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Department of Ethics
www.thelancet.com
Vol 373 January 31, 2009
423
Principles for allocation of scarce medical interventions
Govind Persad, Alan Wertheimer, Ezekiel J Emanuel
Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. Weevaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouringthe worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle issuffi cient to incorporate all morally relevant considerations and therefore individual principles must be combinedinto multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing pointssystems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system—thecomplete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporatesprognosis, save the most lives, lottery, and instrumental value principles.
In health care, as elsewhere, scarcity is the mother of allocation.
1
Although the extent is debated,
2,3
the scarcityof many specific interventions—including beds inintensive care units,
4
organs, and vaccines duringpandemic influenza
5
—is widely acknowledged. For someinterventions, demand exceeds supply. For others, anincreased supply would necessitate redirection of important resources, and allocation decisions would stillbe necessary.
6
Allocation of scarce medical interventions is a perennialchallenge. During the 1940s, an expert committeeallocated—without public input—then-novel penicillinto American soldiers before civilians, using expectedeffi cacy and speed of return to duty as criteria.
7
Duringthe 1960s, committees in Seattle allocated scarce dialysismachines using prognosis, current health, social worth,and dependants as criteria.
7
How can scarce medicalinterventions be allocated justly? This paper identifiesand evaluates eight simple principles that have beensuggested.
8–12
Although some are better than others, nosingle principle allocates interventions justly. Rather,morally relevant simple principles must be combinedinto multiprinciple allocation systems. We evaluate threeexisting systems and then recommend a new one: thecomplete lives system.
Simple allocation principles
Eight simple ethical principles for allocation can beclassified into four categories, according to their coreethical values: treating people equally, favouring theworst-off, maximising total benefits, and promoting andrewarding social usefulness (table 1). We do not regardability to pay as a plausible option for the scarce life-savinginterventions we discuss.Some people wrongly suggest that allocation can bebased purely on scientific or clinical facts, often using theterm “medical need”.
13,14
There are no value-free medicalcriteria for allocation.
15,16
Although biomedical factsdetermine a person’s post-transplant prognosis or thedose of vaccine that would confer immunity, respondingto these facts requires ethical, value-based judgments.When evaluating principles, we need to distinguishbetween those that are insuffi cient and those that areflawed. Insuffi cient principles ignore some morallyrelevant considerations. Conversely, flawed principlesrecognise morally irrelevant considerations: inherentlyflawed principles necessarily recognise irrelevantconsiderations, whereas practically flawed principlesallow irrelevant considerations to affect allocation.Principles that are individually insuffi cient could formpart of an acceptable multiprinciple system, whereassystems that include flawed principles are untenablebecause they will always recognise irrelevant con-siderations.
Treating people equally
Many scarce medical interventions, such as organtransplants, are indivisible. For indivisible goods, bene-fiting people equally entails providing equal chances atthe scarce intervention—equality of opportunity, ratherthan equal amounts of it.
1
Two principles attempt toembody this value.
Lottery
Allocation by lottery has been used, sometimes withexplicit judicial and legislative endorsement, in militaryconscription, immigration, education, and distributionof vaccines.
10,17,18
Lotteries have several attractions. Equal moral statussupports an equal claim to scarce resources.
19
Evenamong only roughly equal candidates, lotteries preventsmall differences from drastically affecting outcome.
18
Some people also support lottery allocation because “eachperson’s desire to stay alive should be regarded as of thesame importance and deserving the same respect as thatof anyone else”.
20
Practically, lottery allocation is quickand requires little knowledge about recipients.
18
Finally,lotteries resist corruption.
18
The major disadvantage of lotteries is their blindnessto many seemingly relevant factors.
21,22
Random decisionsbetween someone who can gain 40 years and someonewho can gain only 4 months, or someone who hasalready lived for 80 years and someone who has livedonly 20 years, are inappropriate. Treating people equallyoften fails to treat them as equals.
23
Ultimately, althoughallocation solely by lottery is insuffi cient, the lottery’s
Lancet
2009; 373: 423–31Department of Bioethics,The Clinical Center, NationalInstitutes of Health, Bethesda,Maryland, USA
(G Persad BS,A Wertheimer PhD,E J Emanuel MD)Correspondence to:Ezekiel J Emanuel,Department of Bioethics,The Clinical Center, NationalInstitutes of Health, Bethesda,MD 20892-1156, USA
eemanuel@nih.gov
Department of Ethics
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www.thelancet.com
Vol 373 January 31, 2009
simplicity and resistance to corruption suggests that itcould be incorporated into a multiprinciple system.
22
First-come, first-served
Within health care, many people endorse a first-come,first-served distribution of beds in intensive care units
24
or organs for transplant.
25
The American Thoracic Societydefends this principle as “a natural lottery—an egalitarianapproach for fair [intensive care unit] resourceallocation.”
24
Others believe it promotes fair equality of opportunity,
25
and allows physicians to avoiddiscontinuing interventions, such as respirators, evenwhen other criteria support moving those interventionsto new arrivals.
26
Some people simply equate it to lotteryallocation.
19
As with lottery allocation, first-come, first-served ignoresrelevant differences between people, but in practice failseven to treat people equally. It favours people who arewell-off, who become informed, and travel more quickly,and can queue for interventions without competing foremployment or child-care concerns.
27
Queues are alsovulnerable to additional corruption. As New York State’spandemic influenza planners stated, “Those who couldfiguratively (and sometimes literally) push to the front of the line would be vaccinated and stand the best chancefor survival”.
28
First-come, first-served allows morallyirrelevant qualities—such as wealth, power, andconnections—to decide who receives scarce interventions,and is therefore practically flawed.
Favouring the worst-off: prioritarianism
Franklin Roosevelt argued that “the test of our progressis not whether we add more to the abundance of thosewho have much; it is whether we provide enough forthose who have too little”.
29
Philosophers call thispreference for the worst-off prioritarianism
.
30
Somedefine being worst-off as currently lacking valuablegoods, whereas others define it as lacking valuable goodsthroughout one’s entire life.
8
Two principles embodythese two interpretations.
Sickest first
Treating the sickest people first prioritises those with theworst future prospects if left untreated. The so-called ruleof rescue, which claims that “our moral response to theimminence of death demands that we rescue thedoomed”, exemplifies this principle.
31
Transplantablelivers and hearts, as well as emergency-room care, areallocated to the sickest individuals first.
21
Some people might argue that treating the sickestindividuals first is intuitively obvious.
32
Others claim thatthe sickest people are also probably worst off overall,because healthier people might recover unaided or besaved later by new interventions.
33
Finally, sickest-firstallocation appeals to prognosis if untreated—a criterionclinicians frequently consider.
14
On its own, sickest-first allocation ignores post-treatmentprognosis: it applies even when only minor gains at highcost can be achieved. To circumvent this result, some
AdvantagesDisadvantagesExamples of useRecommendationTreating people equally
LotteryHard to corrupt; little information aboutrecipients neededIgnores other relevant principlesMilitary draft; schools;vaccinationIncludeFirst-come,first-servedProtects existing doctor-patient relationships;little information about recipients neededFavours wealthy, powerful, and well-connected; ignoresother relevant principlesICU beds; part of organallocationExclude
Favouring the worst-off: prioritarianism
Sickest firstAids those who are suffering right now; appealsto “rule of rescue”; makes sense in temporaryscarcity; proxy for being worst off overallSurreptitious use of prognosis; ignores needs of those whowill become sick in future; might falsely assume temporaryscarcity; leads to people receiving interventions only afterprognosis deteriorates; ignores other relevant principlesEmergency rooms; part of organ allocationExcludeYoungest firstBenefits those who have had least life; prudentplanners have an interest in living to old ageUndesirable priority to infants over adolescents and youngadults; ignores other relevant principlesNew NVAC/ACIP pandemic fluvaccine proposalInclude
Maximising total benefits: utilitarianism
Number of livessavedSaves more lives, benefiting the greatestnumber; avoids need for comparative judgmentsabout quality or other aspects of livesIgnores other relevant principlesPast ACIP/NVAC pandemic fluvaccine policy; bioterrorismresponse policy; disaster triageIncludePrognosis orlife-years savedMaximises life-years producedIgnores other relevant principles, particularly distributiveprinciplesPenicillin allocation; traditionalmilitary triage (prognosis) anddisaster triage (life-years saved)Include
Promoting and rewarding social usefulness
Instrumental valueHelps promote other important values; futureorientedVulnerable to abuse through choice of prioritisedoccupations or activities; can direct health resources awayfrom health needsPast and current NVAC/ACIPpandemic flu vaccine policyInclude but only in somepublic healthemergenciesReciprocityRewards those who implemented importantvalues; past orientedVulnerable to abuse; can direct health resources away fromhealth needs; intrusive assessment processSome organ donation policiesInclude only irreplaceablepeople who havesuffered serious losses
Table 1:
Simple principles and their core ethical values
Department of Ethics
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Vol 373 January 31, 2009
425
misleadingly claim that sick people with a small but clearchance of benefit do not have a medical need.
13
Sickrecipients’ prognoses are wrongly assumed to be normal,even though many interventions—such as livertransplants—are less effective for the sickest people.
34
If the failure to take account of prognosis were its onlyproblem, sickest-first allocation would merely beinsuffi cient. However, it myopically bases allocation onhow sick someone is at the current time—a morallyarbitrary factor in genuine scarcity.
16
Preferentialallocation of a scarce liver to an acutely ill personunjustly ignores a currently
healthier person withprogressive liver disease, who might be worse off whenhe or she later suffers liver failure.
8,22
Favouring thosewho are currently sickest seems to assume that resourcescarcity is temporary: that we can save the person who isnow sickest and then save the progressively ill personlater.
8,22
However, even temporary scarcity does notguarantee another chance to save the progressively illperson. Furthermore, when interventions are per-sistently scarce, saving the progressively ill person laterwill always involve depriving others. When we cannotsave everyone, saving the sickest first is inherentlyflawed and inconsistent with the core idea of priority tothe worst-off.
Youngest first
Although not always recognised as such, youngest-firstallocation directs resources to those who have had lessof something supremely valuable—life-years.
8
Dialysismachines and scarce organs have been allocated to youngerrecipients first,
35
and proposals for allocation in pandemicinfluenza prioritise infants and children.
36
Daniel Callahan
37
has suggested strict age cut-offs for scarce life-savinginterventions, whereas Alan Williams
38
has suggested asystem that allocates interventions based on individuals’distance from a normal life-span if left unaided.Prioritising the youngest gives priority to theworst-off—those who would otherwise die having hadthe fewest life-years—and is thus fundamentally differentfrom favouritism towards adults or people who arewell-off.
8,9
Also, allocating preferentially to the young hasan appeal that favouring other worst-off individuals suchas women, poor people, or minorities lacks: “Because [allpeople] age, treating people of different ages differentlydoes not mean that we are treating persons unequally.”
39
Prudent planners would allocate life-saving interventionsto themselves earlier in life to improve their chances of living to old age.
39
These justifications explain much of thepublic preference for allocating scarce life-savinginterventions to younger people.
40,41
Strict youngest-first allocation directs scarce resourcespredominantly to infants. This approach seems incorrect.
5
The death of a 20-year-old young woman is intuitivelyworse than that of a 2-month-old girl, even though thebaby has had less life.
40
The 20-year-old has a much moredeveloped personality than the infant, and has drawn uponthe investment of others to begin as-yet-unfulfilled projects.Youngest-first allocation also ignores prognosis,
42
andcategorically excludes older people.
34
Thus, youngest-firstallocation seems insuffi cient on its own, but it could becombined with prognosis and lottery principles in amultiprinciple allocation system.
34
Maximising total benefits: utilitarianism
Maximising benefits is a utilitarian value, althoughprinciples differ about which benefits to maximise.
Save the most lives
One maximising strategy involves saving the mostindividual lives, and it has motivated policies on allocationof influenza vaccine
5
and responses to bioterrorism.
43
Sinceeach life is valuable, this principle seems to need no specialjustification. It also avoids comparing individual lives.Other things being equal, we should always save five livesrather than one.
44
However, other things are rarely equal. Some lives havebeen shorter than others; 20-year-olds have lived less than70-year-olds.
40
Similarly, some lives can be extended longerthan others. How to weigh these other relevantconsiderations against saving more lives—whether to saveone 20-year-old, who might live another 60 years if saved,or three 70-year-olds who could only live for 10 yearseach—is unclear.
45
Although insuffi cient on its own, savingmore lives should be part of a multiprinciple allocationsystem.
Prognosis or life-years
Rather than saving the most lives, prognosis allocationaims to save the most life-years. This strategy has beenused in disaster triage and penicillin allocation, andmotivates the exclusion of people with poor prognosesfrom organ transplantation waiting lists.
7,21,46
Maximisinglife-years has intuitive appeal. Living more years is valuable,so saving more years also seems valuable.
8
However, even supporters of prognosis-based allocationacknowledge its inability to consider distribution as well asquantity.
46
Making a well-off person slightly better off ratherthan slightly improving a worse-off person’s life would beunjust; likewise, why give an extra year to a person whohas lived for many when it could be given to someone whowould otherwise die having had few?
8,47
Similarly, giving afew life-years to many differs from giving many life-yearsto a few.
8
As with the principle of saving the most lives,prognosis is undeniably relevant but insuffi cient alone.
Promoting and rewarding social usefulness
Unlike the previous values, social value cannot directallocation on its own.
20
Rather, social value allocationprioritises specific individuals to enable them to promoteother important values, or rewards them for havingpromoted these values.In view of the multiplicity of reasonable values in societyand in view of what is at stake, social value allocation must