By Julian Savulescu and Jonathan Pugh.
The current UK approach to allocating limited life-saving resources is on the basis of need. Guidance issued by The General Medical Council states that all doctors must “Make sure that decisions about setting priorities that affect patients are fair and based on clinical need and the likely effectiveness of treatments”
This is most vividly illustrated in the JCVI’s strategy for vaccination. The prioritization order recommended by JVIC and that the UK Government intends to follow is:
- older adults’ resident in a care home and care home workers
- all those 80 years of age and over and health and social care workers
- all those 75 years of age and over
And then younger age groups in descending order.
The aim of this scheme is to address the greatest need and possibly also to save the greatest number of lives. Indeed, the Joint Committee on Vaccination and Immunisation (JCVI) state that their priority groups represent 99% of preventable mortality from COVID-19.The downside of this strategy is that people in each lower tier will predictably and avoidably die as they wait for the tier above to be vaccinated.
To take an example. A systematic review and meta-analysis of infection fatality rates in Covid-19 suggests that the chance of an infected 80 year old dying from COVID-19 is 15%. The chance of a infected 65 yr old dying is 1.4%. For a 25 year old, it is 0.01%. While the strategy focuses on over 80 year-olds, some 65 year-olds will die. They can legitimately complain that they were at an increased risk and should have had a chance to access the vaccine.
The procedure will save the most lives, but with no regard to length or quality of life (utilitarianism). But it also has no regard to fairness in the following way.
If A has a 15% chance of dying without vaccine, B has a 10%, need says give it to A. But for B, it is the only way to remove a chance of dying. If you have organ failure and your chance of surviving with a transplant is 30%, and mine is 25%, it makes no difference to me that yours is higher. I want my chance.
One competitor to need is utilitarianism: maximise the outcome in terms of QALYs. This would not favour the current distribution, e.g. giving vaccine to centenarians. Although QALYs are used to determine resource allocation in healthcare, some have argued that it is unfair to incorporate considerations of quality and length of life into prioritisation.
Another approach gives weight to fairness as well as need and outcome. One of us has called it, after John Mackie, a “right to a fair go.” It has also been called sufficientarianism. It requires drawing a line – a fair go. This could be a minimum reduction in the chance of dying, or raising people to a minimum quality of life, or providing a minimum level of life extension. Distribution of limited resources should then get as many people as possible above the line. It should give as many as possible a fair go.
Consider an example with ventilators. There is only one ventilator and three patients who could have their lives extended.
A would require a ventilator for two weeks and his life would be extended by one year.
A* would have her life extended by 10 years and require it for one week
If A* is treated for one week, either B or B* could be treated in Week 2.
B*’s life would be extended by 10 years.
B’s life would be extended by one month.
The following combinations are possible. Treat:
Utilitarianism would obviously favour the second option. However, that combination can also be justified by considerations of fairness. If we set the minimum threshold for benefit at more than a year of life extension, then the second option A* B* gets the most patients across that line. Fairness speaks in favour of A*B.*
The current UK system of vaccine distribution is not fair in the following way. Everyone over the age of 50 is at a significantly increased risk of dying of COVID. Fairness could require everyone over the age of 50, or 60 (depending on where you draw the line of a fair go) having an equal chance of getting the vaccine.
In fact, in Europe, the UK is an outlier is stratifying priority groups by age to the degree that it does. A survey of vaccine priority guidance performed by the European Centre for Disease Control and Protection suggests that the published guidance in many EU countries incorporates a far simpler form of age prioritisation, in which all people over a certain age are prioritised equally. For example, the Netherlands simply prioritises those aged over 60. In this system, an 85 year old has equal priority to a 60 year old. In the UK, these two individuals will receive the vaccine months apart.
One of us have previously argued that we should give weight to both equality (fairness) and outcome (utility). A right to a fair go strikes this balance.
Giving some weight to fairness will reduce the numbers of lives saved. But it will give more people a chance to benefit from the limited resources.
A plausible alternative to the current need-based distribution is a right to a fair go. One might also call this a Partial Fairness-Based allocation.
This could also be applied to the allocation of ventilators: provided people have a chance of surviving, to gain a life of minimum length and quality, they should have an equal chance. But those who are very old or who have advanced dementia, would not be candidates for ventilators, when these are limited in supply.
How much weight we give to fairness vs utility is value judgement that might not allow a precise answer. And it is a judgment that will be affected by contextual factors, such as the current strain the healthcare system is under. But it is plausible some weight should be given to both utility and fairness. Perhaps we should give everyone over the age of 65 an equal chance of getting the vaccine.
Authors: Julian Savulescu and Jonathan Pugh
Affiliations: Oxford Uehiro Centre for Practical Ethics, University of Oxford
Competing interests: None declared.