Health Policy Journal Club, Health Policy, Advocacy, COVID-19

Health Policy Journal Club: The Ethics of Allocation

One of the greatest challenges in health care - and in generations - is upon us

COVID-19 continues to detrimentally affect every aspect of our health care system. Clinicians have been faced with grim life-and-death decisions amid a shortage of critical resources such as ventilators, intensive care unit (ICU) beds, personal protective equipment (PPE), and pharmaceutical treatments.

It is estimated that only 68,400 ICU beds exist for adult patients in the United States, with a similar number of full-featured ventilators. The disparity between available supply and likely demand is sobering. Rationing of medical resources is a difficult but necessary concept for a health care system overwhelmed during a pandemic.

A recent opinion article aimed to develop a consistent and ethical framework for approaching such decisions. The authors suggest that between 1.3 million and 5.1 million Americans will require hospitalization due to COVID-19 illness. Up to 3.8 million patients may require advanced intervention in an ICU setting.

Four fundamental values are provided for clinicians:

  1. Maximize the benefits produced by scarce resources
  2. Treat people equally
  3. Promote and reward instrumental value
  4. Give priority to the worst off

These values serve as a core basis for ethical allocation of health care assets. Finally, the authors provide 6 recommendations to operationalize these values.

  • Recommendation 1: Maximize the benefit of care by saving the greatest number of lives and prioritizing individuals’ posttreatment length of life.
  • Recommendation 2: Testing, PPE, ICU beds, ventilators, therapeutics, and vaccines should go first to front-line health care workers.
  • Recommendation 3: For patients with similar prognoses, equality should occur via random allocation rather than a firstcome, first-served process.
  • Recommendation 4: Prioritization guidelines should differ by unique intervention and should incorporate changing scientific evidence.
  • Recommendation 5: Patients who participate in research to prove the safety and effectiveness of vaccines and therapeutics should receive priority.
  • Recommendation 6: There should be equal allocation of scarce resources between patients with COVID-19 and patients with other medical conditions.

The ethical implementation of such plans remains a topic of controversy. The U.S. Office for Civil Rights released a bulletin in March 2020 to emphasize the equal dignity of every human life while prohibiting discrimination in provision of care on the basis of race, color, national origin, disability, age, sex, and religion. The civil rights implications of protocols to ration care is a further dilemma for both providers and systems level stakeholders.

While much uncertainty remains regarding future policies related to COVID-19, it is clear that front-line clinicians will face challenging situations never before seen in the modern health care system. Further exploration of these complex issues is crucial for developing ethical guidelines in managing this pandemic.

Abstract: Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of COVID-19N Engl J Med. 2020;382(21):2049-2055.

BACKGROUND: In the midst of a global pandemic, with worsening case numbers in the United States, the fair and equitable allocation of limited health care resources poses a challenge. How can clinicians practice ethically in this crisis?

CONCLUSIONS: The authors offer 6 recommendations, based on 4 fundamental values.

PMID: 32202722

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care providers, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.