This guidance from the British Medical Association (BMA) addresses ethical issues in allocating scarce life-saving medical resources during the COVID-19 pandemic, building on an ethical framework most recently revised in 2017 and providing updated guidance specific to COVID-19.

The guidance provides that it is essential for all resource allocation decisions to be:

• • Reasonable in the circumstances
  • Based on the best available clinical data and opinion
  • Based on coherent ethical principles and reasoning
  • Agreed on in advance where practicable, while recognizing that decisions may need to be rapidly revised in changing circumstances
  • Consistent between different professionals as far as possible
  • Communicated openly and transparently

• Subject to modification and review as the situation develops.

The BMA guidance notes that current data show a strong correlation between older age and COVID-19 mortality. However, the guidance provides that triage decisions must not be based solely on age, but rather on clinically relevant facts about individual patients and their likelihood of benefiting from available resources, though age may be a clinically relevant factor. To that end, the document notes that co-morbidities may exclude individuals from eligibility.

Notably, decisions on this basis must be careful not to categorically disadvantage individuals with disabilities based on disability alone or based on biases with respect to disability and quality of life or long-term life expectancy. These issues are explored more fully in other posts in this series.

When multiple persons have similar chances of survival once relevant factors are considered, the BMA guidance notes that the most likely approach to fair allocation within a similarly-situated group is “first come, first served,” which prioritizes persons who are assessed first. Of note, this is the approach outlined in Indiana’s 2014 Crisis Standards of Care plan regarding triage and ventilator allocation. However, as explained in the BMA guidelines, this approach may prioritize persons who are more mobile, have better access to transportation, or who live closer to health care facilities. This may disadvantage persons with disabilities, persons with fewer resources, and persons in rural or outlying communities. Additionally, in the U.S. context, “first come, first served” may inadvertently prioritize persons with health insurance (who may more readily seek care compared to those without insurance who are concerned with ability to pay). First come, first served may also inadvertently prioritize persons who fail to follow social distancing or other recommendations and orders, as such persons may become ill earlier than those who do follow these rules.