How to fairly allocate scarce medical resources: Ethical argumentation under scrutiny by health professionals and lay people

Pius Krütli*, Thomas Rosemann, Kjell Y. Törnblom, Timo Smieszek

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

31 Citations (Scopus)

Abstract

Background Societies are facing medical resource scarcities, inter alia due to increased life expectancy and limited health budgets and also due to temporal or continuous physical shortages of resources like donor organs. This makes it challenging to meet the medical needs of all. Ethicists provide normative guidance for how to fairly allocate scarce medical resources, but legitimate decisions require additionally information regarding what the general public considers to be fair. The purpose of this study was to explore how lay people, general practitioners, medical students and other health professionals evaluate the fairness of ten allocation principles for scarce medical resources: ‘sickest first’, ‘waiting list’, ‘prognosis’, ‘behaviour’ (i.e., those who engage in risky behaviour should not be prioritized), ‘instrumental value’ (e.g., health care workers should be favoured during epidemics), ‘combination of criteria’ (i.e., a sequence of the ‘youngest first’, ‘prognosis’, and ‘lottery’ principles), ‘reciprocity’ (i.e., those who provided services to the society in the past should be rewarded), ‘youngest first’, ‘lottery’, and ‘monetary contribution’. Methods 1,267 respondents to an online questionnaire were confronted with hypothetical situations of scarcity regarding (i) donor organs, (ii) hospital beds during an epidemic, and (iii) joint replacements. Nine allocation principles were evaluated in terms of fairness for each type of scarcity along 7-point Likert scales. The relationship between demographic factors (gender, age, religiosity, political orientation, and health status) and fairness evaluations was modelled with logistic regression. Results Medical background was a major predictor of fairness evaluations. While general practitioners showed different response patterns for all three allocation situations, the responses by lay people were very similar. Lay people rated ‘sickest first’ and ‘waiting list’ on top of all allocation principles—e.g., for donor organs 83.8% (95% CI: [81.2%–86.2%]) rated ‘sickest first’ as fair (‘fair’ is represented by scale points 5–7), and 69.5% [66.2%–72.4%] rated ‘waiting list’ as fair. The corresponding results for general practitioners: ‘prognosis’ 79.7% [74.2%–84.9%], ‘combination of criteria’ 72.6% [66.4%–78.5%], and ‘sickest first’ 74.5% [68.6%–80.1%); these were the highest-rated allocation principles for donor organs allocation. Interestingly, only 44.3% [37.7%–50.9%] of the general practitioners rated ‘instrumental value’ as fair for the allocation of hospital beds during a flu epidemic. The fairness evaluations by general practitioners obtained for joint replacements: ‘sickest first’ 84.0% [78.8%–88.6%], ‘combination of criteria’ 65.6% [59.2%–71.8%], and ‘prognosis’ 63.7% [57.1%–70.0%]. ‘Lottery’, ‘reciprocity’, ‘instrumental value’, and ‘monetary contribution’ were considered very unfair allocation principles by both groups. Medical students’ ratings were similar to those of general practitioners, and the ratings by other health professionals resembled those of lay people. Conclusions Results are partly at odds with current conclusions proposed by some ethicists. A number of ethicists reject ‘sickest first’ and ‘waiting list’ as morally unjustifiable allocation principles, whereas those allocation principles received the highest fairness endorsements by lay people and to some extent also by health professionals. Decision makers are advised to consider whether or not to give ethicists, health professionals, and the general public an equal voice when attempting to arrive at maximally endorsed allocations of scarce medical resources.

Original languageEnglish
Article numbere0159086
JournalPLoS ONE
Volume11
Issue number7
DOIs
Publication statusPublished - Jul 2016

Bibliographical note

Funding Information:
Funding: The Cogito Foundation funded this study (S-117/12). The Institute of Primary Care of the University of Zurich supported the data collection.

Funding Information:
We acknowledge and express our gratitude to the Cogito Foundation for funding this research and to the Institute of Primary Care at the University of Zurich for supporting the data collection. We also thank Sandro Bösch for assembling and laying out figures, Maria Rey for administrative support, the project’s advisory board (Drs Daniel Koch, Christian Studer, and Jakob Zinsstag) for giving generously of their time and for their helpful suggestions, Drs Hans C. Matter and Elvira Del Prete for their advice on the legal history of donor organ and pandemic influenza vaccine allocation in Switzerland, several ETH faculty members for participating in a pilot study, and the respondents for their time to complete the questionnaire. We gratefully acknowledge Dr Govind Persad’s comments that helped to sharpen up the quality of this manuscript, as well as the helpful comments of two reviewers and the journal’s editor.

Funding Information:
The Cogito Foundation funded this study (S-117/12). The Institute of Primary Care of the University of Zurich supported the data collection. We acknowledge and express our gratitude to the Cogito Foundation for funding this research and to the Institute of Primary Care at the University of Zurich for supporting the data collection. We also thank Sandro B?sch for assembling and laying out figures, Maria Rey for administrative support, the project?s advisory board (Drs Daniel Koch, Christian Studer, and Jakob Zinsstag) for giving generously of their time and for their helpful suggestions, Drs Hans C. Matter and Elvira Del Prete for their advice on the legal history of donor organ and pandemic influenza vaccine allocation in Switzerland, several ETH faculty members for participating in a pilot study, and the respondents for their time to complete the questionnaire. We gratefully acknowledge Dr Govind Persad?s comments that helped to sharpen up the quality of this manuscript, as well as the helpful comments of two reviewers and the journal?s editor.

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