Introduction
Resource allocation has long been a key issue for health economists and medical ethicists. Especially since the 1970s, various attempts have been made to ensure fair and sensible healthcare resource allocation in the light of increasing healthcare costs and limited healthcare budgets. Against this background, the utilitarian-inspired concept of economic “efficiency” of mainstream health economics has become increasingly popular with scholars and political decision-makers. Since the 1970s, the number of economic evaluations of healthcare programs conducted has virtually doubled every five years, and regulators and legislators worldwide have become increasingly reliant on considerations of economic “efficiency” to inform their funding decisions (see Neumann et al.
2017a,
b; Widrig
2015). In the last two decades, for instance, cost-effectiveness studies have been made integral parts of funding decisions in healthcare in many countries worldwide, including the UK, France, Australia, and Canada (see Neumann et al.
2017a,
b).
Despite this increasing popularity of the paradigm of economic “efficiency” in healthcare resource allocation, health economists have provided little support for political decisions on resource allocation to Covid-19 preventive measures (see Schlander
2020). At first look, this relative silence of health economists is surprising, given the fact that disaster ethics has generally assumed a shift towards a more utilitarian allocation of healthcare resources in disaster situations like a pandemic (Mallia
2015; Wagner and Dahnke
2015; Satkoske et al.
2019). It can, however, be explained by three reasons: Firstly, even if robust economic evaluation was available, political decision-makers would likely consider it inappropriate to make “efficiency” the main guideline of preventive measures against an infectious disease which threatens the health of every single citizen and which has cost more than four million lives worldwide and has led to the death of between 1 and 3% of the populations of most European and American States (by July 14, 2021, according to data from the Johns Hopkins Coronavirus Resource Center). Secondly, utilitarian-inspired economic evaluation of Covid-19 preventive measures is heavily dependent on robust empirical knowledge about Covid-19 in general (e.g., its age- and morbidity-dependent case-fatality ratio) and the epidemiology of Covid-19 in particular (e.g., the impact of certain preventive measures on infection rates), which remain disputed even more than one year after the first Covid-19 waves in Western States (see Schlander
2020). Thirdly, the epidemiological setting changes fast and Covid-19 preventive measures are time-critical, meaning that robust and reliable economic evaluation cannot be produced in time for political decision-making.
Given these limitations, paradigms other than economic “efficiency” appear more suited to understand the allocative decisions taken in response to the Covid-19 pandemic. Amongst these alternative paradigms, the Rule of Rescue (see Box
1 for a definition), which has been important in the academic debate on derogations from the mantra of economic “efficiency” in cases of life-threatening and life-changing diseases since its introduction by Jonsen (
1986), is of particular significance.
The decisions on resource allocation in the Covid-19 pandemic were motivated by complex and multi-facetted ethical considerations, and it is not the purpose of the present paper to condense these considerations into one ethical concept (which, of course, would be impossible). Furthermore, it is not the purpose of the present paper to engage in the debate about whether the allocative decisions with regard to Covid-19 preventive measures were normatively justified at the time when they were made, or whether it is possible now to provide an adequate normative justification. Rather, the present paper seeks to show that Rule of Rescue considerations are helpful in order to capture and describe the allocative decisions taken during the Covid-19 pandemic, and that Rule of Rescue considerations may to some extent explain some of the decisions. That is, it is plausible that the decision-makers have used Rule of Rescue because they believed such considerations had normative or social force.
To this purpose, we will proceed in two steps: In a first step, we will discuss the concept of the Rule of Rescue in general as it was theorized before the Covid-19 pandemic. In a second step, we will demonstrate that the preventive measures taken by policymakers to tackle the Covid-19 pandemic are consistent with the Rule of Rescue.
Box 1: Definition of the Rule of Rescue
“
In order to save people from imminent peril, societies incur high costs largely irrespective of the fact that many more lives could be saved under alternative uses of the resources. This practice is usually referred to by the expression ‘Rule of Rescue’” (Lübbe
2019).
The concept of the Rule of Rescue thus primarily describes the practice to allocate high amounts of healthcare or other resources to “rescue cases” and to largely ignore “efficiency” considerations in these cases.
In contrast, the Duty of Easy Rescue, which was theorized mainly by Peter Singer (e.g. Singer
1972) and Julian Savulescu (e.g. Savulescu
2007; Porsdam Mann et al.
2016; Giubilini et al.
2018a; Giubilini et al.
2018b; Koplin et al.
2020) is a normative principle that requires “
individuals […]
to benefit others, or to prevent harm to others, when doing so entails a small cost to them” (Giubilini et al.
2018a). The Duty of Easy Rescue equally applies to collectives (Giubilini et al.
2018b), i.e., also to policy-making in healthcare resource allocation, but only covers “easy” “rescue cases” (whereas costs and difficulty are not considered in the Rule of Rescue logic).
Conclusion
As the present paper has argued, Covid-19 preventive measures, for instance population-wide vaccination campaigns, large-scale SARS-CoV-2 testing, and the large-scale distribution of protective equipment to high-risk groups and hospitals and nursing homes, have been consistent with the Rule of Rescue.
The present paper does not claim that the Rule of Rescue has been the only or even the main rationale of decision-making on Covid-19 preventive measures. Rather, it has shown that the Rule of Rescue can be a helpful instrument in studying and analyzing the decisions on healthcare resource allocation taken during the Covid-19 pandemic.
Thereby, the present paper wants to encourage academic debate about the role that the Rule of Rescue has and should have in healthcare resource allocation. Furthermore, it seeks to encourage academic debate about the rationales of allocative decisions in the Covid-19 pandemic. As the present paper has underlined, the Rule of Rescue is a helpful instrument in understanding allocative decisions in healthcare, but it is neither a conclusive nor an exclusive answer.
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