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Dueling Ethical Frameworks For Allocating Health Resources.
Dueling Ethical Frameworks For Allocating Health Resources.
to have a deep interest in critically reecting on tough allocation problems, we ought to have a deeper and more abiding interest in reecting on why, at any given moment, background conditions force us into these dilemmas in the rst place. Sometimes they will be unavoidable, but many times they are not but for our own collective will. I especially worry when theorists feel comfortable taking ideas like the modied youngest-rst principle and apply them to least advantaged populations in poorer parts of the world. There can be no denying that, in such places, resources are frighteningly scarce, but there also can be no denying that our complacency towards rst-order
REFERENCES
Harris, J. 1999. The concept of the person and the value of life. Kennedy Institutue of Ethics Journal 9(4): 293308. Kerstein, S., and G. Bognar. 2010. Complete lives in the balance. American Journal of Bioethics 10(4): 3745. Persad, G., A. Wertheimer, and E. J. Emanuel. 2009. Principles for the allocation of scarce medical interventions. Lancet 373: 423431.
Address correspondence to Dorothy E. Vawter, Minnesota Center for Health Care Ethics, 1890 Randolph Avenue, St. Paul, MN 55105, USA. E-mail: vawter@mnhealthethics.org
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yielded multiple ethical frameworks to guide statewide rationing of health-related resources during a severe inuenza pandemic. These pandemic-specic frameworks differ in important ways from those by Persad and colleagues and Kerstein and Bogner. We next highlight a few of the most signicant substantive differences. Sickest First Minnesotas project participants would agree that Persad and colleagues too quickly conclude that giving to the sickest rst is an inherently awed principle for allocating scarce resources (Kerstein and Bognar 2010). Participants in the Minnesota project recommended a form of the principle sickest persons rst, that is, prioritize persons at high risk of u-related mortality and serious morbidity who have an acceptable response to the resource. Maximize Life-Years Both sets of authors consider maximizing life-years (or maximizing the life-years of persons with the capacities to set ends and to form, act on, and revise plans for attaining them) as undeniably relevant to allocating resources. Minnesotas project participants, on the other hand, concluded that during a severe pandemic, allocating resources to maximize life-years would be unfair, exacerbate health disparities, be impractical, and cause distrust of the states allocation system. First and foremost, relying on actuarial data about different demographic groups would unfairly favor healthier, wealthier, and more empowered groups over groups systematically left behind. For instance, the principle unfairly allows 40-year-old white women living in highincome areas routinely to be prioritized over 40-year-old men of color living in low-income areas for the simple reason that the former have a longer life expectancy. Moreover, the principle relies on unreasonable assumptions about the accuracy of predictions that a particular person will live decades into the future. It is infeasible during a severe pandemic for clinic staff to have detailed health histories about everyone seeking a pandemic u vaccine, treatment antivirals, and the like. Finally, the principle gives patients and clinicians incentive to hide health histories and important comorbidities that might otherwise contraindicate the patients receipt of resources. The most closely related recommendation offered by the Minnesota project is that persons be de-prioritized from receiving resources if they are known to be imminently and irreversibly dyingfor example, if they are known to have a comorbidity incompatible with life beyond a short time frame. De-prioritizing imminently dying persons maximizes the number of lives saved; it is not concerned with maximizing the number of life-years saved. Quality of Life Minnesotas project participants would reject Kerstein and Bogners recommendation that persons with specic psychological capacities be prioritized to receive resources be-
fore those lacking those capacities, including all infants and young children. Project participants explicitly recommended that resources not be rationed based on perceived differences in quality of life, regardless of the denition or method used to dene it. Quality-of-life judgments are notoriously subjective and difcult to implement consistently. Such judgments are likely to result in unacceptable discrimination and to exacerbate health disparities. (Modied) Youngest-First Kerstein and Bogner raise several valid concerns about Persad and colleagues modied principle of prioritizing the youngest rst, including its inconsistency with competing principles. The Minnesota Pandemic Ethics Project provides some support for rejecting the principle of prioritizing older children and young adults over other age groups. Many Minnesotans believe that during a severe inuenza pandemic it can be justied under some limited circumstances to prioritize younger before older persons, and especially children before adults. They explicitly rejected the notion of prioritizing younger children before older children or vice versa. Project participants recommendations regarding children stand in stark contrast with the recommendations of Persad and colleagues and Kerstein and Bogner. These two sets of authors recommend de-prioritizing infants and young children relative to older children and young adults. They base their recommendations on different rationales, both of which are not only inconsistent with the Minnesota Pandemic Ethics Projects recommendations, but also expressly rejected as unfair. An exhaustive review of the conicting age-based recommendations is beyond the scope of this commentary. It is worth observing, however, that the recommendations of the Minnesota Pandemic Ethics Project were developed from a statewide public health perspective in which it was assumed that many of the pandemic resources are public goods. It is perhaps not unexpected that persons design different allocation frameworks depending on the perspective brought to the task. Persad and colleagues ask, Assuming that you will live a normal life span, at what life-stage(s) would you prefer to have the greatest access to (life-saving) resources? Contrast this with the Minnesota projects core question: In a severe pandemic, how would you advise your states department of health to ration health resources fairly to protect the publics health? Project participants frequently observed that decisions they might make about allocating scarce resources within their families or at their place of employment should not necessarily be the same as decisions made by state government on behalf of all. CONCLUSION The need for ethical frameworks for allocating resources is clear. Fortunately, an increasing number of groups are tackling this challenging task. Particularly encouraging are the efforts that actively engage a diverse range of professionals and laypersons. The differences between
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various proposed allocation schemes suggest an urgent agenda of ethical issues in resource allocation deserving additional professional and public consideration. REFERENCES
Kerstein, S., and G. Bognar. 2010. Complete lives in the balance. American Journal of Bioethics 10(4): 3745.
Persad, G., A. Wertheimer, and E. J. Emanuel. 2009. Principles for the allocation of scarce medical interventions. Lancet 373: 423431. Vawter, D. E., J. E. Garrett, K. G. Gervais, et al. 2010. For the good of us all: Ethically rationing health resources in Minnesota in a severe inuenza pandemic. Final report. St. Paul, MN: Minnesota Center for Health Care Ethics and University of Minnesota Center for Bioethics. 2010.
Address correspondence to Erik Nord, Department of Mental Health, Norwegian Institute of Public Health, Sandakerveien 24c, bygg b, Oslo, 1403, Norway. E-mail: erik.nord@fhi.no
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