In the context of your coursework, resource allocation presents a set of ethical quandaries for healthcare professionals and hospital administrators. We focus here on problems pertaining to scarcity. Traditionally, scarcity is considered in courses on economics or philosophy, and now more commonly in the context of medicine. The following module, then, will assist us in navigating some of the pressing matters related to scarcity of resources, whether those resources are such things as PPE or ventilators. PubMed GPT 2.7B and other recent releases from OpenAI also render us all more aware of the ways artificial intelligence (AI) and machine learning (ML) are integrated today in medical decision-making; the modules here offer some exploration of decision-making and the constraints arising from scarcity of resources.
"One of the most disheartening things at the outset of this pandemic was that access to testing really depended on whether you had resources or you were a celebrity. The people who needed testing the most were essentially an afterthought. I'm passionate about not repeating this inequity in access for the vaccine." Michelle A. Williams, ScD Dean of the faculty, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
The link above to the EMCrit Project is a useful resource for the science and shared practices around COVID-19 care, particularly for emergency medical professionals.
A group of theorists re-presenting arguments for what to do in our present encounters with scarcity made it clear that the foundational principles upon which they argued where taken from game theory. It is not essential that you become an expert in how game theory impacts bioethics in this module. However, it is important that your education leads you to the discernment process whereby you are able to spot quickly the underlying assumptions guiding the reasons people give for how decisions are to be made. (For a compelling analysis of game theory through documentary film, see Adam Curtis's "The Trap.") Framed in terms of the tragic decisions that must be made in triage, here is a sample of what the authors have to say about ethical reasoning from the foundations of game theory: "Just as surgeons aim to use the best available tools when operating, those at the front lines of the pandemic need the best decision-making tools available to allocate scarce resources fairly. That means moving beyond intuitive thinking, harnessing their deliberative cognitive capacities — and empowering them to make these tragic decisions as ethically as possible." (Bazerman, Bernhard, Greene, Huang, Barak-Corren)
Notice that Bazerman et. al. are concerned with justice, which is the larger framework into which all your bioethical deliberations fit. Furthermore, they want to move intuitions for justice into deliberative practice, which involves premeditation on how we are to act in given situations, followed by deliberative practice within the premeditated framework. Theories of justice articulated at length in philosophical treatises find application in the context you are considering here. Since we face scarcity when caring for patients, and we desire that care to be as just as possible for all involved, how can we account for the justice so provided before we encounter the daily decisions requiring us to follow through on decisions constrained by that scarcity. We will find that it behoves us also to understand the sources of scarcity, which are naturally related to economics and government policies, as well as the available theoretical options trotted out by ethicists.
"Transparency and social inclusion are essential conditions in the process of building any ethical structure for decision making in situations of scarce resources because it is of paramount importance that citizens trust health institutions and the provision of care in the system of which they are part." (dos Santos, et al.)
Let us take a moment to watch this international trailer for the film Arrival (2016), which is an adaptation from a 1998 short story "Story of Your Life" by Ted Chiang. My intention is to use this as a "parable" for our times.
Arrival is parabolic for us to the degree it helps us think about how international cooperation might be performed differently than it is today. At around the 2-minute mark of the trailer you notice the screens shutting down. Countries are afraid that the translation provided by the Amy Adams character of an alien language identifies their hostile intent, so they hoard information and isolate to protect. In contrast, her experience of communicating directly convinces her otherwise, that the intention is to unify rather than divide. At times, the present pandemic has unified countries, but mostly it has divided us and greatly complicated the supply chains necessary for ensuring medical professionals have access to the Personal Protective Equipment (PPE) they need, as well as other necessary life-saving materials, such as ventilators.
In terms of ethics, I'm using the film trailer to expand our imaginations on the topic of what ethicists today call Global Public Goods (GPGs). Can access to health products for COVID-19 count as "global public goods?" If so, what renders such products goods of this kind? How might such a designation differ from what was classically called the common good? The WHO Director General gave a speech in November of 2020, stating: "The world has come together as never before to ensure vaccines, diagnostics and therapeutics are developed, produced and allocated fairly as global public goods, not private commodities." The distinction, in this case at least, is that between global public goods and private commodities. (The exhortation is especially urgent in a context where now water futures are beings sold as commodities on Wall Street.)
If global public goods become private commodities, then those commodities can be priced and sold according to market dynamics where access can easily become possible only for the wealthy, or at least those willing to find ways to pay. Commitments to equitable access to global public goods aim to found decision-making in principles of equity focused on the most vulnerable.
The specter of "vaccine nationalism" is alive and well, however. Witness the US purchase of 90% of available Remdesivir in June 2020, or Canada's bid to purchase vaccines from COVAX, a vaccine-sharing global plan for low- and middle-income countries (LMICs).
According to Irene Torres et. al. vaccine scarcity is in fact a failure of "global solidarity and multilateral instruments" (Lancet, May 15, 2021). "Ensuring efficacious vaccines are made widely available and at fair cost, when high-income countries are hoarding up to five times what they need and prices are speculative, would require making alliances with countries (eg, Brazil or India) with the capacity to produce generic vaccines, alongside efficient syringes, and means of storage and transportation. Notwithstanding, LMICs will need support from additional partners in other regions of the world."
Responses to calls like that of Torres's for increased global solidarity include urging us to move beyond rhetoric into real action involving reconsiderations of international IP laws pertaining to vaccine creation. Marienne Meijer et. al. argue thus in the European Journal of Public Health:
"The current global response to the COVID-19 pandemic is insufficient in curbing the pandemic; the world is in the midst of a third wave and new strains of the virus are constantly developing. Vaccines are vital to overcome this crisis, but their supply is scarce and the worldwide distribution both inadequate and unequal. Whilst some countries await first vaccine batches, others warm up for potential third doses. In spite of the fact that vaccines were soon crowned ‘global public goods’,1 little came of it in reality, and low-income countries are dependent on inadequate donation-based systems. Key in changing the tide is to ensure better global access, for which more vaccines must become available. To this end, Intellectual property (IP) rights, know-how and technology must be shared to maximize vaccine production."
The German Institute of Global and Area Studies (GIGA) published an article by Wolfgang Hein and Anne Paschke titled "Access to COVID-19 Vaccines and Medicines -- A Global Public Good" in July 2020. As we shall see, they provide us with insight into the conflicts among stakeholders in securing goods that gum up the supply chain. The following diagram is a timeline from January 2020 through June 2020 that compares stakeholders:
Collective action becomes more difficult as the various stakeholders assert their rights and power. The authors are clear that participants in Global ACT Accelerator initiative are wary of the motives of others because of past experience, particularly with respect to drug development around HIV/AIDS. Though stakeholders used the rhetoric of equitable access, the reality was otherwise. Presently, then, the WHO urges that in the fight against COVID-19 "no one should be left behind" (WHO2020a).
Hein and Paschke explain the sources of stakeholder conflict with reference to three competing interest and stakeholder groups that can be triangulated. "(A) the pharmaceutical industry regarding patent-based exclusive rights; (B) certain nation states interested in securing health products first for themselves to speed up national recovery and (in some cases) to pursue hegemonic interests; and, (C) humanitarian, global, political, and economic interests to realise access to health products as GPGs. This latter interest is pursued by a diverse group of stakeholders, including patients, civil society organisations (CSOs), health workers, international organisations and foundations, and a number of LICs and MICs."
Since our ethics course is being offered in the US, it is important for us to notice how our actions of hoarding can impact international cooperation, especially with CSOs and LICs and MICs. Cultivating an ethic of solidarity is important for us. The final line of the article exhorts us in this direction: "If the global community succeeds in overcoming national protectionism impulses and focuses rather on protecting people’s rights to equitable access instead of industry’s rights to patents, the current pandemic could be a game changer for access to medicines."
"Solidarity between health professionals and society is a key ethical value in minimising mortality and morbidity in a pandemic. Society grants professionals privileges and respect and in a reciprocal way expects them to care for infectious patients. In the current pandemic in the UK, there have been numerous expressions of appreciation of healthcare workers by members of the community, for example, national spontaneous handclapping, banners and congratulatory graffiti." (Relational Ethics, David Ian Jeffrey)
Scarcity & Supply Chain Dynamics for Medical Supplies
Lest we assume problematic access to supplies for healthcare professionals is in all cases willful on the part of stakeholders, let us examine a detailed study by the Center for Strategic and International Studies (CSIS) concerning the global supply chain of medical supplies by Meredith Broadbent.
Broadbent focuses our attention on stakeholder preparedness and resiliency in the face of increased product demand. According to Meredith Broadbant, "CSIS research has found that resiliency is best achieved through diversification and frameworks that provide certainty in times of crisis. Across the medical sector, supply chain issues that arose during the early months of the pandemic were caused not by lack of domestic production capacity in most cases but by an uncertain and often chaotic policy environment" (Demand Shock Preparedness, p. 19). The diversification identified by the research includes improved international cooperation in the creation, procurement, and distribution of supplies backed by an ethics of trust and communication. Ventilators provide a good test case for cooperation insofar as advanced models contain as many as 1,700 parts, and these parts "are imported from around the globe; for instance, circuit boards, an essential ventilator component, are overwhelmingly manufactured in Asia" (Broadbent, 16). Breakdowns in cooperation in times of global distress further exacerbate dire pandemic conditions. The CSIS offers the following recommendation to counteract the breakdown in supply chain logistics as follows:
"We recommend that Congress enact legislation stating that it is the policy of the United States to offer countries willing to become trusted supply partners through the reciprocal reduction of trade, investment, and regulatory barriers: 1) enhanced commercial ties grounded in a new network of trusted partner countries and 2) a commitment to coordinate and offer reciprocal support to trusted partner countries during emergencies. This would include commitments to avoid new trade restrictions. Trusted supplier partners would keep general medical supply lines open and work together to provide vaccines, therapies, and medical supplies during disruptions caused by a pandemic or another emergency. The United States should also consider public–private cooperative understandings and other initiatives to encourage research and development (R&D) on pharmaceuticals, medical devices, and advanced manufacturing processes among trusted partners." (Broadbent, p.2)
As you know, many people rallied to assist in supplanting the shortfall in supplies by manufacturing masks. Some also created ventilators. Take a look at "The Grainger College of Engineering and Carle Health demonstrate working prototype of emergency ventilator for COVID-19 patients." The authors provide us with another cinematic comparison, this time to Apollo 13 in its demonstration of emergency engineering.
Recall that the article we are citing presently offered 1,700 as a number indicating how many parts can be in a ventilator! "On March 16, 2020, a team of more than 40 engineers, doctors, medical professionals, designers, and manufacturing experts from industry launched an Apollo 13-style project to help address that need."
"The team focused on designing a device that could help the sickest patients to breathe, by plugging into the oxygen source available in most hospital rooms or into a tank of oxygen. Less than one week later, the team demonstrated a working prototype."
Note the language most relevant to your ethics course presently, namely the team's prioritization of the "sickest first" in its design. The link below titled The Toughest Triage (also supplied at the opening of this content) situates that ethical phrase within the present context of scarcity. The examples are by no means exhaustive, but they do represent some early attempts during the pandemic at articulating for lay audiences the kinds of principles available during the crisis for decision-making under conditions of scarcity.
The Apollo-13 style creation of the RapidVent surely demonstrates an ethics of cooperation and care that is to be praised, especially given the reduction in cost that may create a chance for poorer countries to gain access to life-saving technology at affordable prices. The CSIS report also offers Pfizer's partnership with BioNTech on its COVID-19 vaccine variant as exemplary in its demonstration of international cooperation. The creation of the vaccine succeeded "through transatlantic scientific and commercial collaboration" (p. 10). In contrast, supply chains for PPE proved less resilient and capable of being weaponized during lockdown requirements. "As the Strategic National Stockpile's (SNS) PPE supply was exhausted, states, firms, and hospitals competed against each other in a procurement free-for-all. Counterfeit manufacturers took advantage of the situation and began to peddle ineffective PPE to desperate suitors. PPE export restrictions imposed by governments around the world contributed to shortages. As the pandemic accelerated, the United States quickly realized that it relied only on a few countries for most of its PPE imports; for many PPE products, China is the single largest supplier to the United States. This led to supply chain vulnerabilities...It should be kept in mind that the collection of trade statistics for certain medical products will be more granular and reliable in the future due to adjustments made as a result of heightened in trade in these goods" (p. 10). Here is the data Broadbent provides to show the changes in supply chain dynamics:
Healthcare personnel were forced to reuse single-use PPE early on in the pandemic and ED physicians were especially strong in their recommendation that such actions were required, despite the sub-optimal nature of the choice to re-use. Scott Weingart and Reub Strayer discussed the matter of ventilator allocation in the ED as well as PPE re-use, encouraging healthcare professionals to consider whether they would have similar misgivings or hesitancy in deciding how to act if the context were Ebola. Certainly not! But when facing scarcity of resources in the context of COVD-19 emergency care, re-use of single-use, disposable PPE such as a mask, is a necessity.
So what caused the PPE shortage early on in the pandemic? Broadbent cites an article from Preventive Medicine 141 (2020) by Cohen and van der Muelen Rodgers identifying four factors influencing PPE shortage.
1) "a dysfunctional costing model used by hospitals to budget for PPE"
2) “a very large demand shock triggered by both acute healthcare need and panicked marketplace behavior that depleted domestic PPE inventories"
3) "the lack of effective action on the part of the federal government to maintain and distribute domestic inventories"
4) "severe disruptions to the PPE global supply chain.”
What I'd like you to notice from this summary of Broadbent's research are the complexities of human cooperation at the core of many of our problems with supply shortages and scarcity. Scholars of the economics of scarcity are clear that this is one type of scarcity, the kind resulting from human decisions rather than those to which we are subject by virtue of "nature." (Climate and scarcity are no longer separable from human factors, as they may once have been in the literature; hence the bracketing of "nature."). You are the new leaders of the world and thus have the capacity to change law, policy, and practice around these matters. Your experience of continuing education during this pandemic has drastically changed all our trajectories, but also provided you new ways to exercise your privilege, influence, and imagination in seeking to address global health needs. Can we allow our imaginations to be informed by the dream of Chiang/Villenueve in Arrival? Or are we rather more tempted by a spirit of "vaccine nationalism"?
As we depart from this present analysis, register that Broadbent provides us with data on ventilator production at the time of publication: "nearly 120,000 ventilators" were sitting in warehouses "due in large part to the early DPA [Defense Production Acts] contracts" invoked by the Trump Administration, which they later cancelled. (Similar supply chain disruption through government purchasing occurred in the farming industry early in the 20th-century.). Scarcity turned to surplus rather quickly.
The rapid reaction to offer support for increasing ventilation production has met with critiques that humans are biased to immediate, visible results of this kind, rather than the more complex behavioral agreements surrounding sound public health practices. "Why are so many people distressed at the possibility that a patient in plain view—such as a person presenting to an emergency department with severe respiratory distress—would be denied an attempt at rescue because of a ventilator shortfall, but do not mount similarly impassioned concerns regarding failures to implement earlier, more aggressive physical distancing, testing, and contact tracing policies that would have saved far more lives? These inconsistent responses may be related to errors in human cognition that prioritize the readily imaginable over the statistical, the present over the future, and the direct over the indirect. Together, these biases may have promoted medicalized responses to and messaging about the pandemic, rather than those rooted in the traditions and practices of public health." (Cognitive Bias and Public Health Policy During the COVID-19 Pandemic)
Ethics of Decision-Making
Ethics in the age of COVID-19, Ananya Arora and Anmol Arora (University of Cambridge, UK)
Dear Editor,
The current COVID-19 pandemic is continuing to inflict unprecedented strain on healthcare systems worldwide. Hospitals are demonstrating great flexibility, with many outpatient consultations and elective operations widely cancelled. These decisions are not made lightly but as similar decisions are continued to be made, it is important to reflect on key ethical principles from the outset. The framework for ethical medical practice is governed by four key doctrines: autonomy, beneficence, non-maleficence and justice. These are essential components of clinical practice, especially when dealing with individual patients, but they may not provide enough guidance in unprecedented public health crises, such as the one we are currently dealing with.
Decisions around prioritising treatment are not new in healthcare, but the COVID-19 pandemic has highlighted these discussions in mainstream media and public debate. Scarcity of resources brings decisions involving conflicts of beneficence and non-maleficence between patients under great scrutiny. The pillar of justice is also under strain with a substantial amount of non-urgent care cancelled, which will surely have long-term implications. Amongst COVID-19 patients, those with better expected outcomes following treatment will generally be prioritised for treatment escalation. There is a strong correlation between age and mortality and hence, age is an important, but not the sole, factor in prioritisation decisions [1, 2]. This raises the question, would other protected characteristics such as sex, ethnicity or disability be acceptable to use in these decisions if correlations with mortality were discovered? Furthermore, if care providers determine that a patient’s outcomes appear less favourable than other candidates, should the patient have the autonomous right to demand ventilation? They may also face the ethical dilemma of whether they should withdraw support from a stable or even improving patient in order to provide it to another patient with more favourable outcomes [2]. These decisions are made even harder by the potentially rapid deterioration in COVID-19 and the risk that families may have less involvement in care planning due to visiting restrictions.
Priority decisions, if they are to be made, will be entrusted to experienced clinicians in trained teams who will use all available resources at their disposal. Yet the ambiguity and the potential scale for disruption has introduced unprecedented public scrutiny to the issue. There are also ethical questions revolving around persistent PPE issues, especially on the topic of how clinicians should act in situations where they do not have adequate PPE immediately available. Should doctors withhold treatment if they do not have adequate protective equipment? What are the legal ramifications of doing so, or not? To deal with such ethico-legal issues, doctors should be provided with clear guidance to govern, unify and defend their decisions. It is especially important that guidance continues to evolve as the context of clinical practice changes and we learn more about the emergent disease. As new research emerges regarding PPE effectiveness and supply, changes to practice may be warranted. Guidelines should also reflect that there should be scope for doctors to exercise their own professional judgement, without fear of unreasonable retribution. Traditionally, doctors have relied on the conventional aforementioned ‘four pillars’ for these principles. Unfortunately, it may be argued that in the face of a global pandemic the conventional ‘four pillars’ framework may be insufficient.
1. Ruan S. Likelihood of survival of coronavirus disease 2019. The Lancet Infect Dis. 2020 doi: 10.1016/S1473-3099(20)30257-7. [PMC free article] [PubMed] [CrossRef] [Google Scholar] 2. British Medical Association. COVID-19—ethical issues. A guidance note. Available from: https://www.bma.org.uk/media/2226/bma-covid-19-ethics-guidance.pdf. Accessed 8th Apr 2020.
Intern Emerg Med. 2020 May 21 : 1–2. doi: 10.1007/s11739-020-02368-2 [Epub ahead of print]
A Conversation with ED Physicians practicing in the US & UK
Above are two examples of diagrams guiding practice. The first is from David's article on Ceiling of Care and the other is an example of the "substrate" decision-tree to which David referred in our conversation. Such "trees" provide guidelines, but as David noted, the clinical practitioner's genius comes into play in thinking more flexibly in the day-to-day applications of such diagrams. Indeed, it is he who gifted me with Kathryn Montgomery's How Doctors Think, and her masterful text expresses the matter similarly: "Helpful as these diagrams of decision pathways are, clinical reasoning is far more situated and flexible than even the most complex clinical algorithm can express. These decision trees are aids to clinical judgment--teaching the young and reminding the old--but they are not a substitute. While the tension inherent in medical decision-making is regularly resolved, it regularly reappears. Medical schools and residency programs must cultivate a capacity for complex and flexible but often inconclusive clinical reasoning. The learners, luckily, are intelligent, but they are also (most of them) longtime students of science who are not used to negotiating ambiguous alternatives or to tolerating incomplete or uncertain answers. The solution is not more book-learning but experience: years of clinical apprenticeship spent taking care of patients and steadily reviewing cases and the reasoning that has gone into their diagnosis and treatment" (103-104). As we've noticed in the past few months, more attention is also being paid to the augmenting role played by artificial intelligence (AI) and machine learning (ML) in medical decision-making; research in this area is also a speciality of David's.
Unvaccinated man denied heart transplant by Boston hospital (BBC News, Jan. 25, 2022)
According to the article, Brigham and Women's hospital has "rejected a patient for a heart transplant at least in part because he is not vaccinated against Covid-19."
Consequent to such decisions, there are live debates in the literature of medical ethics concerning the viability of allowing vaccination status to impact triage decision-making.
Read the following:
Schuman, O., Robertson-Preidler, J., & Bibler, T. M. (2022). COVID-19 vaccination status should not be used in triage tie-breaking. Journal of Medical Ethics
Iserson, K. V. (2022). Ethics, Personal Responsibility and the Pandemic: A New Triage Paradigm. The Journal of Emergency Medicine.
Shubham Debmath, et. al. (2020). Machine learning to assist clinical decision-making during the COVID-19 pandemic. Bioelectronic Medicine.
Other Resources to Peruse
Increased personal protective equipment litter as a result of COVID-19 measures
The Effect of The Covid-19 Pandemic on the Environment following One Year in Lockdown
Code of Medical Ethics Opinion 11.1.3
Resource Allocation (UW Medicine, Department of Bioethics and Humanities)
Credits:
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