This forthcoming article discusses the application of ethical principles to resource allocation in response to a public health crisis, such as COVID-19, emphasizing both the continuity of central ethical principles such as respect for persons and the increased relevance of justice considerations during times of scarcity.
The authors note that COVID-19 is disproportionately fatal to elderly patients, especially those with pre-existing health conditions, including a large number of patients with dementia and other neurological disabilities. Such patients are often residents of institutions in which the virus is more difficult to control, and they also face existing social stigma that is heightened during times of crisis when decisions of resource allocation may turn on public perception of quality of life.
The article emphasizes that central ethical principles remain the same even in times of crisis. This includes respect for persons and respect for their wishes regarding medical treatment, including advance directives communicating decisions for end-of-life care. Many older patients have expressed their decisions, but a significant minority have not, and excluding patients’ whose wishes are unknown from allocations of scarce resource based on generalizations about their quality of life is a form of unjustified discrimination.
The authors explain that there is no universally accepted framework for allocating scarce resources during a public health emergency, but many groups have developed guidelines. All of these approaches prioritize short-term survival, and a majority also consider long-term prognosis in some form. Other considerations, such as prioritizing health care workers or younger patients, are more controversial and may depend on specific circumstances of a crisis situation. The authors argue that the most important point of agreement among various approaches is that any framework used must substantively engage and reflect the views of the public to have the necessary legitimacy for the public to be confident that the rules are fair and reflective of social priorities.