When rationing becomes inevitable in a pandemic: A discussion on the ethical considerations from a public health perspective.

Objectives: Coronavirus Disease 2019 has presented extreme difficulties to healthcare resource allocation worldwide. Health resources, particularly during a pandemic, are limited even in developed countries. The main challenge for healthcare professionals is to be able to ration resources in an ethical manner. Therefore, this leads to ethical considerations that we aim to discuss in this paper, based on which, recommendations can be made for reference by healthcare management, policymakers, and public health practitioners. Study design: This is a discussion paper.
Methods: A brief review of the major principles as they relate to the notion of rationing in a pandemic was conducted. We organized an ethical discussion from public health perspectives based on these major principles.
Results: Prior to deciding the principles to adopt, a transparent and robust guideline for rationing must be established. There are four considerations that need to be made: transparency, consistency, inclusiveness, and accountability. There does not exist a "perfect" principle to adopt during rationing. However, in the authors' opinion, the most obvious principles that would be unsuitable during a healthcare crisis would be the equal worth and prioritarian principles. This leaves the equity principle, utilitarian and urgent need principles.
Conclusion: The recommendation of this discussion paper is to adopt multiple principles according to the situation of each country or even the particular hospital.

Background

Rationing during the COVID-19 pandemic

In a pandemic, an infectious disease spreads rapidly worldwide and has negative economic, social, health, and/or emotional impacts on many individuals. The most notable pandemic in recent times is undoubtedly the coronavirus disease (COVID-19). COVID-19 has presented extreme difficulties to healthcare resources allocation throughout the world in terms of prevention of infection, controlling the spread of the disease, and provision of medical care and attention to infected individuals with severe forms of the symptoms. As such, the health departments of every nation would have to strategize, accordingly respond, and control the spread of the disease [1]. Most notably, distribution of healthcare resources to people will be a challenge.

Rationing is the distribution of limited resources to reach as many people as possible. During a pandemic, the spike of demand for specific healthcare resources is frequently higher than the supply. This is when rationing is required, and this further has an impact on healthcare providers [2]. Consideration must be made in handling rationing whereby there must be a balance in terms of distributive justice, autonomy, and beneficence. Rationing is paramount during such a crisis, and the scarce resources must be distributed to as many people as possible [3]. This, therefore, leads to ethical considerations which we aim to discuss in this paper, based upon which recommendations can be made for reference by healthcare management, policymakers, and public health practitioners.

Rationing as an inevitable event when resources are limited in the pandemic

Health resources, particularly during a pandemic, are limited even in developed countries. Their healthcare system will collapse if they attempt to satisfy every single demand for healthcare supplies. Healthcare rationing is therefore inevitable in order to have balanced well-being for a society [4]. During the COVID pandemic, rationing occurs for individual’s accessibility to ICU where space was limited against a spike of demand. Patients with milder symptoms may be transferred to another ward, despite requiring the ICU, in favour of another individual with more severe symptoms. Healthcare professionals would also have to ration their attention and time depending on patients as well as other responsibilities such as their private and family lives [5].

The main challenge for healthcare professionals is to be able to ethically ration resources [6]. The WHO has recommended healthcare professionals to take the initiative to adopt and apply present rationing frameworks within their respective context. In an ideal scenario, a society is homogenous, whereby each person has equal rights. Thus, resources could just be distributed equally and on a first-come, first-serve basis. Such a method is suitable to act as a guideline in allocating limited resources to individuals that may equally benefit from them. An example of this are ventilators being shared between patients that have similar diagnoses [7]. However, it is not practical as allocation also involves other considerations, such as cost optimisation [8]. Additionally, first-come, first-serve basis favours individuals that have more accessibility to the resources, thus this is unfair to the others.

Discussion

Rationing based on utilitarian principle

Health policies are generally created based on utilitarianism [9]. Utilitarianism means that the action that has the maximum benefit should be taken [10]. It is a form of consequentialism whereby each action is determined based on the consequences. Utilitarian-based rationing will therefore be based on the execution of actions that has the most benefits and with the least negative consequences. During the COVID-19 pandemic, rationing of health services involved prioritising patients who are deemed to have a better response to a treatment. Patients who are found to only have only a short-term benefit will be excluded. These include those with terminal illnesses, the aged and those that have underlying conditions that prevent full recovery. This presents an ethical dilemma whereby the vulnerable are not protected, especially the disadvantaged groups.

Equity principle rationing

Equity resourcing means that resources are shared as fairly as possible regardless of whether the consequence is positive or negative. This is to reduce disparity so that the more privileged and the disadvantaged within the society could both receive a fair share [9]. In terms of the pandemic, patients with the highest risk, such as those with severe symptoms, high infectivity, or risk of death, will be prioritised and receive the necessary resources without considering their financial background. Equity rationing does not mean equal distribution for every single individual but rather, it means prioritising those that needed it the most.

Equal worth principle

This principle does not conform to the idea of rationing and treats everyone independently without discrimination or any form of prejudice. It means each that person is equal regardless of what background they are from. It is ideal in scenarios where the healthcare supplies are sufficient for everyone. Therefore, it is not possible during the pandemic where there is a serious shortage of healthcare equipment, supplies, and even personnel to deal with the large influx of patients that require medical attention.

Urgent need principle

Urgent need principle refers to allocation of resources according to the level of need of a particular individual. Allocation of resources are focused on those who needed it the most. In terms of the COVID-19 pandemic, this means prioritising individuals that will die or deteriorate in health if the resources are not allocated to them. Such principle has merit as those that need resources shall be given the necessary priority.

Prioritarian principle

This principle prioritises the most disadvantaged individuals in the society. During the COVID-19 pandemic, this means the individuals that are most vulnerable such as the elderly, homeless, poorest and such, shall be prioritised in the allocation of resources. The disadvantage of this is of course, it completely disregards the need or the severity of symptoms of the individuals.

Conclusion and recommendations

Much of the discussion among policymakers and public health practitioners centres on the most suitable or optimal form of rationing during a pandemic. Prior to deciding the principles to adopt, a transparent and robust guideline for rationing must be established. There are four considerations that need to be made; transparency, consistency, inclusiveness and accountability. First, transparency of rationing ensures that all levels of stakeholders such as the public and health care workers will be kept informed. The guideline is to be practiced and executed with consistency without any form of prejudice or partiality including loved ones. Inclusiveness involves allowing individuals to challenge or possibly to amend the guidelines as time passes or as the situation changes. Accountability is the trust placed in individuals that they will execute these actions according to the guidelines and remain fair at all times.

There does not exist a “perfect” principle to adopt during rationing. However, in authors’ opinion, the most obvious principles that would be unsuitable during a healthcare crisis would be the equal worth and prioritarian principles. Prioritarian is purely discriminative against those who are not disadvantaged. People should not be discriminated regardless of whether or not they have a disability.

The unsuitability of the equal need principle should be evident especially in the context of the COVID-19 pandemic. Since healthcare resources are already scarce, and patients vary in severity of symptoms, it will not make much sense to have equal distribution. The resources would be better allocated to save lives or those that have the possibility to respond better.

This leaves the equity, utilitarian, and urgent need principles. The recommendation of this discussion paper is to adopt multiple principles according to the situation of each country or even the particular hospital. The utilitarian and equity principles, despite their contradictory natures, should be the foundation of guidelines as they focus on the best outcome for the greatest amount of people. Therefore, there needs to be a balance between benefiting the greatest number of people and ensuring that those in need receive their required resources without prejudice.

Funding sources

This discussion paper received funding support (reference no.: IDG210216P) from the Caritas Institute of Higher Education.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.