COVID-19: Should we allocate health care resources based on citizens’ individual contribution to society?

By Rebecca Limb


There has not been a time in recent memory where the NHS’s resources have been under so much pressure that questions around resource allocation have become pressing and persistent ethical concerns.

With COVID-19 lockdown measures due to be eased in the coming weeks there is a significant threat of a second potentially more serious peak that could see the NHS overwhelmed.

The British Medical Association declared that if demand for NHS resources “outstrips the ability to deliver to existing standards, more strictly utilitarian considerations will have to be applied, and decisions about how to meet individual need will give way to decisions about how to maximise overall benefit”.

Although the UK is under an international obligation to ensure all citizens enjoy the “highest attainable standard of physical and mental health”, it is up to each member state to determine how they allocate their limited medical resources based on their particular range of policy considerations.

Where there are limited resources, “difficult and agonising judgments have to be made as to how a limited budget is best allocated to the maximum advantage of the maximum number of patients”.

Decisions about the allocation of resources must be “fair and based on clinical need and the likely effectiveness of treatments, and are not based on factors that may introduce discriminatory access to care”.  Article 14 of the EHRC deems it unlawful to allocate resources based solely on a person’s age, race, religion or other protected characteristics.

Those most disadvantaged by these guiding principles and least likely to be prioritised in decisions about the allocation of NHS resources are the 1.5 million extremely vulnerable people in the UK who are at “significant risk of increased morbidity or mortality from COVID-19”.

Lucy Watt, the 9th most influential disabled person in Britain, feels that this guidance devalues her life on the basis of her disability and needs, rather than valuing her life on the difference she has made to the world.

If we were to allocate resources based on personal contribution it would be necessary to conduct a cost-benefit analysis. Where a patient’s gross contribution outweighs their health-care costs resulting in a higher net contribution utilitarian’s may argue that patients like Lucy are deserving of higher priority for NHS resources.

However, allocating resources based on one’s societal contribution leads to concerns about how to define and quantify contribution. Does contribution refer to economic or social contributions? Does contribution require a global, national or local impact? Does it include a person’s financial contribution in the form of tax or charitable donations to the NHS?

In 2017 the NHS faced significant criticism after it sought to impose a rule that persons could not receive surgery unless they stopped smoking. Smoking related diseases creates a huge burden on resources as patients require chronic medical interventions. However, economically smokers collectively contribute £12 billion in direct tax, thus, are paying significantly more for their medical treatment than non-smokers. Therefore, it would be not be cost effective to punish those who contribute the most financially.

Allocation based on personal contribution disadvantages the poorest in society. Those able to make charitable donations or who pay more tax would be those that benefit from this scheme.

Moreover, focusing on individual contribution may fail to consider important and often unrecognised contributions that individuals make to their families, their dependencies and children. Some people indirectly contribute to society for example, being a career to a disability activist.

If we start allocating resources based on contribution, we begin to discriminate not only between types of contribution but those unable to contribute to society. We also fail to consider a person’s future contribution, such as, the future contribution of a child who would be significantly disadvantaged by this allocation criteria.

Instead of personal contribution we could offer maximum protection of those that adhere to social distancing guidance, contributing to the national effort to reduce the spread of COVID-19.

The ethical principle of social responsibility holds individuals accountable for failing in their civic duty to act for the benefit of society as a whole. Not following distancing guidance puts the population at increased risk of contracting COVID-19 and consequently, the individual is not prioritised in a resource shortage.

Practically it is impossible to determine who followed government guidance on admission into hospital. Moreover, social responsibility models are not compatible with a liberal society.

Although there is legislation to restrict the liberty of citizens during this pandemic, most of the governments rules are guidance and advice. The government has sought to keep liberty as a core ethical principle throughout the pandemic. Therefore, whilst many in a liberal society believe in their ethical and moral obligation to be socially responsible, holding those to account that do not adhere infringes on people’s right to choose how they wish to live, an ethical principle underpinning our society.

Overall, it is not ethical to allocate resources based on a person’s contribution to society.

Ultimately, the current method of allocation which seeks to maximise the benefit of the NHS resources is the ethical approach.

However, as lockdown measures are relaxed and the rest of the population begins to return to a new normal, there is an increased moral responsibility to adhere to social distancing and shield those most vulnerable who, if the NHS were overwhelmed, may not be offered the opportunity to recover from the virus.


Author: Rebecca Limb

Affiliations:  Early Career Fellow at the University of Warwick, School of Law and IATL, Coventry, England, CV4 7AL

Competing interests: I am a patient on the extremely vulnerable list. I can declare no further competing interests.

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