Rewarding through prioritization: The limits of reciprocal obligation in allocating scarce medical resources in the COVID-19 crisis

By Thibaud Haaser

In the face of the COVID-19 pandemic, health systems are under severe strain. Some countries are currently experiencing, or may experience within a few weeks, shortages of medical resources (in particular intensive care beds and mechanical ventilation). In this context, the health community may have to make impossible choices regarding the allocation of scarce resources. In such cases, decisional strategies or algorithms have been considered. In addition to clinical and care burden evaluations, some authors suggest that other criteria could be used in order to break the tie in specific situations. Thus, being a health worker or participating in a research protocol could be rewarded in difficult decision-making situations.

In this pandemic context, health workers are key players. Faced with what is described as a war against COVID-19, health workers must be given priority because we need them to go back to the front line as soon as possible. Their instrumental value must be taken into account in the event of arbitration. In addition, the commitment of health workers is remarkable. Testimonies from Italy and north-eastern France underline their bravery and solicitude in the face of tragic situations. They do everything they can to take care of as many people as possible, often in difficult practical conditions and by putting themselves in danger in the absence of optimal personal protective equipment. Some doctors have even died because they have agreed to help and therefore put themselves at risk of contamination. Thus, some authors suggest that this commitment to the specific COVID-19 effort should be rewarded in the event of a decision to allocate resources: it would be unethical not to intubate a 70-year-old physician who returned to work in intensive care to save of others’ life.

One of the priorities in managing this crisis is to develop preventive (vaccines) or curative strategies against COVID-19 as quickly and effectively as possible. These processes require a large number of volunteers, healthy ones as well as infected patients. Their consent to research can be seen as active participation in a global effort against COVID-19. Their commitment should also be rewarded by prioritizing them for intensive care and mechanical ventilation.

In these two cases, the principle of reciprocal obligations is evoked: in response to the commitment of some people to face this collective crisis, the community owes them in return to reward them proportionately. It is not about making this criterion the only one to be considered but in case of arbitration for allocation of scarce resources, their engagement must be taken into account. It seems logical, natural and ethically justified.

However, these reward models need to be carefully weighed, whether for caregivers or research participants. Attention is currently focused on intensive care units and emergency units: it makes sense because they are on the front line. But there are many front lines in health systems, and all of them face ethical dilemmas and require genuine and authentic commitment from health workers. For example oncological, psychiatric, geriatric or surgical units are not on the front line but must face concrete ethical questions: rethinking the therapeutic balance, prioritizing surgical procedures, etc. Numerous health workers are involved in the silent work of continuity of care, far from COVID-19 front line but with equal commitment, questioning and self-denial. Shouldn’t they be rewarded like those on the visible front lines?

Faced with this general crisis, the mobilization is also general and occurs outside hospitals. Essential services such as cleaning services, security or those who supply stores are fundamental. Workers are involved so life goes on as much as possible. They do not have optimal personal protective equipment either:  they take a risk (maybe less important than for emergency professionals, but a risk nonetheless). These basic services are all the more important in containment contexts. Could not a reciprocal obligation be evoked for them? By focusing only on healthcare professionals, we could set aside a whole group of volunteers who do everything they can in their own area of expertise.

Third, research participant enrollment is essential for curative or preventive strategies to be implemented. It is an urgent issue. It seems justified to optimize their recruitment by this reward through prioritization. However, one cannot help thinking that with such arguments, people are likely to consent to research above all to optimize their chances of survival and not with the primary will to participate to a global effort. Prioritization would be the reason of their consent and not a secondary benefit of their consent. The problem is that this idea of commitment to the collective effort is the main reason for reciprocal obligation. If their consent is based solely on the possibility of a reward, does reciprocal obligation have to be applied?

Reciprocal obligation is the key principle of prioritization rewards for health workers and research participants. However, the definition of a valid and authentic commitment (leading to a reciprocal obligation) seems difficult to draw. Arbitrary decisions could result from possible interpretations of the principle of reciprocal obligations. Unfortunately, in this unprecedented (and for many aspects insufficiently anticipated) crisis, we are running out of time to create solid and final decision-making frameworks. The main way to avoid arbitrariness (or at least to minimize it) is to share decisions. Processes such as decision support committees including physicians, but also ethicists, other health professionals, community representatives are needed to share the burden of these impossible choices. Ethicists have a major role to play and must be involved in such committees.


Author:  Thibaud Haaser

Affiliations: University of Bordeaux, France

Competing interests: None

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