Criteria for the Allocation of Limited Healthcare Resources: The Timeless Challenge of the Coronavirus (COVID-19) Crisis

 

The Individual Patient[1]

Willingness

Attending to each patient appropriately in the face of a scarcity of healthcare resources requires giving due respect to each patient’s particular wishes and values. God takes human choices very seriously: love is genuine only if it is voluntary and uncoerced. Even when eternal destiny is at stake, people are challenged to choose for or against God. And just as people are given the responsibility to make eternal choices, so they should be granted the responsibility to make critical decisions that may extend their lives here and now. They should be empowered either to forgo scarce lifesaving medical treatments or to pursue treatment.

In other words, a willingness criterion is warranted to ensure that only those who genuinely want treatment receive it. A willingness criterion has widespread support in medical practice. It also corresponds to a major ethical consideration, namely the patient’s wishes. Whether the issue is ending treatment or beginning it, the patient’s wishes are extremely important. Determining the patient’s true wishes is more complicated than the common notion of “informed consent” might suggest, but it is doable.

While respect for freedom entails considering the patient’s willingness to receive treatment, freedom in the biblical writings is not synonymous with license. Some choices are better than others; some, for example, are more in line with the ethical guides that God has provided. For example, the significance of each life entails that it is generally appropriate for people to want to receive resources they need in order to stay alive. Other people such as family members also may need the continued presence of their ill relatives for a variety of reasons. Yet the example of Jesus adds the admirable alternative of laying down one’s life so that others might live—an affirmation of life in its own right. If such prioritizing of the lives of others is to be a genuine expression of freedom, though, the decision must be that of the person making the sacrifice. It must not be the forcibly imposed judgment of society or the subtly imposed suggestion of any other individual. Ultimately, then, a willingness criterion suggests that a patient’s wishes regarding whether or not to receive a scarce lifesaving resource should be honored, although some wishes may be more morally commendable than others.

Attending to the individual patient in an appropriate manner also entails giving due attention to each patient’s medical condition. Given the tremendous significance that God ascribes to the life of every person, we should seek to meet the vital needs of each to the fullest extent possible. This understanding of life and justice points to the importance of two other patient selection criteria: medical benefit and imminent death.

Medical Benefit

A medical-benefit criterion, first of all, dictates that resources should go to those who genuinely need them. It includes for further consideration in the selection process all (and only) those who will likely receive a significant medical benefit as a result of treatment. In addition to serving as a criterion in its own right for the allocation of vital resources, the medical-benefit criterion serves as the basis for assessing the medical legitimacy of any other selection criterion. This can inform an ethical assessment of age, supportive-environment, and psychological-ability selection criteria. Not surprisingly, then, the medical-benefit criterion is commonly advocated and employed in the practice of medicine today.

Admittedly, other medical considerations such as length of benefit and quality of benefit have a place in assessing medical benefit. Rather than using these considerations as criteria in their own right to compare and rank candidates for treatment, however, a medical-benefit criterion employs them in a noncomparative and minimal sense. Those expected to lack a significant length and quality of benefit from treatment are excluded from treatment on medical grounds. “Significant” here means the smallest amount that can reasonably be considered important. If living a year longer, for instance, can reasonably be considered a significant benefit, then the minimal length-of-benefit requirement of the medical-benefit criterion should not be longer than a year. Candidates expected to receive borderline medical benefit from treatment should probably not be excluded from treatment on the basis of this criterion in view of the imprecision of the judgments involved.

Imminent Death

All who will die because they lack access to a particular resource need that resource, but those who will die imminently because they lack such access fall into a category of special need. They require the resource now, unlike others who can survive for a while without it. So if one is to attend to the particular medical need of each patient in an appropriate manner, an imminent-death criterion becomes an important vehicle. The criterion allots priority treatment to those whose death is expected within a few days or weeks (or perhaps slightly longer) according to competent medical judgment. Although this definition of imminent death is not precise, it is the best that the circumstances will allow, and it has been found workable by many in clinical practice. In fact, some sort of imminent-death criterion has long played an important role in patient selection. According to a national survey, it has also enjoyed a broad measure of public support in the United States.

Because of serious problems with certain forms of the criterion, however, we need to look carefully at the way it is employed. For example, some forms of the criterion give priority to patients who have deteriorated to the extent that they can no longer benefit significantly from treatment. Such an application of the criterion neglects the important medical-benefit criterion. An imminent-death criterion should instead give priority to those candidates who are within, say, two weeks of being disqualified from treatment on the basis of the medical-benefit criterion. Such predictions are often difficult to make, especially when patients who do not seem to be very sick are nevertheless at significant risk of dying (e.g., those with rapidly deteriorating heart conditions). If a prediction cannot be made with reasonable accuracy, the imminent-death criterion should not be employed.

For those who are concerned that an imminent-death criterion aspires to an unrealistic degree of precision or is open to abuse, three remedies are available. First, we can avoid the attempts that some have made to break down the time period when death is imminent into subperiods. These smaller categories are more difficult to define precisely and place more emphasis on precise categorization than is necessary. Patients ought simply to be categorized as being in or out of the imminent-death period. Second, whenever caregivers have reason to question whether a patient is in the imminent-death period, they can err on the side of safety and include all such questionable cases in the higher priority category. Meanwhile, research can continue so that clinicians will become more adept at determining when the death of a particular patient is imminent. Third, all documentable evidence of the imminence of death can be documented and subject to later review. Sanctions could then be imposed on anyone invoking the criterion when it clearly is not applicable—which is to say, anyone manifestly violating standard medical practice.

The Social Context

Impartial Selection

While attending to individual patients—their wishes as well as their needs—it is also essential that we attend to their social context. There may be many other patients who want and need the same treatment, and justice entails equal provision for all those in need. However, in situations of scarcity, when all alike cannot receive the needed resources, the best that can be done in the interests of equality is to provide each patient with an equal opportunity to obtain treatment. (Whether people responsible for their own illness should be denied access to scarce lifesaving resources is a justice issue of a different sort; but such a consideration is presently too difficult to apply in the practice of health care.)[2]

An impartial-selection criterion that selects patients randomly is the surest way to protect equal opportunity. Such impartial selection may strike some as irrational and unappealing because of its arbitrariness. However, this arbitrariness is its ethical strength, for it guards against the intrusion of comparative evaluations of the worth or value of persons. In fact, this arbitrariness may even act as a subtle incentive for those who hold economic and political power to reduce the scarcity of resources, since impartial selection would preclude them from relying on their special position to obtain priority access for themselves, their family, or their friends should thy need treatment. The arbitrariness of impartial selection would also serve to keep the tragedy of scarce resources clearly visible, unlike social-value selection, for example, which may give the appearance that a “solution” to the scarcity has been found. A clearer awareness of the scarcity will tend to stimulate greater efforts to reduce it.

The use of impartial (random) selection to prevent improper human decision making has a long history. In the Bible it is sometimes seen as a way to leave the decision to God (Prov. 16:33; cf. Josh. 18:6–10; 1 Sam. 10:20–21; 14:42; 1 Chron. 26:13; Neh. 10:34; Esth. 3:7; Prov. 18:18; Jon. 1:7–8; Acts 1:24–26), but it is also employed there simply to ensure that a decision does not reflect the value judgments or preferences of the decision-maker (Num. 26:55; Judg. 20:9–10; Job 6:27; Joel 3:3; Obad. 1:11; Nah. 3:10; Matt. 27:35). This latter motivation has been particularly influential in the practice of medicine, where impartial selection has received significant support in situations such as determining access to organ transplantation, kidney dialysis, and vital vaccines.

Impartial selection generally takes one of two forms. One is a traditional lottery in which names are randomly selected from a list of all patients waiting for treatment. The other is a first-come, first-served approach. Since the time that each person is stricken with a medical condition and seeks treatment is more or less random, the first-come, first-served approach functions as a sort of natural lottery. The first-come, first-served approach has more commonly been employed in health care than has the lottery, perhaps because it does not seem quite as starkly random as a lottery.

From the perspective of justice, however, randomness is precisely what is being sought. In fact, one moral problem with the first-come, first-served approach is that it is not truly random or impartial. Patients with greater wealth (and those with the greater power, information, and confidence associated with the wealthier classes) have better access to health care generally and to referral networks in particular. Accordingly, they tend to get on the waiting lists for scarce medical resources sooner than those who are less wealthy and empowered.

The first-come, first-served approach may seem just on grounds other than randomness, however. For instance, many would find appealing its insistence that those who have waited longest should be treated first. And yet, while such a priority may be justifiable in most situations, it must be disputed when life is at stake. No amount of waiting can make one person deserve life more than another. With a lottery, some might have to wait longer than others because of “the luck of the draw”—but that would be better than leaving some to wait longer just to get on the waiting list because they are victims of social inequities.

Moreover, the first-come, first-served approach to patient selection also has two bad side effects that a lottery avoids. One stems from the fact that the criterion favors the patients who have been waiting longest for treatment: it tends to select the sickest patients, the patients with the least likelihood of recovery. As a result, it produces limited results or even wastes vital resources altogether. The second bad side effect of the first-come, first-served approach stems from the fact that it creates legitimate expectations on the part of patients about the order in which they should be treated. Once such an order is established, patients will understandably be upset if it is interrupted to accord special priority to an individual—for example, when ethically mandated by the imminent-death criterion. The approach thus has the effect of promoting ill will among patients and caregivers. These two side effects are worth considering in our evaluation of the first-come, first-served approach, but they remain secondary considerations. The primary consideration here is the justice issue—that is, identifying the form of impartial selection that is most truly random and thus impartial. A lottery is usually the preferable form.

Justice is not the only basic guide that undergirds an impartial-selection criterion, however. If equality were all we were interested in, then it could be argued that the best way to ensure it would be to deny treatment to everyone alike. But other concerns are also important. Life has a unique significance rooted in God and is worthy of great care and respect. Therefore, the equality we seek should be life-affirming rather than life-denying, and so the significance of life supports a criterion like impartial selection that protects as many lives as possible while safeguarding equality.

Likelihood of Benefit

Respect for life entails three additional criteria rooted not in an assessment of the patient as an individual but in larger social considerations. The first of these criteria prioritizes those patients who are in a group significantly more likely to benefit than other groups. The rationale is that more lives can be saved as a result. Saving a group of lives over one life is readily accepted by most people when the choice simply involves those individuals. But people often miss, in a larger social context, that the same choice is involved regarding much larger groups of people. If the right group is prioritized over other groups, more lives will be saved.

Groups should be distinguished on the basis of relevant medical indicators alone. For example, if degree of organ failure is directly related to surviving a stay in the ICU, then it is appropriate to divide patients into groups according to some measure such as their Sequential Organ Failure Assessment (SOFA) score. If a limited resource always goes to a patient in a group with higher scores than to one in a group with lower scores, more lives will end up being saved. Grouping patients by non-medical considerations such as age should not be done. Age per se is not a reason that any particular patient is a good or bad candidate for treatment. Older patients in excellent health other than the medical threat requiring a scarce resource can be much better candidates for treatment than younger patients who were in poor health before encountering this medical threat.

Likelihood of benefit should not be confused with the ethically unacceptable criteria of length of benefit and quality of benefit. Basing who is allowed to live either on how long a patient will live after treatment or on how high a quality that life will be is dangerous. It affirms the idea that some people are more worthy of being allowed to live than other people. Remaining length of life and quality of life are no more legitimate than social status as reasons to allow one person to live over another. Deploying medical resources to allow as many people to live as possible, on the other hand, makes no judgments about what sorts of people ought to be allowed to live. A likelihood of benefit criterion only increases the number of people who survive because of using the scarce resource—it requires no prioritizing of one type of survivor over another.

Any differences in likelihood of benefit must be sufficiently large and certain to ensure that additional lives will be saved by using this criterion. Estimations of likelihood of benefit are not precise enough to base prioritizing some people’s lives over others based on minute differences of likelihood. And in situations where only limited or unreliable data are available to ground estimations of likelihood, use of this criterion is unwarranted due to uncertainty over whether or not additional lives will be saved. If a group of people receives priority according to this criterion and there are not enough resources to treat everyone in that group, impartial selection as discussed above should be employed within the group.

Resources Required

The second criterion suggested by taking the social context seriously dictates that patients needing less of a given resource should be treated before patients needing more of the same resource if a greater number of lives can be saved as a result. A resources-required criterion has not received as much attention as other selection criteria, partly because the possibility of a major disparity in the amount of resources required by various patients does not arise in relation to many treatments. Patients who need a kidney transplant, for instance, all alike need a kidney, and once a kidney has been received by one person it cannot be used by another.[3] In other circumstances, however, such as the early allocation of penicillin and the provision of dialysis, the criterion has played a significant role. Those needing less of the resource, or needing it only temporarily, have traditionally received priority.

It is important to distinguish this criterion from a more general utilitarian endeavor to maximize the benefits resulting from the use of limited resources. A resources-required criterion recognizes that life has special significance and is not merely something of value that can be traded off against other things of value. Unlike utilitarian attempts to compare incommensurables, the criterion simply prefers more of that which is uniquely important, human life, over less of the same.

Because choosing some over others is never a light matter in view of the importance of equality, those employing the resources-required criterion should be relatively certain that they will in fact save additional lives by doing so. It would be wrong to grant one patient priority over another on the basis of a negligible difference in the amount of vital resources each is predicted to require for treatment, since such predictions are inherently imprecise. Only major disparities in the amount of resources required should be employed as a basis for patient selection, according to the described approach. Perhaps the clearest case is the choice between someone needing a vital scarce resource (e.g., an artificial organ) long-term and one needing it only temporarily. Such a choice involves using the same resource either to sustain the long-term patient or to save the lives of many patients with temporary needs, one after the other. If it is not clear whether a given patient falls into a priority group, it would be best here as elsewhere to err on the side of caution and include the patient when something as important as life is at stake.

Vital Responsibilities

The final criterion suggested by attending to the social context similarly affirms the special importance of life. Yet it differs from the resources-required criterion in that it broadens the scope of what the social context entails. Taking into consideration patients and nonpatients alike whose lives may be affected by selection decisions, a vital-responsibilities criterion favors patients on whom the lives of others literally depend. Classic illustrations of its use include providing antibiotics and other scarce treatments in wartime to those able to return most quickly to battle in order to prevent further killing—killing either of people on the patient’s own side only or, more broadly considered, of people on both sides through a faster conclusion of the hostilities. Similarly, it has often been determined that those with medical expertise should be treated first so that they can regain the capacity to treat others. At issue here is the importance of all human lives, patients and nonpatients. Any selection decision resulting in more lives saved is supported by the significance of life.

Unless the goal of saving more lives remains clearly in view, this criterion can collapse into a mere social-value criterion designed to favor those who are considered to be more “important” or “valuable” than others. So it is essential that anyone being favored by this criterion be truly indispensable to the saving of others’ lives—a condition that rarely applies—and that they not be so weakened following treatment that they would be unable to perform the service on which others’ lives depend. Each case must be considered on its merits rather than automatically approved because of its type. Top politicians, physicians, and military leaders would not necessarily qualify for special priority.

An Overall Approach

The significance of human life mandates not only protecting it but also its protection for as many people as possible. Moreover, furthering freedom and justice as well as life is not only important in its own right but also tends to be beneficial for people in the long run. All three concerns are basic components of the biblically-affirmed environment in which God intends for people to flourish. They undergird the various criteria discussed above.

These seven criteria work together in the process of patient selection as follows:

  1. Only patients who satisfy the medical-benefit criterion and willingness criterion are to be considered eligible.
  2. Available resources are to be given first to eligible patients who satisfy the imminent-death criterion, vital-responsibilities criterion, or resources-required criterion.[4]
  3. Likelihood-of-benefit criterion:  If resources are still available, recipients in a group significantly more likely to benefit than other groups should receive resources, with groups ordered according to their degree of likelihood.
  4. Impartial-selection criterion:  If resources are still available, recipients should be impartially selected, generally by lottery, from among the remaining eligible patients.[5]

We should also keep in mind two exceptional circumstances. On the limited occasions when a favored group criterion (e.g., geographic residence) is legitimate, it should serve as a prerequisite criterion—alongside of medical benefit and willingness—that must be satisfied by any recipient of the resource involved. Legitimate applications of the ability-to-pay criterion,[6] on the other hand, should not be made until after a patient has been chosen according to the selection procedure outlined above.

The overall approach described here will have various implications depending on the setting. In particular, the considerations involved in establishing medical benefit will vary from resource to resource. Nevertheless, despite such variations, patient selection remains ethically consistent so long as it continues to be anchored in a specific ethical outlook, such as biblical God-centered, reality-bounded, and love-impelled ethics.[7]

 

References


[1] Adapted and updated from chapter 11 of the Eerdmans book Life on the Line: Ethics, Aging, Ending Patients' Lives, and Allocating Vital Resources.

[2] Some have suggested that when vital resources are scarce, the first people to be excluded from treatment should be those who are responsible for their illness. There is considerable difference of opinion about who would fall into this category, but some would nominate alcoholics, heavy smokers, overeaters, AIDS patients, and the like who have engaged in behaviors that they knew posed risks to their health. However, it would probably be too difficult to apply this sort of criterion fairly in the practice of health care with our current level of knowledge. Were such a criterion to be employed; though, the described perspective’s commitment to fairness would suggest that people should not be denied treatment unless a number of conditions were met. First, their disorder would have to have been demonstrably caused by their own actions and not by other factors. Second, they would have to have been capable of freely engaging in these actions. Third, they would have to have been aware of the strong possibility that the disorder in question would result. Fourth, the search for all connections between personal behavior and medical disorders should at least be under way, and the criterion would have to be used consistently on the basis of our best knowledge about such connections. We should not require alcoholics to pledge abstinence, for example, if we have no intention of requiring comparable abstinence on the part of those with other destructive behaviors (smoking, overeating, etc.). It would be so difficult to meet these conditions that a fair and workable selection criterion is unlikely in the foreseeable future.

[3] Arguments about whether we should distinguish between a patient who has never received an organ transplant and a patient who has received an organ but now needs another are not addressed by the resources-required criterion. The reason for applying the criterion—saving more lives—is not applicable in such a case: no matter who receives the available organ, lives beyond that of the recipient are not likely to be saved.

[4] If not all eligible candidates who satisfy at least one of these criteria can be treated with available resources, the selection that saves the greatest number of lives is to be preferred. When it is not possible to determine on the basis of available information which of several patients should receive treatment, recipients should be selected by means of a lottery. These three criteria take priority over a likelihood-of-benefit criterion because in every single instance that one of these three is applied, more human lives are saved.

[5] With respect to special cases such as natural disasters and organ transplantation in which exceptions may be warranted, see Kilner, Who Lives? Who Dies? Ethical Criteria in Patient Selection (New Haven: Yale University Press, 1990), pp. 198–206.

[6] On the inescapable instances where ability to pay cannot be overlooked, see John F. Kilner, Life on the Line: Ethics, Aging, Ending Patients’ Lives, and Allocating Vital Resources (Grand Rapids: Eerdmans Publishing Co., 1992), pp. 214-221.

[7] For the full development of an ethical framework that is God-centered, reality-bounded, and love-impelled, see John F. Kilner, Life on the Line, chs. 1-3.