Justice and Ethical Allocation of Resources 

Khizra Shafiq, Racheli Zirman, Isra Nazlin, Rebecca Murdikhayeva

York College

Biomedical Ethics

Professor McGarry

July 14, 2023

Distributive justice can be defined as “providing moral guidance for the political processes and structures that affect the distribution of benefits and burdens in society” (Oedingen et al., 2021). When healthcare resources are inadequate, medical providers are tasked with deciding how resources should be allocated under the ethical principle of distributive justice. The allocation of scarce resources such as donor organs, ventilators, surgical resources, and healthcare workers has multiple approaches to ensure the maximum benefit to each patient. The COVID-19 pandemic has forced healthcare providers to make difficult decisions regarding what should be done once hospitals reach capacity and how resources in intensive care units should be allocated (Rawling et al., 2021). Furthermore, the pandemic has led to increased demand on healthcare, particularly in critical care, requiring healthcare workers to be reallocated to acute care settings, which posed significant risks to healthcare workers (Dunn et al., 2020).

Another important consideration when discussing allocation of scarce resources is donor organs. Oftentimes clinicians may struggle to decide how deceased donor organs should be allocated and what makes one patient more deserving than the other. To make the decision a little easier, the public should be involved in deciding what factors are most important and how clinicians should approach this ethical issue (Oedingen et al., 2021). The Sequential Organ Failure Assessment Score, otherwise known as the SOFA, is a score that is utilized by healthcare providers to assess the severity of their patient’s condition and their likelihood of surviving. While the Scoring system is helpful to providers, it can often overlook the ethnic and racial disparities that are associated with certain healthcare conditions, and it is therefore an imperfect scoring system to use alone for the fair allocation of resources (Galiatsatos et al, 2022). It is therefore imperative that changes be made such as having a correction factor for ethnic disparities and bias training.

Additionally, the pandemic placed a heightened burden of disease, as it exceeded the capacity of the current therapeutic and diagnostic resources of many hospitals. Thus, it resulted in the question of the proper allocation of hospital beds, personal protective equipment, ventilators, and other scarce resources. In the article titled “Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic,” it highlights the impact of the pandemic on ethical considerations for allocation of scarce resources and alterations in surgical care. As of now, it is important to make decisions of resource allocation based on a legitimate ethical foundation and the most updated information on the emergency at hand. Although the ethical principle of beneficence is foundational to clinical practice, the situations brought on by the pandemic forced clinicians to focus on the well-being of many patients and a larger affected society rather than an individual patient. This article highlights how the benefits to the entire population take priority over the benefit to a singular patient, resulting in the lack of fulfillment of a patient’s request for certain resources for care. This does not deny the patient’s autonomy, but rather emphasizes that the pandemic set forth limitations such that not all requests for intervention can be met (Rawling et al., 2021). Thus, it forces clinicians to recognize certain values in the resource allocation decision making process.

For example, they must consider that the best decision would be one that maximizes benefits, such as saving the most lives possible. This ideology demonstrates that saving five lives as opposed to saving one life would be more ethically sound. Providing hospital beds and ICU beds for COVID-19 patients rather than patients undergoing elective surgery is an example of maximizing benefits (Rawling et al., 2021). Another value in the resource allocation decision making process should be treating all people equally. For example, the “first-come, first-serve” principle does not treat all people equally. The more advantaged patients who have better access to vital information and can travel to receive higher quality care would receive the limited resources first. This results in a lack of life-saving resources for patients who presented later. Furthermore, during a pandemic, it would be important to allocate resources to those who provide instrumental value to society. For example, treating essential workers and getting them back into the workforce would provide value to society. Provisions should be granted for those who are actively participating in fighting against the pandemic (Rawling et al., 2021). Lastly, each hospital should designate a well-trained clinical triage team to help guide decisions for allocation. It is already exhausting to be a healthcare worker during a pandemic, but relying on them to make ethical decisions to remove certain resources from certain patients would only add to the stress and grief. An effective clinical triage team would result in better patient outcomes and increase objective decision making.

In addition to the scarce resources within the surgical specialty, the COVID-19 pandemic placed an increasing demand on healthcare, particularly in critical care. It required healthcare workers to change well established pathways and be “reallocated” to acute care settings to handle the high intake of critically ill patients. But when these healthcare workers were being asked to provide care in these acute care settings, they were doing so in an environment that posed significant risks to themselves. Clinical interventions that expose healthcare workers to secretions of patients who are ill with COVID-19 are particularly dangerous, as the secretions contain the highest concentration of virus particles (Dunn et al., 2020). The ethical question arises of whether these professionals should be reallocated to high-risk clinical roles. It could be seen as a simplistic issue of beneficence where the health professionals have the obligation to do what is right for their patient, which may extend to meaning that health professionals may be bound by their duties to their patients during a pandemic, and reallocation for the benefit of patients during the pandemic may be justified. However, reallocating these health professionals to high-risk clinical roles poses an elevated risk of harm to the professionals, and raises an issue of nonmaleficence towards the professionals. The argument can be made that due to the personal risk, the ‘obligation to treat’ does not outweigh the professionals’ duties to themselves. The article summarizes the ethical bind as: pandemic treatment needs to be provided, but no individual in a healthcare role is specifically obliged to provide it (Dunn et al., 2020).

The article “’Your country needs you’: the ethics of allocating staff to high-risk clinical roles in the management of patients with COVID-19”, discusses the ethical steps that need to be taken to reallocate healthcare professionals, which answer three questions: What constitutes a justifiable process for deciding which staff are chosen to be reallocated? What reallocation models for making these choices are justifiable? What is owed to those reallocated to high-risk clinical roles? (Dunn et al., 2020). To answer the first question regarding a justifiable process for deciding which staff are chosen for reallocation, three options are offered: no choice, individual choice, collective choice. Having no choice in who will be reallocated is considered to be unethical since no staff member will retain control over how their job is enacted. Individual choice, which follows a volunteer model, allows control over being exposed to the risks. Collective choice, where a group can reach a consensus on who will be deployed, which if done correctly, is a proposal accepted by all (Dunn et al., 2020).

The article next discusses reallocation models to make these choices justifiable, including volunteering, lottery, and equal sharing of risk. For example, equal sharing of risk is a more justifiable approach rather than allocating a role to one person that is consistently undertaking more high-risk interventions (Dunn et al., 2020). Finally, the article addresses what is owed to those who are allocated to high-risk roles. They should receive appropriate acknowledgement for the special demands of their roles, sufficient preparation, and necessary training to be able to work in established clinical teams, and prioritization for resources; that is, priority provision for compensation for those who are undertaking high-risk roles (Dunn et al., 2020).

When considering the ethical principle of distributive justice and the allocation of resources, it is important to consider the allocation of donor organs, especially since it is such a scarce resource. The gap between supply and demand in the field of organ transplantation brings upon an ethical dilemma of who should receive an organ from a deceased donor and what makes one patient more deserving compared to another. In the article “Public Preferences for Allocation of Donor Organs for Transplantation: A Discrete Choice Experiment” by Oedingen et al., the authors investigated public preferences regarding allocation of organs in Germany and ranked them to determine which factors the public considered to be most important.

The authors considered six essential attributes based off the distributive justice principles: life years gained after transplantation, a patient’s quality of life after receiving a transplant, a patient’s chance of receiving another donor organ offer, age, whether the patient was a registered donor themselves, and an individual’s role in the cause of their organ failure (Oedingen et al., 2021). When considering these six factors, clinicians and non-medical professionals can make a more ethical decision when allocating donor organs under the principle of distributive justice.

Based on the results obtained from the study, good quality of life was rated as the most crucial factor regarding allocation of donor organs (Oedingen et al., 2021). Under the principle of distributive justice, this factor can be classified as utilitarianism, which is defined as maximizing total benefit (Oedingen et al., 2021). The second most important factor was age. Younger patients were seen as more worthy of receiving a donor organ compared to older patients which can be best understood when considering medical and sociodemographic status since younger patients can be seen as those who have their entire life ahead of them and would benefit most from receiving a transplant (Oedingen et al., 2021). Other factors that were considered such as those listed above, did not seem to play such a significant role when considering distributive justice regarding organ transplantation.

When the world faces a healthcare crisis, such as the recent COVID pandemic or the influenza pandemic, the fair and just allocation of resources becomes a challenge. Many hospitals in the United States utilize a tool known as the SOFA score in critical care (Galiatsatos et al, 2022). The SOFA score, also known as the sequential organ failure assessment score, assesses the function of multiple organs in the patient’s body and assigns a score that represents the patient’s likelihood of survival versus mortality (Galiatsatos et al, 2022). This score can be helpful for clinicians to allocate the scarce resources to those with the best chance of survival, however, there are several ethical issues with the usage of this scoring system.

Firstly, the SOFA score has not been proven to be correct in its estimation of mortality in the recent COVID pandemic and therefore basing ethical decisions off it without it being validated can be unethical. Secondly, the SOFA score does not fairly report based on race and ethnicity. An example of this was in the COVID pandemic, African American patients were experiencing more cases of sepsis than White patients as well as worse physiological side effects. This gave the African American race a worse outcome predictor than Whites even if that was not the case but merely based on their higher incidence of sepsis in the pandemic. It is therefore imperative to incorporate the principles of distributive justice and health equity into our clinical decision of the allocation of resources (Galiatsatos et al, 2022).

The first concept that is suggested in the article is mandating bias training to recognize and mitigate prejudice. The second suggestion is to have healthcare teams periodically look to identify health disparities in their patient populations and ensure that their allocation of resources is not increasing these disparities. Thirdly, resources that evaluate the outcomes of patients should take into consideration different variables such as race, access to healthcare, gender, and other sociodemographic variables. This resource should be evaluated by a multidisciplinary team that is not making any of the triage decisions (Galiatsatos et al, 2022).

  A possible change that can be made to the SOFA score would be to incorporate a correction factor to the scoring system to consider the ethnicities who are affected. Another proposal to the allocation of resources is to set aside a set number of resources to be used for populations who are at a higher risk of negative impact during a pandemic or health crisis. The rest of the resources would be utilized based on scoring systems such as SOFA. This would ensure that these ethnicities would not suffer due to these scoring systems and would get more of a just allocation of resources. The author questions the healthcare system’s focus on the allocation of resources to those with the greatest chance of survival and poses the idea that this might not be justice (Galiatsatos et al, 2022). It is important to remember that justice should not be accomplished at the expense of health equity.

         Ethical decisions should be based on maximizing benefits, saving as many lives as possible, and providing instrumental value to society. In the case of surgical resources, there should also be a cost-effectiveness analysis, an assessment of the severity of the patient’s illness, and a prediction of treatment outcome. Regarding the reallocation of health professionals to high-risk clinical roles during the pandemic, ethical questions should be considered to ensure fair and ethical decision-making. The allocation of other scarce resources such as donor organs may be another source of moral distress for clinicians. In efforts to combat this issue, the public should be involved in deciding which factors should be prioritized when distributing such a valuable resource. The use of a scoring system such as SOFA is a great way to allocate scarce resources to those with the best chance of survival. However, when considering the usage of these scoring systems, clinicians need to be aware of their own biases and be more cognizant of the ethical disparities that are not currently accounted for in assessment tools.

References

Dunn, M., Sheehan, M., Hordern, J., Turnham, H. L., & Wilkinson, D. (2020). ‘Your country

needs you’: the ethics of allocating staff to high-risk clinical roles in the management of patients with COVID-19. Journal of medical ethics, 46(7), 436–440. https://doi.org/10.1136/medethics-2020-106284

Galiatsatos, P. (n.d.). Health equity and distributive justice considerations in critical care …

Health equity and distributive justice considerations in critical care resource allocation. https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(20)30277-0/fulltext

Oedingen, Bartling, T., Schrem, H., Mühlbacher, A. C., & Krauth, C. (2021). Public preferences

for the allocation of donor organs for transplantation: A discrete choice experiment. Social Science & Medicine (1982), 287, 114360–114360. https://doi.org/10.1016/j.socscimed.2021.114360

Rawlings, A., Brandt, L., Ferreres, A., Asbun, H., & Shadduck, P. (2021). Ethical considerations

for allocation of scarce resources and alterations in surgical care during a pandemic. Surgical endoscopy, 35(5), 2217–2222. https://doi.org/10.1007/s00464-020-07629-x