By Varshini Chellapilla
When the coronavirus pandemic began, there was great concern about the allocation of scarce healthcare resources like ventilators, ICU beds and hospital staff.
In large cities like New York, health policy experts feared that hospitals would be overwhelmed by patients needing lifesaving treatment. In some rural areas, health policy experts were also concerned many hospitals did not have the resources they needed to care for patients seriously affected by the novel coronavirus.
“In public health emergencies, there’s always a concern about finite resources,” said Andrew Peterson, PhD, a researcher with the Penn Program on Precision Medicine for the Brain. “How you distribute those resources to patients in need is ethically complicated.”
Dr. Peterson, an assistant professor of philosophy at George Mason University, in collaboration with colleagues at The University of Manchester, conducted a study to understand the opinions of average Americans on these allocation decisions in the pandemic. The study, titled “Public attitudes toward allocating scarce resources in the COVID-19 pandemic,” was published on Nov. 4 in scientific journal PLOS ONE.
Through the survey, researchers found that participants generally agreed on allocation principles that prioritized the worst-off patients during the initial distribution of resources, instead of equal allocation of resources or allocation based on social usefulness.
However, a key finding of the survey was participants’ response when the principles were found to be disadvantaging at-risk or historically marginalized groups of people. In this scenario, participants leaned away from maximizing benefits and favored policies that prioritized patients from different groups equally.
“I pray that physicians will never need to make these life-or-death decisions,” Dr. Peterson said, “but it’s good that we now have emerging information about what Americans would think about these decisions and how health care systems can react to them.”
Dr. Peterson was conducted this survey in response to an article published by University of Pennsylvania’s Dr. Ezekiel Emanuel, the Diane v.S. Levy and Robert M. Levy University Professor in Penn’s Department of Medical Ethics and Health Policy. The article, published in May in the New England Journal of Medicine, proposed recommendations on how to allocate scarce resources in the pandemic based on core ethical principles.
“That paper, as well as previous work on this topic, got the gears turning for me,” Dr. Peterson said. “It is an important document — a standard bearer — but it has also raised concerns in the bioethics community about how to interpret and apply the recommendations.”
Some of the concerns raised dealt with the recommendations’ lack of nuance regarding the impact on people with disabilities, the vague definition of essential workers, and the conditions that would allow for the proposed forcible withdrawal of ventilators for reallocation to COVID-19 patients with a better prognosis.
Dr. Peterson, in collaboration with Penn Memory Center Clark Scholar Emily A. Largent, PhD, JD, RN, and PMC Co-Director Jason Karlawish, MD, initially wrote about these issues in an article published in the British Medical Journal, entitled “Ethics of reallocating ventilators in the Covid-19 pandemic.” A critical unanswered question, however, was how the U.S. public would respond to these allocation decisions in practice.
With his colleague at the University of Manchester, Dr. Peterson conducted an online survey study involving more than 1,800 participants. The study was divided into three experiments that assessed participants’ attitudes toward the ethical principles underlying triage policies.
Triage is the process by which hospitals prioritize the allocation of treatment to patients. Hospitals generally have these policies in place, and many have been examined and updated since the novel coronavirus hit the United States, early in 2020.
The first experiment asked participants which of four different healthcare allocation practices they favored: allocation based on seriousness of illness, allocation based on the maximum number of lives that could be saved, allocation based on a first-come first-serve basis, and allocation based on the social importance of patients. The second experiment analyzed public opinions on the practice of reallocating scarce resource between patients. Finally, the third experiment asked participants how their opinions might change if a triage policy disadvantaged at-risk or historically marginalized patient groups, such as people of color.
“Participants generally agreed with the principle of allocating scarce resources to save the most lives, which is consistent with the recommendations made by Dr. Emanuel and his team,” Dr. Peterson said. “But things become more complicated when asking about reallocating scarce resources between patients, or when resource allocation disadvantages people of color.”
The study found that Americans were ambivalent about the forcible withdrawal of scarce resources from patients with poor prognoses. It also found that Americans favored revising a triage policy to mitigate disadvantage for people of color, even if this meant that more patients might die.
“This survey was a way of showing how the public understands these principles and their attitude towards them. There is very little information about this issue in the current pandemic,” Dr. Peterson said. “The study results only give us partial picture about how to fairly allocate scarce resources. Just because the public disagrees with health policy recommendations doesn’t mean we should change the accepted approach. But it’s important to know what the public thinks about these issues. Acknowledging public concerns—even addressing them—can give triage policies democratic legitimacy.”
Dr. Peterson said that conducting the study again, at a time when cases are spiking throughout the country and when the coronavirus death toll is nearing 250,000, would likely produce new and interesting results.