Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and (...) disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles. (shrink)

Background: Studies from Western countries show that doctors working in neonatal intensive care units find withdrawal of treatment to be their most difficult ethical dilemma. There is less knowledge of how this is experienced in other economic, cultural, religious and educational contexts.Objectives: To explore and describe how Indian doctors experience ethical dilemmas concerning the withdrawal of treatment among critically sick and/or premature neonates.Method: Qualitative data from interviews was analysed according to Giorgi's phenomenological approach. The subjects were 14 doctors with various (...) levels of neonatal experience, recruited from two state‐owned NICUs in India. Main outcome measures: description reflecting the nature of ethical dilemmas and how they are experienced.Results: All doctors reported situations where the question of withdrawal of treatment was experienced as the worst part of their job. They felt that they lacked training in how to handle such dilemmas, and some had never talked about ethics before. They were especially concerned about non‐medical considerations that do not feature in current treatment guidelines. In describing their personal experiences, the informants mentioned their sense of responsibility in situations where they were aware that their decisions would influence a family's economy and reputation, availability of food and education for siblings, other children's access to equipment in the unit, and the use of resources in an underprivileged population. Sometimes lack of resources, usually ventilators, forced them to make decisions about which babies should get the chance to live. Other reported dilemmas included difficulties co‐operating with uneducated and poor parents.Conclusion: While Western doctors seem to focus on the rights and problems of the individual child, Indian doctors tend to refer to consequences for other children, for parents and society. There is a need for further research in this field, and for the development of guidelines on how to cope with differences in resources, and how to handle different patient groups’ cultural and religious concerns. (shrink)