-
Reviews
Back to Reviews
-
Other Comments:
Allocation is a frequently recurring concept from the economic literature which has sneaked into the field of medicine and calls on physicians, patients, their families and policy-makers to face up to complex challenges.
The most difficult problem in the distribution of resources remains the finding of a convincing criterion to provide guidance, when often painful and dramatic choices have to be made, as health care providers have to do in the face of all too real inadequacies in the availability of resources.
The standard that appears fair and acceptable, even if exposed to a certain risk of subjective interpretation, is that of an adequate proportionality of criteria: health may not be for the exclusive good of socially useful individuals but at the same time it cannot be placed above all else, for the benefit of any individual, without consideration of the good of others.
No lottery, no utilitarian privilege, but also the serene consideration of the good/health in relation to the individual who is to recover it and to the entire community which must allocate scant resources.
The definition of ethical, clinical and economical criteria for admission to ICU have been the object of a considerable international effort. The point fundamentally being that resources should be utilised appropriately and that the patient be of the right category, in the right place and at the right time. Furthermore, ethics dictates that resources be allocated where they are more likely to make an impact.
The rationale for ICU admission and discharge can be predicated on a priority scale which classifies patients on the basis of the expected benefit to accrue from intensive treatment. This decreasing priority scale runs from 1 (denoting the maximum expected benefit) to 4 (minimal or nil). However, it is easy enough to generate “on-paper” scenarios, but in everyday practice to actually identify these patients is far from straightforward.
This is far more true when one is faced with emergency situations like the one described by the Authors in this paper.
"Who should have priority? What fairness criteria should be applied in this case? What type of legality are we appealing to?"
Rationalisation, intended as best utilisation and fair limitation, is an economic necessity, juridically and ethically legitimate, albeit still patently inadequate, even if universally pursued. Increased efficiency is contrasted by actual limitations. To define an order of priorities may induce a targeted kind of apportionment, according to a hierarchy of emergencies which must be established at the diagnostic and treatment level. The objective must remain that of equitable apportionment. The basic concepts are those of rationalisation, rationing and priorities.
-
Competing interests:
None
-
Invited by the author to review this article? :
No -
Have you previously published on this or a similar topic?:
No
-
References:
None -
Experience and credentials in the specific area of science:
Consultant Intensivist, interested in the ethics of resource allocation
- How to cite: Luchetti M .Ethical issues in intensive care resource allocation[Review of the article 'Ventilator Allocation In A Pandemic: Discussion And A Model For Rationing Restricted Resources ' by Tsai E].WebmedCentral 2011;2(1):WMCRW00324
This is a discussion we in the medical community need to have, long prior to such outbreaks.
As such I think it's a worthy discussion and I hope helps spur the development of such guidelines prior to being in a disaster setting.
Unfortunately the Appendix II was not available for review, which I think would add nicely to the article as an example of this suggested decision making process would be very useful to see.
None
Yes
No
None
I am a clinical emergency room physician who would be a front line clinician and definitely impacted by ventilator limits in an influenza epidemic.