Commentary on Allocation of Scarce Resources

ASH has added to its website two critically important recent publications from the New England Journal of Medicine. The first,¹ co-authored by an international team of health-policy ethicists, lays out a framework by which hospitals and hospital systems can develop allocation strategies for limited resources such as ventilators or vaccinations. While jarring to read, their approach is one of brutal fairness. The authors outline six recommendations that are geared toward supporting 4 principles: 1) saving the most lives and the most life-years, 2) treating people equally, 3) promoting and rewarding instrumental value, and 4) prioritizing those patients who are the worst off.

Instrumental value refers to a person’s anticipated subsequent contributions to the common good. This might mean, for example, giving priority to those whose work directly saves the lives of others because the loss of these people may result in even more deaths. Operationalizing these principles remains the responsibility of the local care teams (in most cases, a hospital or hospital system), but the guidance provided offers impartial and rational foundations for the excruciating challenges forced upon the national health infrastructure by this pandemic.

The second article,² also written by several distinguished experts, provides additional perspective. The authors not only discuss the trauma and grief experienced by the health care providers facing this state of affairs, they also endorse recommendations that systems develop an independent “triage committee” to arbitrate and prevent bedside providers from having to choose between someone they are caring for and other patients. This may be especially relevant for hematologists and others caring for those with life-threatening illnesses at baseline. Hematologists will need to be involved in these conversations if we are called upon to inform triage committees about the prognoses of our patient populations.

Both articles will likely generate extensive discussion and debate. Hopefully, the principles will be incorporated into the disaster plans now being developed throughout the United States. We need to debate such proposals now and hope that we never need to invoke them. The most seductive option would be to pretend we don't need to plan for this. That is not the case.

References

1. Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med 2020. https://www.nejm.org/doi/full/10.1056/NEJMsb2005114?query=featured_coronavirus
2. Truog RD, Mitchell C, Daley GQ. The Toughest Triage - Allocating Ventilators in a Pandemic. N Engl J Med 2020. https://www.nejm.org/doi/full/10.1056/NEJMp2005689?query=featured_coronavirus