Department of EthicsPrinciples for allocation of scarce medical interventions
Section snippets
Simple allocation principles
Eight simple ethical principles for allocation can be classified into four categories, according to their core ethical values: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness (table 1). We do not regard ability to pay as a plausible option for the scarce life-saving interventions we discuss.
Some people wrongly suggest that allocation can be based purely on scientific or clinical facts, often using the term “medical need”.
Assessing principles: allocation systems
Which principles best embody morally relevant values? First-come, first-served is flawed in practice because it unwittingly allows irrelevant considerations, such as wealth, to affect allocation decisions, whereas a lottery is insufficient but not flawed. Similarly, sickest-first allocation is inherently flawed, whereas the youngest-first principle, though insufficient, recognises the important value of priority to the worst-off. Both utilitarian principles—maximising lives saved and
The complete lives system
Because none of the currently used systems satisfy all ethical requirements for just allocation, we propose an alternative: the complete lives system. This system incorporates five principles (table 2): youngest-first, prognosis, save the most lives, lottery, and instrumental value.5 As such, it prioritises younger people who have not yet lived a complete life and will be unlikely to do so without aid. Many thinkers have accepted complete lives as the appropriate focus of distributive justice:
Legitimacy
As well as recognising morally relevant values, an allocation system must be legitimate. Legitimacy requires that people see the allocation system as just and accept actual allocations as fair. Consequently, allocation systems must be publicly understandable, accessible, and subject to public discussion and revision.92 They must also resist corruption, since easy corruptibility undermines the public trust on which legitimacy depends. Some systems, like the UNOS points systems or QALY systems,
Conclusion
Ultimately, none of the eight simple principles recognise all morally relevant values, and some recognise irrelevant values. QALY and DALY multiprinciple systems neglect the importance of fair distribution. UNOS points systems attempt to address distributive justice, but recognise morally irrelevant values and are vulnerable to corruption. By contrast, the complete lives system combines four morally relevant principles: youngest-first, prognosis, lottery, and saving the most lives. In pandemic
References (97)
Fair process in patient selection for antiretroviral treatment in WHO's goal of 3 by 5
Lancet
(2005)- et al.
Measuring people's preferences regarding ageism in health: some methodological issues and some fresh evidence
Soc Sci Med
(2003) - et al.
Consequences of eliminating HLA-B in deceased donor kidney allocation to increase minority transplantation
Am J Transplant
(2005) - et al.
The role of adaptation to disability and disease in health state valuation: a preliminary normative analysis
Soc Sci Med
(2002) - et al.
Understanding DALYs
J Health Econ
(1997) - et al.
Healthy life expectancy in 191 countries, 1999
Lancet
(2001) - et al.
Type 1 diabetes: new perspectives on disease pathogenesis and treatment
Lancet
(2001) - et al.
Effect of oestrogen during menopause on risk and age at onset of Alzheimer's disease
Lancet
(1996) A theory of justice
(1999)QALYfying the value of life
J Med Ethics
(1987)
Organ transplant rationing: a window to the future?
Health Prog
Rationing in the intensive care unit
Crit Care Med
Who should get influenza vaccine when not all can?
Science
Disaster preparedness and triage
Mount Sinai J Med
Which patients first? Setting priorities for antiretroviral therapy where resources are limited
Am J Pub Health
Morality, mortality, volume 1: death and whom to save from it
Principles of justice in health care rationing
J Med Ethics
Rationing vaccine during an avian influenza pandemic: why it won't be easy
Yale J Biol Med
The allocation of exotic medical lifesaving therapy
Ethics
Principles of biomedical ethics
Who should get the kidney machine?
J Med Ethics
Hard choices in public health: the allocation of scarce resources
Scand J Public Health
“Not clinically indicated”: patients' interests or resource allocation?
BMJ
The misplaced role of urgency in allocation of persistently scarce life-saving organs
Casting and drawing lots: a time honoured way of dealing with uncertainty and ensuring fairness
BMJ
Selecting people randomly
Ethics
The patient as person: exploration in medical ethics
The value of life
The distribution of life-saving medical resources: equality, life expectancy, and choice behind the veil
Soc Philos Policy
Allocating health care morally
Calif Law Rev
Sovereign virtue: the theory and practice of equality
Fair allocation of intensive care unit resources
Am J Respir Crit Care Med
Putting patients first in organ allocation: an ethical analysis of the US debate
Camb Q Healthc Ethics
Who goes first?
J Public Health Manag Pract
Equality and priority
Ratio
Bentham in a box: technology assessment and health care allocation
Law Med Health Care
Justice between the young and the old
Philos Publ Aff
Equity in liver allocation: Professor Veatch's reply
Med Ethics
Hope versus efficiency in organ allocation
Transplantation
Dialysis as a resource allocation paradigm: confronting tragic choices once again?
Semin Dial
Draft guidance on allocating and targeting pandemic influenza vaccine
Setting limits: medical goals in an aging society
Inequalities in health and intergenerational equity
Ethical Theory Moral Pract
Am I my parents' keeper? An essay on justice between the young and the old
Neglected equity issues in cost-effectiveness analysis, Part 1: severity of pre-treatment condition, realisation of potential for health, concentration and dispersion of health benefits, and age-related social preferences
Children's rights to health care
J Med Philos
Cited by (665)
A quadrant shrinking heuristic for solving the dynamic multi-objective disaster response personnel routing and scheduling problem
2024, European Journal of Operational ResearchSituating 'best practice': Making healthcare familiar and good enough in the face of unknowns
2023, SSM - Qualitative Research in HealthEthical dilemmas in prioritizing patients for scarce radiotherapy resources
2024, BMC Medical Ethics