Alaa Daoud and Ezio Di Nucci.

Wilkinson proposed that health systems should aim to prioritise patients who have the highest chance of survival, based on Taurek’s ‘lifeboat’ experiment, where the general public chose to save five patients instead of one patient. This is no more or less true of saying that the current approaches are all in line with a utilitarian approach of maximising benefits. However, some Jewish and Islamic scholars advocated a non-utilitarian approach in saying that once treatment has begun it is not permissible to reallocate the treatment. In such matters bioethical principles must be considered to better provide equity for patients. However, when bioethical principles come into conflict in priority setting, it indicates the lack of guidelines to strike a positive balance between benefits and harms in decision-making.

Our guidance: Benefits differ in rank as some benefits are more desirable than others e.g. a guaranteed benefit is given priority over an uncertain one, and lasting benefits are given priority over temporary ones. Harms should be managed in a similar manner while bearing in mind that all benefits are good, and all harms are bad. As a rule, no harm shall be inflicted. For this reason, no harm shall be removed by causing other similar harm. In a case where two harms are unavoidable, the lesser one should be endured. We must point out that preventing a great harm is given priority over obtaining a great benefit. So, how do we strike a balance between benefits and harms in decision-making? By simply balancing them against each other to know which ones play the dominant role.

Our recommendations: In contrast to recent recommendations, we recommend that the most serious of two cases (the worst off) gets the ventilator no matter the age, health condition and potential benefit. So, the one in greater need is given preference, as per our rules preventing the greatest harm is given priority over obtaining the greatest benefit. We only recommend the patient to be taken off the ventilator if the ventilator only has temporary benefit e.g. when further treatment is futile and if the ventilator will be given to someone else who in all probability have a lasting benefit e.g. convincing likelihood of recovery. This is because a lasting benefit ought be given priority over temporary benefits. In line with our rules, the most harmful option should be avoided. In that case the one with ventilator will not get better and die anyhow, and the other one is inevitably dying without the ventilator. Keeping the ventilator for the former patient will assure both die, which is a more harmful decision than letting one die and giving someone else a chance to survive. However, the patient shall not be taken off the ventilator if it is guaranteed that the ventilator will only be of temporary benefit to someone else as no harm shall be removed by causing other similar harm.

If both things are equal in two patients and we are to choose one, the equitable approach will of course be to choose one of them rather than losing both lives. This can be done on a first come, first served basis. In case that may lead to violence or unfair advantage, choosing one through random allocation (lottery) is recommended. However, if it became clear that the ventilator will be of only temporary benefit, priority should be given to someone else who may have a lasting benefit.

Usually, we warn against reallocation of ventilators to prevent the death of patients due to inadequate time of treatment, except for clearly sound reasons as mentioned above. Withdrawing ventilators to treat other patients who may require the ventilator for shorter time is an act of actively killing. We cannot stress this enough. It is morally wrong to kill a patient even in the prospect of saving more lives. So that’s also why, forcibly withdrawing ventilators from patients at nursing homes with the intention to save more lives is unjustified.

Paper title: A guidance for rationing scarce resources during the Covid-19 pandemic

Authors: Alaa Daoud^a and Ezio Di Nucci^b,c

Affiliations:

^aDepartment of Clinical Medicine, Faculty of Health and Medical science, University of Copenhagen, Denmark

^bDepartment of Public Health, University of Copenhagen, Denmark

^cCentre for Medical Science and Technology Studies, University of Copenhagen, Denmark

Competing interests: None

Social media account of post author: https://www.linkedin.com/in/alaa-daoud