Ethical resource allocation in pandemics

In a pandemic setting, excess demand on ordinary healthcare resources and services

is expected. Access to ventilators, vaccines, antivirals, and other necessary resources

in hospitals and in the community will need to be prioritized. Clinical criteria is

insufficient in priority setting. Value - based decisions in a pandemic setting need to be

made.

The ethical goals of resource allocation or priority setting are legitimacy, fairness, and

equity. Research indicates the following parameters are acceptable to the public in

resource allocation decisions: need, survivability, and social value. Need takes into

consideration not just the sickest person; persons who are responsible for caring for

others may take priority. Social utility of individuals (healthcare workers, critical

infrastructure workers, etc.) who are sick is a key concept in prioritizing. Establishing

transparent priority setting criteria in advance of a crisis is another key concept, to

enforce fairness and public trust in priority setting. There is public consensus that

priority should be given to healthcare workers, whose social utility value is high; and

whose risk assumption is high. Research indicates there is public consensus that

children should be given second priority after healthcare workers. The WHO (2008)

emphasizes that priority setting is typically based on the principle of efficiency (saving

most lives), which prioritizes protecting individuals responsible for caring the sick, and

is not necessarily based on prioritizing resources for the “sickest”. The principle of

equity is typically a failed principle in priority setting because equitable distribution of

resources may not achieve the goals of public safety in pandemic situations.

In the WHO report “Ethical Considerations in Developing a Public Health Response to

Pandemic Influenza”, the elements of a fair process for setting priorities are described

(http://www.who.int/csr/resources/publications/WHO_CDS_EPR_GIP_2007_2c.pdf):

- Publicity: The process, including the rationale for setting priorities, must be made

public and transparent; consultations and public hearings should be held. Publicity and

involvement of key stakeholders are particularly important in con¬texts where policy

and programmatic decisions occur in a multi-actor environment and affect large parts

of the population.

- Relevance: The affected stakeholders must view as relevant the reasons, principles

and evidence that form the basis of the rationale for fair decision-making on priorities.

- Reversibility and appeals mechanisms: In the case of new evidence and arguments,

the process must allow for reconsidering and revising decisions. It must allow for an

appeals process that protects those who have legitimate reasons for being an

exception to the adopted ropolicies.

-Enforcement or regulation: There must be a mechanism in place that ensures that the

previous three conditions are met.

Source: http://ukhealthcare.uky.edu/uploadedfiles/UKpandemicethicsresource.pdf