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by Iestyn Williams Helen Dickinson and Suzanne Robinson
15th May 2020

Many health systems are struggling to equip clinicians, carers and citizens with the things they need to fight the effects of the coronavirus outbreak. As infection and death rates began to rapidly increase in the US and parts of Europe, attention is increasingly focussed on physical resource limits, especially in relation to diagnostic tests, personal protective equipment and critical care facilities.   

Governments are reluctant to admit it, but there is little doubt the pandemic response would have been greatly improved without these shortages. Difficult choices have been made in terms of which groups and individuals gain access to such resources in the face of limited supply. In our book, Rationing in Health Care, we argue that, despite their importance to population health decision-making, ethical principles shouldn’t be applied to the allocation of resources at the bedside when individual patient lives are at stake.  

International experiences vary 

Many have compared the response of countries such as the US, the UK, Italy and France unfavourably with, for example, South Korea, where the response to COVID-19 seems to have been relatively unhindered by resource shortages. A recent online conference of the International Society for Priorities in Health suggests this was a consequence of earlier infectious disease outbreaks, and a resulting willingness to direct substantial resources towards development and manufacture of tests, distribution of personal protection equipment and designing of dedicated pathways for COVID-19 patients.  

It is also notable that Germany has been able to ‘catch up’ more quickly than their European counterparts, perhaps due to manufacturing capacity and significant amounts of resource slack within the health system. Ironically, these inefficiencies have proven to be highly valuable, whereas leaner systems such as in the four countries of the UK have been forced to make difficult choices over access to critical care, as well as expanding capacity, to avoid becoming overwhelmed.  

Difficult rationing decisions 

Since the outbreak, there is no doubt that health systems across the UK have been hugely effective in maximising the resources available to deal with it, but this will have consequences for other aspects of health care demand and delivery which won’t be truly known for some time. As well as the impact on other patients, the system has, controversially, been triaging COVID-19 patients in the hope of avoiding the system becoming overwhelmed, as we saw vividly play out in Italy.   

This is the most recent example of the rationing scenario, which has occurred many times before in health care systems across the world: how to decide who should receive treatment when not every need can be met.  These decisions are even more fraught as, rather than assessing treatments, they pitch patient against patient, in the competition for potentially lifesaving treatment.  

What can ethics tell us? 

There is a tendency in such situations to search for the answer in the field of ethics, and for good reason as this can tell us much about how to weigh competing moral claims when distributing public resources. However, the ethical rights and wrongs of resource allocation are best debated in the abstract when planning services for whole populations, and not at the bedside where they translate into callous and unfeeling principles that violate the fundamental injunction to save lives. Guidance from the National Institute for Health and Care Excellence suggests access to life-saving ventilation should be determined by the likelihood and expected extent of patient recovery. However, the unfettered implementation of this principle would inevitably infringe the rights of disabled people, among others, to treatment.  

The failings of rational planning 

The reality is that the need for such appalling treatment decisions represents a failure of rational planning, and recourse to abstract ethical principles will not mitigate the damage involved. In France, ‘ethical support units’ at least provide case-by-case support to clinicians, drawing on a range of perspectives and considerations. However, the purpose of population health priority setting, informed by ethics, is not to inform such decisions, but to remove the need for doctors and patients to make them in the first place.  

Of course, these are exceptional times, and the coronavirus has unexpectedly redefined health care demand and taken systems to the brink and beyond.  At this stage of the crisis, rational schemes for allocating resources are largely irrelevant as the priority becomes how to ‘muddle through’ using judgement, patient input and moral instincts.   

In the longer run, the challenge will be how to ensure such terrible choices never need to be made again, and this will require a rethink of what constitutes an efficient and safe allocation of resources to health care.  In adult social care, the acute shortage of basic protection for many service users and their carers has compounded their de-prioritisation vis a vis younger, healthier patients.  This may finally be the moment when the funding shortfall for this service user population cuts through into public consciousness.  

Where next? 

The hope is that these extraordinary times won’t return and that, as with countries elsewhere, this tragedy will engender greater future readiness. But this will be scant consolation to the current victims, their families and those making the sorts of decisions which none of us should ever have to face. And the need for some level of rationing ‘at the bedside’ may well be inevitable. In the short term, this means providing support for those making decisions which goes beyond offering ethical injunctions that are themselves likely to be contested. In the long run, the aspiration must be towards priority setting and strategic planning that is effective in reducing the requirement for rationing. 

 

Rationing in health care by Helen Dickinson, Iestyn Williams and Suzanne Robinson is available on the Policy Press website. Order here for £15.99

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