patients who need it face life-threatening conditions. Maximizing benefits requires consideration of prognosis – how long a patient is likely to live if treated – which may mean prioritizing younger patients and those with fewer coexisting conditions. This is in line with Italian guidelines that would likely give higher priority to intensive care access for younger patients who are severely ill than for elderly patients.3,4 Determining the allocation of maximizing benefits to antiviral drugs and other experimental therapies, which are likely to be most effective in patients with serious but not critical condition, will be based on scientific evidence. These treatments may achieve the greatest benefit if they are allocated preferentially to patients with bad breath.

Recommendation 5: People who are involved in research to demonstrate the safety and efficacy of vaccines and treatments should receive some priority for Covid-19 interventions. Their assumption of risk while participating in research helps patients in the future, and they should be rewarded for this contribution. These rewards will also encourage other patients to participate in clinical trials. However, research participation should act as a tie-breaking factor among patients with similar prognosis.

Recommendation 6: There should be no difference in allocating scarce resources between patients with Covid-19 and those with other medical conditions. If the Covid-19 pandemic leads to an absolute rarity, this rarity will affect all patients, including those with heart failure, cancer and other serious and life-threatening conditions that require immediate medical attention. The equitable allocation of resources that prioritizes the value of maximizing benefits applies to all patients who need the resources. For example, a doctor with an allergy who is in anaphylactic shock and needs life-saving intubation and ventilator support, should have priority over Covid-19 patients who are not frontline health care workers.

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