2009 PrinciplesforAllocationofScarce
- (Persad et al., 2009) ⇒ Govind Persad, Alan Wertheimer, and Ezekiel J Emanuel. (2009). “Principles for Allocation of Scarce Medical Interventions.” In: The Lancet Journal, 373(9661).
Subject Headings: Ethical Principle, Medical Intervention, Moral Decision, Economic Decision.
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Abstract
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.
Introduction
In health care, as elsewhere, scarcity is the mother of allocation.1 Although the extent is debated,2,3 the scarcity of many specific interventions — including beds in intensive care units,4 organs, and vaccines during pandemic influenza5 — is widely acknowledged. For some interventions, demand exceeds supply. For others, an increased supply would necessitate redirection of important resources, and allocation decisions would still be necessary.6
Allocation of scarce medical interventions is a perennial challenge. During the 1940s, an expert committee allocated — without public input — then-novel penicillin to American soldiers before civilians, using expected efficacy and speed of return to duty as criteria.7 During the 1960s, committees in Seattle allocated scarce dialysis machines using prognosis, current health, social worth, and dependants as criteria.7 How can scarce medical interventions be allocated justly? This paper identifies and evaluates eight simple principles that have been suggested.8–12 Although some are better than others, no single principle allocates interventions justly. Rather, morally relevant simple principles must be combined into multi-principle allocation systems. We evaluate three existing systems and then recommend a new one: the complete lives system.
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”.13,14 There are no value-free medical criteria for allocation.15,16 Although biomedical facts determine a person’s post-transplant prognosis or the dose of vaccine that would confer immunity, responding to these facts requires ethical, value-based judgments.
When evaluating principles, we need to distinguish between those that are insufficient and those that are flawed. Insufficient principles ignore some morally relevant considerations. Conversely, flawed principles recognise morally irrelevant considerations: inherently flawed principles necessarily recognise irrelevant considerations, whereas practically flawed principles allow irrelevant considerations to affect allocation. Principles that are individually insufficient could form part of an acceptable multi-principle system, whereas systems that include flawed principles are untenable because they will always recognise irrelevant considerations.
Treating people equally
Many scarce medical interventions, such as organ transplants, are indivisible. For indivisible goods, benefiting people equally entails providing equal chances at the scarce intervention — equality of opportunity, rather than equal amounts of it.1 Two principles attempt to embody this value.
References
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| Author | volume | Date Value | title | type | journal | titleUrl | doi | note | year | |
|---|---|---|---|---|---|---|---|---|---|---|
| 2009 PrinciplesforAllocationofScarce | Govind Persad Alan Wertheimer Ezekiel J Emanuel | Principles for Allocation of Scarce Medical Interventions | 2009 |