In the recent literature across philosophy, medicine and public health policy, many influential arguments have been put forward to support the use of randomization procedures to allocate scarce life-saving resources. In this paper, I provide a systematic categorization and a critical evaluation of these arguments. I shall argue that those arguments justify using RAND to allocate SLSR in fewer cases than their proponents maintain and that the relevant decision-makers should typically allocate SLSR directly to the individuals with the strongest claims (...) to these resources rather than use RAND to allocate such resources. (shrink)

In the first wave of the COVID-19 pandemic, healthcare workers in some countries were forced to make distressing triaging decisions about which individual patients should receive potentially life-saving treatment. Much of the ethical discussion prompted by the pandemic has concerned which moral principles should ground our response to these individual triage questions. In this paper we aim to broaden the scope of this discussion by considering the ethics of broader structural allocation decisions raised by the COVID-19 pandemic. More specifically, we (...) consider how nations ought to distribute a scarce life-saving resource across healthcare regions in a public health emergency, particularly in view of regional differences in projected need and existing capacity. We call this the regional triage question. Using the case study of ventilators in the COVID-19 pandemic, we show how the moral frameworks that we might adopt in response to individual triage decisions do not translate straightforwardly to this regional-level triage question. Having outlined what we take to be a plausible egalitarian approach to the regional triage question, we go on to propose a novel way of operationalising the ‘save the most lives’ principle in this context. We claim that the latter principle ought to take some precedence in the regional triage question, but also note important limitations to the extent of the influence that it should have in regional allocation decisions. (shrink)

A queue‐jumping argument concludes that some course of action is impermissible by likening it to the presumptively impermissible act of jumping a queue. Arguments of this sort may be found in a disparate range of contexts and in support of policies favoured by both left and right. Examples include arguments against private education and private health care but also arguments against accommodations for learning disabilities, refugee resettlement, and birthright citizenship. We infer that, although queue‐jumping arguments are strictly analogies, they constitute (...) a sufficiently distinct class of arguments to justify their separate treatment. The paper proposes an argumentation scheme for queue‐jumping arguments and demonstrates its applicability to some existing arguments of this type. (shrink)

Fair allocation of scarce healthcare resources has been much studied within philosophy and bioethics, but analysis has focused on a narrow range of cases. The Covid-19 pandemic provided significant new challenges, making powerfully visible the extent to which health systems can be fragile, and how scarcities within crucial elements of interlinked care pathways can lead to cascading failures. Health system resilience, while previously a key topic in global health, can now be seen to be a vital concern in high-income countries (...) too. Unfortunately, mainstream philosophical approaches to the ethics of rationing and prioritisation provide little guidance for these new problems of scarcity. Indeed, the cascading failures were arguably exacerbated by earlier attempts to make health systems leaner and more efficient. This paper argues that health systems should move from simple and atomistic approaches to measuring effectiveness to approaches that are holistic both in focusing on performance at the level of the health system as a whole, and also in incorporating a wider range of ethical concerns in thinking about what makes a health system good. (shrink)

Zusammenfassung Die Einführung von Impfprogrammen bei einer immun-naiven Bevölkerung in Europa spielte eine wesentliche Rolle für den Verlauf der COVID-19 Pandemie. Vor allem zu Beginn waren Impfprogramme jedoch durch einen Mangel an Impfdosen gekennzeichnet. Bei einer Zuteilung geringer Dosen an Krankenhäuser in der Initialphase, waren Krankenhausleitungen durch eine möglichst faire Verteilung dieser Impfdosen unter dem Krankenhauspersonal gefordert. Der Beitrag dokumentiert das Vorgehen im ersten Quartal 2021 an fünf deutschen Krankenhäusern in einem Klinikverbund. Wir berichten über einen regel-konsequentialistischen Ansatz auf der (...) strategischen Ebene, der durch einen egalitären Ansatz auf der taktischen Ebene ergänzt wurde. Es erfolgte die ethisch begleitete Entwicklung eines hybriden Schemas unter Verzicht auf klassische Verteilungsmuster, wie dem First-Come-First-Served Schema. Die Kombination des strategischen regel-konsequentialistischen Schemas mit egalitärer Verteilung auf der taktischen Ebene war vollständig funktional und unter den Mitarbeitenden des Klinikverbundes gut akzeptiert. In Zeiten von Pandemien und knappen Ressourcen spielt die Verteilung von medizinischen Gütern für die Funktionalität medizinischer Einrichtungen eine wichtige Rolle. Die Verteilung von Gütern, die durch den Staat bereitgestellt werden, bedarf jedoch einer Anpassung an die jeweiligen Gegebenheiten der Institutionen. Dieser Bericht zeigt eine mögliche Option für die Verteilung knapper Impfdosen auf, die nicht nur unter Personen der Zielgruppe verteilt wurden, sondern die auch die Funktionalität der medizinischen Versorgung in einer Region sicherte. (shrink)

The National Health Service (NHS) in the UK is currently facing a significant waiting list backlog following the disruption of the COVID-19 pandemic, with millions of patients waiting for elective surgical procedures. Effective treatment prioritisation has been identified as a key element of addressing this backlog, with NHS England's delivery plan highlighting the importance of ensuring that those with ‘the clinically most urgent conditions are diagnosed and treated most rapidly’. Indeed, we describe how the current clinical guidance on prioritisation issued (...) by The Federation of Surgical Specialty Associations serves this aim. However, whilst there are strong reasons to prioritise elective surgery in accordance with clinical need, we argue that it would be a mistake to assume that prioritisation in accordance with clinical need requires only a clinical or scientific judgement. The understanding of clinical need that we choose to employ in a prioritisation system will be grounded by some key ethical judgements. Moreover, we may also have to make trade-offs between addressing clinical need, safeguarding equality, and achieving other benefits. As the UK faces up to the backlog, it is important that surgical prioritisation guidelines enshrine a broad range of values that we believe ought to determine access to care in non-emergency circumstances. Our analysis suggests that the current approach to prioritisation is not a sufficiently nuanced way of balancing the different moral values that are operative in this context. (shrink)

The COVID-19 pandemic put a large burden on many healthcare systems, causing fears about resource scarcity and triage. Several COVID-19 guidelines included age as an explicit factor and practices of both triage and ‘anticipatory triage’ likely limited access to hospital care for elderly patients, especially those in care homes. To ensure the legitimacy of triage guidelines, which affect the public, it is important to engage the public’s moral intuitions. Our study aimed to explore general public views in the UK on (...) the role of age, and related factors like frailty and quality of life, in triage during the COVID-19 pandemic. We held online deliberative workshops with members of the general public. Participants were guided through a deliberative process to maximise eliciting informed and considered preferences. Participants generally accepted the need for triage but strongly rejected ‘fair innings’ and ‘life projects’ principles as justifications for age-based allocation. They were also wary of the ‘maximise life-years’ principle, preferring to maximise the number of lives rather than life years saved. Although they did not arrive at a unified recommendation of one principle, a concern for three core principles and values eventually emerged: equality, efficiency and vulnerability. While these remain difficult to fully respect at once, they captured a considered, multifaceted consensus: utilitarian considerations of efficiency should be tempered with a concern for equality and vulnerability. This ‘triad’ of ethical principles may be a useful structure to guide ethical deliberation as societies negotiate the conflicting ethical demands of triage. (shrink)

Waiting lists are a standard approach to managing excess demand in elective health care. While waiting times are an important policy issue, the ethical validity of the first come, first served (FCFS) principle as such is rarely questioned. Presenting a psychiatric day hospital where all eligible patients have roughly equal claims as a case study, we criticize the reflex use of FCFS for allocation of elective psychiatric care, consider conditions under which this may not be the optimal strategy, and discuss (...) alternatives. We conclude that in our example prioritizing more recent referrals (last come, first served [LCFS]) makes more sense, clinically and ethically. Where several referrals arrive (near-)simultaneously under LCFS, we propose that a higher level of scrutiny be applied to detect possible good reasons for prioritizing one of them. We believe that our observations can be applied to other health care settings that share relevant characteristics with our case. (shrink)

This essay discusses the ethical challenges and dilemmas in allocating scarce medical resources during the COVID-19 pandemic, using the German legislative process as a starting point. It is guided by the right to non-discrimination of people with disability and generally contrasts utilitarian and rights-based principles of allocation. Three approaches that were suggested in the German discussion, are presented, the lottery principle, the first come first served principle and the probability to survive principle. Arguments in favour and against each principle are (...) discussed. The focus is on the utilitarian probability to survive principle, which was adopted in German legislation in 2022, and its discriminatory potential against people with disability. The essay suggests ways to mitigate the concerns of discrimination related to the probability to survive principle. It concludes that resolving the triage dilemma requires a balanced approach between utilitarian and rights-based concerns, which promotes both maximising the number of patients surviving and the right not to be discriminated against and be treated equally. It calls for a further debate on how many ethical values such as equity, fairness and non-discrimination we are willing to sacrifice for a higher number of survivors and when we are willing to sacrifice survivors to secure ethical values. (shrink)