By: Elizabeth Fenton, Esther Willing, Neil Pickering, Wenna Yeo, Sophie Barham
The COVID-19 pandemic highlighted the ethical limitations of ‘save the most lives’ as a prioritisation principle for intensive care (ICU) resources during times of scarcity, such as pandemics. A key problem is that following this principle can disadvantage patients with worse overall health, often those whose health status reflects historical and structural disadvantages. In these cases, a focus on saving the most lives can exacerbate existing health inequities.
In our qualitative, interview-based study we examined an alternative approach to allocating scarce ICU resources that attempts to address this concern about health inequities. Economists and ethicists have argued that reserve systems, in which some of a scarce resource is reserved or set aside for specific groups, offers a way to ensure that those who might otherwise be deprioritised have an opportunity to access the resource.
During the COVID-19 pandemic colleagues at the University of Otago found that clinicians making complex prioritization decisions experienced challenges incorporating considerations of social justice or patients’ disadvantage into those decisions. Partly in response to this finding, we wanted to examine a reserve bed system (RBS) for the ICU setting in Aotearoa New Zealand, where there were concerns about the disproportionate impact of the pandemic on indigenous Māori, for whom significant health inequities are long-standing and persistent.
Would clinicians, nurses, and other ICU decision makers see the RBS as an ethically acceptable method for addressing this problem?
The small sample of ICU key informants in our study, while recognising that Maōri health inequities are urgent, were reluctant to support the RBS proposal, for two main reasons. First, they were concerned that addressing health inequities through an RBS would create other unfairnesses, for example by potentially denying someone an available bed because they were not Māori. Second, they were concerned that interventions targeted by ethnicity can struggle to find widespread social and political support.
This second concern reflects the broader debate on health inequities in New Zealand and the role of interventions designed to improve health outcomes for disadvantaged groups. For example, in 2023, several hospitals introduced an equity adjuster into prioritisation tools for planned surgery to address wait list inequities. Despite evidence that Māori have longer wait times for elective surgery than non-Māori, critics argued that wait list priority should be determined only on the basis of health need and not ethnicity. In 2024 the government issued a directive to all public service agencies setting out its expectation that public services will be “prioritised on the basis of need, not race.” Critics of this directive argued that it overlooks important factors influencing need that are tied to race or ethnicity, such as racism.
Fairness is a widely held value in New Zealand society, often captured in the idea of giving everyone an equal opportunity. Interventions targeted by ethnicity, like the RBS in our study, are sometimes viewed as unfair, because they appear to give members of one group a better opportunity to access the resource than others. While participants in our study recognised that some patients in the ICU are worse off as a result of upstream injustices, including those associated with colonisation and racism, they also recognised a potential unfairness of the RBS in permitting resources to be withheld from patients who could benefit from them, and were concerned that an RBS would be perceived as giving Māori an unfair advantage.
In response to similar concerns some researchers have advocated using measures of deprivation to capture disadvantage rather than focusing on ethnicity, since there is often considerable overlap between ethnicity and deprivation. However, recent research from Aotearoa highlights that ethnicity remains an independent marker of high health need even when deprivation is controlled for. This finding provides support for interventions targeted by ethnicity to reduce health inequities. Despite the reservations of our participants about the RBS, the fact that there was agreement on the importance of equity in relation to health differences related to ethnicity suggests that the RBS warrants further exploration, and/or that alternatives which achieve the same ends should be developed and investigated.
Authors: Elizabeth Fenton (1), Esther Willing (2), Neil Pickering (3), Wenna Yeo (4), Sophie Barham (5)
Affiliations:
- Department of Bioethics, University of Otago
- Kōhatu Centre for Hauroa Māori, University of Otago
- Department of Bioethics, University of Otago
- Bioethics Centre, University of Otago
- Te Whatu Ora—Health New Zealand
Competing interests: None to declare