Principles for allocation of scarce medical interventions

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[Editors note: Thos who are seeking an ethical framework for HIV

response may find this article interesting. A PDF copy of this

article is available from the editor of the FORUM]

Principles for allocation of scarce medical interventions

Govind Persad BS a, Alan Wertheimer PhD a, Ezekiel J Emanuel MD a

The Lancet, Volume 373, Issue 9661, Pages 353-432 - 31 January 2009-6

February 2009. doi:10.1016/S0140-6736(09)60137-9 C

Summary

Allocation of very scarce medical interventions such as organs and

vaccines is a persistent ethical challenge. We evaluate eight simple

allocation principles that can be classified into four categories:

treating people equally, favouring the worst-off, maximising total

benefits, and promoting and rewarding social usefulness.

No single principle is sufficient to incorporate all morally relevant

considerations and therefore individual principles must be combined

into multiprinciple allocation systems. We evaluate three systems:

the United Network for Organ Sharing points systems, quality-adjusted

life-years, and disability-adjusted life-years. We recommend an

alternative system—the complete lives system—which prioritises

younger people who have not yet lived a complete life, and also

incorporates prognosis, 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 scarcity of many specific

interventions—including beds in intensive care units,4 organs, and

vaccines during pandemic influenza5—is widely acknowledged.

For some interventions, demand exceeds supply. For others, an

increased supply would necessitate redirection of important

resources, and allocation decisions would still be necessary.6

Allocation of scarce medical interventions is a perennial challenge.

During the 1940s, an expert committee allocated—without public input—

then-novel penicillin to American soldiers before civilians, using

expected efficacy and speed of return to duty as criteria.7 During

the 1960s, committees in Seattle allocated scarce dialysis machines

using prognosis, current health, social worth, and dependants as

criteria.7 How can scarce medical interventions be allocated justly?

This paper identifies and evaluates eight simple principles that have

been suggested.8—12 Although some are better than others, no single

principle allocates interventions justly. Rather, morally relevant

simple principles must be combined into multiprinciple allocation

systems. We evaluate three existing systems and then recommend a new

one: the complete lives system.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)

60137-9/fulltext