Priority setting and allocation of resources

The need to allocate limited resources (medical or otherwise) is the issue likely to generate the most social and ethical tensions. Importantly, access to medical assistance (including equipment, such as ventilators, pharmaceuticals, testing capacity and so on) will not be the only domain in which key interventions will need prioritising. Access to testing, for example, proved controversial in the ongoing COVID-19 crisis, as the lack of prioritisation of testing for UK care home elderly residents and staff resulted in many deaths in these settings, which are believed to have been largely preventable {The Guardian 2020a).

Examples of other scarce resources in need of prioritising include access to non-pandemic related medical services, which may be reduced to a minimum in pandemic circumstances, but also access to a range of other non-medical goods and services. The latter include access to schooling or creche facilities for children of key workers and for children who may be classed as vulnerable, access to food and supermarkets, to economic assistance, such as furlough schemes, access to travel and transport in a lockdown, to repatriation, and so on.

There are many principles that could be invoked in theory to allocate valuable and limited resources. They range widely and can sometimes be in tension with each other.

For example, one could argue in favour of prioritising assistance to some groups above others, such as healthcare workers, who then have to assist others, or to vulnerable groups in relation to a specific type of pandemic - for example, the elderly, or the young, those with existing complex medical conditions, with compromised immune systems, newborn babies or pregnant women.

Some of these groups may become vulnerable only once the disease mortality and infectivity rates are observed. Notably, the current COVID-19 virus seriously affects the elderly, but is much less serious and dangerous to children aged 12 and younger, whereas the 2009 swine flu pandemic more seriously affected young adults.

Other groups, already vulnerable in society due to various circumstances, may experience a greater burden trying to cope during a pandemic — for example, the destitute, the uninsured, the unemployed, the socially isolated and marginalised, the homeless, illegal workers and so on. These groups may struggle with accessing information and services, including basic medical assistance, let alone emergency one. They may need a targeted prioritisation to ensure they are not left behind in the pandemic response. Their prioritisation may be pursued by invoking the principle of social justice.

Nonetheless, establishing who ought to be prioritised may lead to controversy. While the medical professionals may push medical judgements and promote likely medical outcomes as criteria, these must not be the only nor main criteria when prioritising allocation of scarce medical resources. Given the margins of uncertainty with a novel pathogen, it is difficult and perhaps impossible to establish a solid evidence base to predict that a response in a given patient would be so much higher than that in another. Deciding what to do when the evidence base is limited or when the anticipated difference in response is not large, yet the resources (e.g. antiviral medication or access to a mechanical ventilator) are limited is going to be contentious.

Medical judgements and likely medical outcomes should also not be considered key criteria when prioritising non-medical interventions, which however will have impacts on health, and the likelihood of preserving or restoring good health — such as access to food parcels or financial assistance.

Many arguments may be put forward to prioritise utility (beyond the medical utility or efficacy criteria mentioned prior), for example understood in terms of saving the greatest number of lives. But, equally, many other principles can be mobilised to prioritise social justice through fair and equitable access to care and resources instead. From the point of view of utilitarianism, with the aim of maximising the size of the positive outcome, should economic arguments based on ‘health gains’ be mobilised? This would involve a prioritisation of those who would have more years left to live, on average. Or should its similar, though slightly more palatable, counterpart be mobilised — the argument about ‘fair innings’? This argument works with broader age categories, but would still involve prioritising saving children over senior citizens (see CEAPI 2009 and ASSET 2015).

Furthermore, if healthcare workers are prioritised in accessing limited medical resources in view of their function, should healthcare workers be prioritised everywhere or only in a context where universal healthcare is available to all, where therefore we could assume that they will go on to potentially assist any citizen regardless of private medical insurance? If medics are prioritised because of their role, should others be prioritised too on the basis of their professional or social role — from a person’s job to their role as parent or carer (CEAPI 2009)?

Conversely, could it be fairer, if only in the sense of less prone to bias, to allocate a resource like scarce antiviral medication through a randomised, draw-like and chance-based process? Other criteria that can be mobilised and that invoke fairness could include prioritising a random sample of the population that faithfully reproduces on a smaller scale the composition of society as it was at the inception of the pandemic. For example, if a society has a certain ratio of age groups, ethnic composition, gender composition and so on, should the same ratio be taken into account when distributing limited resources like life-saving vaccines? Or should no ratio or a different ratio be engineered?

These are just some of the options, tensions and arguments that could and would be mobilised in relation to the allocation of scarce resources and the issue of their prioritisation. Far from being abstract and obscure concepts, they also reflect the options, tensions and arguments mobilised by members of the public when they are invited to engage on these issues. For example, in 2017 and 2018, I organised two public events in a city centre library in Manchester, UK.2 Box 4.1 illustrates how these principles are being bounced back and forward in the comments of those who attended the first event:

Box 4.1 Pieri 2017, A Public Debate on Pandemics, Manchester, UK

Excerpt from my Public Debate on Pandemics, November 2017, John Rylands Library, Manchester, UK

E (ELISA): We are going to start with the task that the Blue team here had, which says ‘In the event of a pandemic, limited medication and medical equipment may be available. So it is really about priorities, who are we prioritising? Who is going to access these medications and what ideas have you got about what issues this might generate?

PA (Participant A, woman, pensioner): I thought that the medics should have the first treatment, because they, they are going to have to deal with what happens, and then you said . . .

PB (man, pensioner): I said key services, like police and fire, and leaders of local government. And the national government, if it was that kind of

E: yes, that’s a very good idea

PA: and the children

PB: well I wrote children, the first thing I put down, but

E: what is the thinking behind the children?

PA: they’re more vulnerable

PB: well, more vulnerable, but also they’ve got longer lives to live

E: ah ah, those are good points, we are going to pick on them in a second. Any other ideas that you can think of? Who would you prioritise with limited resources, who should be prioritised in a situation of limited . . . ventilators or limited beds in a hospital?

PC (male): well basically anyone that [inaudible, but to the effect that: no one with complications] and concentrate on the healthy people

E: Unhealthy?

PC: no, the healthy

E: so that would be the opposite argument of what has been made here. Instead of the vulnerable being given a chance, you would focus on the strong, the ones that are more likely to survive potentially?

PC: yeah, yeah

PD (WOMAN): the ones that would otherwise be healthy

PX: the young ones

E: so you would prioritise the young ones, why?

PX: I hope I am not going to offend anyone, but because they’ve got a better chance to survive

PE (woman, young): perhaps more so than the children! I get the point about the children, but if you just save the children beyond a certain age, then they won’t be able to do much for a while.

Although this exercise asked the members of the public present at the event to quickly brainstorm options and issues, which were later discussed in more detail and nuance, it is immediately evident that the points made resonate with many of the criteria and ethical principles mentioned in the scholarly literature and presented earlier. What also emerges, in view of the fact that the principles invoked are many, varied and sometimes in clear opposition to one another, is that they need to be discussed in a much more sustained, inclusive and transparent fashion in society, the media and the public sphere. This needs to happen in prepandemic times too, with a view to informing a better decisionmaking process when the time to make decisions comes (during a pandemic emergency). Decisions reached after sustained and inclusive debate are more robust and accountable, as I go on to show in Chapter 6, where I introduce the notion of participatory crisis governance.

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