Resource Allocation

This article by Buckwalter and Peterson examines U.S. public attitudes toward scarce resource allocation strategies using a set of three studies involving a combined 1,868 participants through online platforms. The research questions targeted attitudes about specific principles used for allocation (utilitarian, prioritizing the worst off, egalitarian, and social usefulness), attempting to determine: 1) to what extent scarcity affects public evaluations of each principle, 2) whether the same pattern of judgments applies to reallocation of resources between existing patients, and 3) to what extent disadvantages to at-risk or historically marginalized groups impact support for utilitarian allocation.

Principles were presented in part by using statements about allocating lifesaving resources to patients based on “the order in which they arrive,” “the seriousness of illness,” “what saves the most lives,” and “how important the patient is to society.” Overall, participants generally agreed with the principles of utilitarianism (i.e., saving the most lives) and prioritizing the worst off (i.e., seriousness of illness) and disagreed with egalitarian and social usefulness principles. Situations of scarcity increased ratings for the principle of prioritizing the worst off.

When presented with potential reallocation of resources between existing patients, participants were split as to whether they agreed with taking resources from one patient for another based on utilitarian principles or prioritization of the worst off. Participants were more likely than in the first scenario to support allocation based on order of arrival (i.e., not allowing reallocation) until the death or recovery of the patient who initially received resources.

When allocation based on utilitarian principles was presented as disadvantaging at-risk or historically marginalized groups, participants’ attitudes depended on the group affect. Participants were more likely to approve of utilitarian allocation even if it disadvantaged the elderly and those with substance use disorders. They were split when allocation disadvantaged persons of color or persons with disabilities.

In general, study participants appeared to support principles of saving the most lives or prioritizing the worst off. One or both of these principles are at the base of most existing scarce resource allocation plans. However, support for these principles was lower with respect to reallocation of resources (vs. initial allocation). While participants were asked about social utility as a principle generally, the study did not investigate prioritization of health care workers, which is a subset of this approach adopted in some existing allocation frameworks. Additionally, due to the disparate impact of the current pandemic on disadvantaged communities, several policies advancing priority for these communities have also been advanced, but this approach received less support among participants in these studies.

These findings add to the base of research into public perceptions of ethical principles in resource allocation, and they highlight the importance of ethical evaluation of allocation policies and the importance of both engaging with the public in policy development and clearly communicating the rationales of adopted policies.

This article by Bhatia, part of a symposium in the Journal of Bioethical Inquiry, addresses the need to normalize discussion of rationing health care resources. These issues are frequently ignored or treated as taboo as matters of public discussion, which significantly limits honest community debate. While the article focuses on Australia and the U.K., the general principles are broadly applicable. Rationing decisions are often highlighted only in unusual circumstances, such as the current pandemic, but occur implicitly in numerous situations, as finite health care budgets do not allow all patients to receive unlimited health care access. Barriers such as referrals to specialists, waiting lists, eligibility criteria, among others, operate to ration care, but do so without broad public consideration of the type allocation of scarce resources during the pandemic has received. In the U.S., discussion is further complicated by the complex web of private and public insurance and persistent problems of uninsurance and underinsurance.

Drugs

FDA announced an Emergency Use Authorization (EUA) for Eli Lilly’s therapeutic bamlanivimab to treat mild to moderate COVID-19 in specified types of cases. HHS and the Department of Defense previously announced an agreement to purchase the first 300,000 does of the monoclonal antibody drug. As a result, the federal government will oversee allocation of these doses and will provide them at no cost to the public (though providers may charge a fee for administering the drug). Following the EUA, HHS announced that doses will be allocated to state and territorial health departments, which will then determine allocation to health care facilities. The drug is currently in phase 3 clinical trials.