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Health Care Analysis
Published in: Health Care Analysis 4/2021

01-12-2021 | Public Health | Original Article

Beyond Individual Triage: Regional Allocation of Life-Saving Resources such as Ventilators in Public Health Emergencies

Authors: Jonathan Pugh, Dominic Wilkinson, Cesar Palacios-Gonzalez, Julian Savulescu

Published in: Health Care Analysis | Issue 4/2021

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Abstract

In the first wave of the COVID-19 pandemic, healthcare workers in some countries were forced to make distressing triaging decisions about which individual patients should receive potentially life-saving treatment. Much of the ethical discussion prompted by the pandemic has concerned which moral principles should ground our response to these individual triage questions. In this paper we aim to broaden the scope of this discussion by considering the ethics of broader structural allocation decisions raised by the COVID-19 pandemic. More specifically, we consider how nations ought to distribute a scarce life-saving resource across healthcare regions in a public health emergency, particularly in view of regional differences in projected need and existing capacity. We call this the regional triage question. Using the case study of ventilators in the COVID-19 pandemic, we show how the moral frameworks that we might adopt in response to individual triage decisions do not translate straightforwardly to this regional-level triage question. Having outlined what we take to be a plausible egalitarian approach to the regional triage question, we go on to propose a novel way of operationalising the ‘save the most lives’ principle in this context. We claim that the latter principle ought to take some precedence in the regional triage question, but also note important limitations to the extent of the influence that it should have in regional allocation decisions.
Footnotes
1
We have been influenced in designing this hypothetical by considering the characteristics of different regions in the UK and questions about where to allocate ventilators. However, the issues are not specific to the UK, and these hypothetical regions should not be taken to be representative of actual locations.
 
2
Obviously, if there are no differences between areas in the nature of the problem, there is no great difficulty in deciding how to allocate treatment. For example, if all areas are completely overwhelmed, any distribution of ventilators may have a similar effect.
 
3
Ventilators require skilled personnel to operate them (with sufficient personal protective equipment), sufficient oxygen to run them, medications (e.g. sedatives) to keep patients sedated etc. Anecdotally, in the first wave of the pandemic in the UK, there were significant shortfalls in all of those factors affecting or threatening patient care, even though ventilator numbers were sufficient. https://​www.​theguardian.​com/​world/​2020/​apr/​07/​high-demand-for-oxygen-risks-system-failure-nhs-england-warns, https://​www.​bbc.​co.​uk/​news/​newsbeat-52440641https://​www.​bbc.​co.​uk/​news/​health-52150861.
 
4
For example, they may arise with respect to other existing treatment resources, such as Extra-Corporeal-Membrane-Oxygenation (ECMO) machines. See [15] They may potentially arise with respect to treatments that are currently under investigations, such as Remdesivir [28] and intravenous immunoglobulin treatment or monoclonal antibodies.
 
5
Notably, it is less clear that our analysis translates to preventative public health interventions such as vaccinations.
 
6
See also [18, 24, 27].
 
7
Savulescu et al. [25]. See also [9].
 
8
The RAPRi assumes that patients in need of the treatment will all die without the therapy (in this case ventilators). If there is a greater than zero chance of survival without treatment, the relevant “probability of survival” is the difference between the chance of surviving without a ventilator, and the chance of surviving if treated with a ventilator. (Obviously, it would be irrational to prioritise a patient who had a high chance of surviving without treatment, and whose chances would be changed little by access to a ventilator).
 
9
Alternatively, there may be surplus ventilators once all patients in the high RAPRi group have been given access, and there may still be a large group falling below the threshold that would benefit from access to a ventilator.
 
10
For discussion, see [10].
 
11
NHS trusts in the city of Liverpool have a sum total of 95 adult critical care beds, whilst NHS trusts in Bristol have 101 [19].
 
12
While not relevant to saving the greatest number, per capita assessments may be of moral relevance in other ways. For instance, it might be argued that it would be fairer to prioritise regions that will have a higher proportion of their population requiring ventilation. We shall return to this point below.
 
13
For an example of such modelling in the UK context, see Edge Health, ‘How Many More Critical Care Beds Are Needed Regionally?’.
 
14
The relevant survival rate for regional triage should include all patients admitted to a hospital, not solely those admitted to intensive care. This would take into account the probability of survival without intensive care and reduce selection effects. See also earlier footnote 8.
 
15
Of course, a more complex case-mix adjusted survival rate could be calculated.
 
16
One factor that might influence length of stay for an intensive care unit will be whether clinicians would consider withdrawal of treatment for patients with relatively poor prognosis who have failed to wean off support. If intensive care units are prepared to withdraw treatment in order to provide it to other patients with better prognosis, [3, 17] that would potentially increase the efficiency of ventilator usage and increase the priority of the region for allocation.
 
17
Such concerns typically focus on arbitrary regional boundaries and differences in distribution of treatment. While regional triage and allocation of a scarce treatment along the lines described in this paper would generate some differences between regions, those differences would not be “arbitrary”—they would be on the basis of justifiable ethical principles.
 
18
See Parfit’s discussion of deontic egalitarianism in [23].
 
19
We have defended this claim in relation to individual triage in [25].
 
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Metadata
Title
Beyond Individual Triage: Regional Allocation of Life-Saving Resources such as Ventilators in Public Health Emergencies
Authors
Jonathan Pugh
Dominic Wilkinson
Cesar Palacios-Gonzalez
Julian Savulescu
Publication date
01-12-2021
Publisher
Springer US
Published in
Health Care Analysis / Issue 4/2021
Print ISSN: 1065-3058
Electronic ISSN: 1573-3394
DOI
https://doi.org/10.1007/s10728-020-00427-5

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