The COVID-19 pandemic has been overwhelming public health-care systems around the world. With demand exceeding the availability of medical resources in several regions, hospitals have been forced to invoke triage. To ensure that this difficult task proceeds in a fair and organised manner, governments scrambled experts to draft triage guidelines under enormous time pressure. Although there are similarities between the documents, they vary considerably in how much weight their respective authors place on the different criteria that they propose. Since most (...) of the recommendations do not come with ethical justifications, analysing them requires that one traces back these criteria to their underlying theories of distributive justice. In the literature, COVID-19 triage has been portrayed as a value conflict solely between utilitarian and egalitarian elements. While these two accounts are indeed the main antipodes, I shall show that in fact all four classic theories of distributive justice are involved: utilitarianism, egalitarianism, libertarianism, and communitarianism. Detecting these in the documents and classifying the suggested criteria accordingly enables one to understand the balancing between the different approaches to distributive justice—which is crucial for both managing the current pandemic and in preparation for the next global health crisis. (shrink)

The two target articles in this issue draw an important connection between disability bioethics and geriatric bioethics. Dominic JC Wilkinson makes a pragmatic case for using frailty as a fa...

In "Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical?," Wilkinson (2021) argues that the use of frailty scores in ICU triage does not necessarily involve discrimination on the basis of disability. In support of this argument, he claims, “it is not the disability per se that the score is measuring – rather it is the underlying physiological and physical vulnerability." While we appreciate the attention Wilkinson explicitly pays to disability in this piece, we find the (...) distinction between disability and underlying vulnerability untenable both theoretically and practically. In this peer commentary, we begin with a brief overview of research in philosophy of disability concerning the meaning of the concept itself. We argue that this research demonstrates that many forms of disability do not involve underlying vulnerabilities, and, furthermore, that Wilkinson equivocates between "disability" understood as a medical category vs. "disability" understood as a feature of lived experience. We reject Wilkinson’s distinction on these grounds and offer further considerations to avoid disability discrimination in emergency and crisis standards of care contexts. (shrink)

This paper examines the ethical implications of healthcare resource allocation during the first wave of COVID-19 in Italy, from 21 February to 31 May 2020, with a focus on the utilitarian principles that prioritized age-based resource allocation. By comparing this approach to an ontological personalist bioethics framework, the study aims to offer a more equitable strategy for healthcare allocation applicable to any pandemic. Data from governmental reports, healthcare policies, and ethical guidelines were analyzed, revealing that Italy’s utilitarian method led to (...) significant ethical concerns, particularly regarding age discrimination. In contrast, the ontological personalist approach emphasizes the dignity and intrinsic worth of each individual, irrespective of age or health condition. The findings demonstrate that this personalist framework fosters a more balanced and fair allocation of resources, respecting human dignity and offering a universally applicable alternative to age-based prioritization. Ultimately, the study suggests that integrating ontological personalist principles into healthcare policies could enhance ethical decision-making in future pandemics, ensuring that resource allocation practices align more closely with human rights and individual dignity. (shrink)

We read with interest Dominic Wilkinson’s article “Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical?” on the utility of the Clinical Frailty Score in...

Sufficientarians face a problem of arbitrariness: why place a sufficiency threshold at any particular point? One response is to seek universal goods to justify a threshold. However, this faces difficulties (despite sincere efforts) by either being too low, or failing to accommodate individuals with significant cognitive disabilities. Some sufficientarians have appealed to individuals’ subjective evaluations of their lives. I build on this idea, considering another individualized threshold: ‘tolerability’. I respond to some traditional challenges to individualistic approaches to justice: ‘expensive’ tastes, (...) and adaptive preferences. Finally, I end by offering some suggestions about how this relates to policymaking. (shrink)

This article provides a critical comparative analysis of the substantive and procedural values and ethical concepts articulated in guidelines for allocating scarce resources in the COVID-19 pandemic. We identified 21 local and national guidelines written in English, Spanish, German and French; applicable to specific and identifiable jurisdictions; and providing guidance to clinicians for decision making when allocating critical care resources during the COVID-19 pandemic. US guidelines were not included, as these had recently been reviewed elsewhere. Information was extracted from each (...) guideline on: 1) the development process; 2) the presence and nature of ethical, medical and social criteria for allocating critical care resources; and 3) the membership of and decision-making procedure of any triage committees. Results of our analysis show the majority appealed primarily to consequentialist reasoning in making allocation decisions, tempered by a largely pluralistic approach to other substantive and procedural values and ethical concepts. Medical and social criteria included medical need, co-morbidities, prognosis, age, disability and other factors, with a focus on seemingly objective medical criteria. There was little or no guidance on how to reconcile competing criteria, and little attention to internal contradictions within individual guidelines. Our analysis reveals the challenges in developing sound ethical guidance for allocating scarce medical resources, highlighting problems in operationalising ethical concepts and principles, divergence between guidelines, unresolved contradictions within the same guideline, and use of naïve objectivism in employing widely used medical criteria for allocating ICU resources. (shrink)

In response to the COVID-19 pandemic, countries around the world developed ICU triaging guidelines. One important point of convergence was an explicit commitment to...

I am grateful to the commentators for their deep engagement with the issues raised in my paper. They raise a number of important challenges and questions about the use of frailty i...

Disability has been traditionally understood as a medical condition. However, people with disabilities have claimed in recent decades for a dephatologized social model of disability—i.e. the functi...

During periods of scarcity, or the fear of it, many health systems create or adopt triage protocols to determine how to best allocate limited resources. Interest in such protocols has become acute...

While triage protocols share a common goal—maximizing life by selecting patients who would most benefit from critical care—there are many variations in the selection of criterion to respond to situ...

We welcome and applaud Wilkinson’s impressive and subtle exploration of the possible considerations of frailty as a criterion for triage in times of pandemic-dr...

Frailty is a state of increased vulnerability to poor resolution of homeostasis after a stressor event. Frailty is most frequently assessed in the old using the Clinical Frailty Scale (CSF) which ranks frailty from 1 to 9. This assessment typically takes less than one minute and is not validated in patients with learning difficulties or those under 65 years old. The National Institute for Health and Care Excellence (NICE) developed guidelines that use “frailty” as one of the priority-setting criteria for (...) how scarce, but potentially lifesaving, health care resources should be allocated during the COVID-19 pandemic. Similar guidelines have been developed elsewhere. This paper discusses the ethical implications of such rationing and argues that this is an unproven and ethically problematic form of health care rationing. It specifically discusses: (1) how the frailty ascription becomes a self-fulfilling prophecy, (2) the problematic use of “frailty” in COVID-19 “triage,” (3) the circularity of the link between age and frailty, (4) indirect discrimination because of the use of a seemingly neutral criterion in health care rationing, and (5) the difficult link between comorbidities and frailty. It is found that there was no research into the use of global frailty scores as a criterion for access to acute treatment before January 2020 and so it is concerning how readily frailty scoring has been adopted to ration access to potentially lifesaving treatments. Existing gerontological frailty scoring systems have not been developed for this purpose, and repurposing them creates significant ethical issues. (shrink)