By Kayla Wiebe, Simon Kelley, Roxanne Kirsch

An arguably positive accident of the COVID-19 pandemic is that it rejuvenated public, political, and academic interest in the ethical dimensions of resource allocation, with specific focus on how extreme resource shortages (like in triage) exacerbates health inequities. Unfortunately, of far greater significance, are the kinds of exacerbations of health inequities prior to and throughout a patient’s engagement with the healthcare system.  These far outweigh any inequities identified during healthcare in extremis. This is precisely why we must counteract health inequities far earlier. One way of doing so is attending to ‘normal’ and everyday contexts of resource allocation with the same degree of vigor as we did in early 2020. Failing to actively improve resource allocation and prioritization in normal contexts has severe consequences, both on patient health and health inequities.

The current delays in accessing surgical services worldwide provides a striking example. Early on, elective surgeries were shut down as a public health measure while urgent cases continued. However, the impacts of prioritizing urgent cases for prolonged periods of time while elective cases continue to be booked and delayed have resulted in unmanageable waitlists.

In broad strokes, two types of cases are significantly impacted. The first are the Avoidably Urgent cases, ones that are not yet urgent enough to warrant treatment but will eventually become urgent. In terms of their natural disease trajectory, the shift to urgent is often preventable. The second are Quality of Life cases, which might never escalate to an ‘urgent’ or ‘emergent’ classification, but for whom the consequences of not accessing timely treatment and preventative care are persistent and significantly compromised quality of life.

An international study across 61 countries found that 10% of patients waiting for elective surgery had not received it 6 months later, described cancer surgery systems as “fragile to lockdowns,” and called for improvements in elective surgical delivery due to reduced overall long-term survival.  A 2020 Canadian study found delays in cancer detection, leading to advanced disease at presentation, and more unresectable, incurable cancers following lockdowns. Delays in surgery often increase surgical complexity, risks of complications, and avoidable disability. In one study, 20% of patients waiting for hip or knee arthroplasty were in health states they considered to be “worse than death.” Prioritizing urgent cases over elective cases for several weeks poses minimal consequence to the “non-urgent” group, for escalating to urgent status, or quality of life costs. However, sustained over months to years – which is the situation we are in now – the cumulative burden to these patients becomes overwhelming. Prioritizing urgency might be the status quo, but passively maintaining the status quo is itself a resource allocation decision, not a foregone conclusion.

Consideration of resource allocation in normal contexts raises a myriad of ethical and logistical questions that deserve our attention. Healthcare delivery in general tends to function on a reactive, ‘rule of rescue’ basis, rather than a preventative one. Novel, expensive, inpatient rescue interventions for rare conditions are heavily prioritized, while ‘everyday’ outpatient preventative or maintenance healthcare resources, such as rehabilitative care, insulin, and mental health resources, are chronically underfunded. While we do not suggest abandoning the imperative to rescue, the accumulating consequences to those who have to wait for timely medical intervention simply because they are not yet ‘urgent’ prompts the question of whether urgency ought to always play the trump in medical resource allocation. At what point, if any, should quality of life consequences be considered equivalent to the urgent risk of losing life and limb?

When medical needs among a patient group are equal, we posit that factors beyond the strictly medical should be considered. The conflict between efficiency and equity is by now a well-trafficked ethical debate, with recent discourse seeming to favour equity. However, how to reasonably incorporate equity-guided allocation in healthcare delivery has not even been begun to be re-imagined outside of crisis. In the context of surgical prioritization, something akin to the Area Deprivation Index might be used to account for social determinants of health that track negative health outcomes, such as socioeconomic status and racism.

Attending to patients who are not in need of rescue is a critical allocation problem to solve. Our focus on extreme emergency contexts is a manifestation of the rule of rescue and a salience bias in our attention, where we rush to rescue identifiable individuals – whether in ICU, or in our news headlines – while neglecting the larger number of unidentified individuals who also need care. And like the rule of rescue, this functions as a barrier to improving health at a population level. The surgical waitlist problems represent just one extended example of this bias in attention. Our fixation on rescue, in fact, fails to rescue at a population level

Authors: Kayla Wiebe^1,2 Simon Kelley³ Roxanne Kirsch ^4,5

Affiliations:

¹Graduate Department of Philosophy, University of Toronto

² Clinical Research, Perioperative Services, The Hospital for Sick Children, Toronto

³Division of Orthopedic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto

⁴Department of Bioethics, The Hospital for Sick Children, Toronto

⁵Department of Critical Care Medicine, The Hospital for Sick Children, Toronto

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