Should The Sickest Patients Get Treatment First? by Peter Rüegg-ETH Zurich

What’s the fairest way to allocate scarce medical resources? Ethicists, doctors, and patients often disagree.

Lay people believe that the sickest patients and those on waiting lists should be treated first. Ethicists—and to some degree medical professionals—tend to have a different set of priorities.

Donor organs are in very short supply. In Switzerland alone, for example, over 1,140 people are waiting to receive a new kidney. However, in the first half of 2016, only 77 patients received a transplant.

Some believe priority should be given to the sickest patients. Other potential approaches include: a lottery; “first come first” (working through a waiting list); giving priority to patients most likely to benefit from treatment (prognosis); treating the youngest first; or a combination of age, prognosis, and lottery.

Sickest Patients
Image source: Wikimedia Commons
Sickest Patients

Reality check

Researchers decided to perform a “reality check”‘ on the fairness criteria proposed by ethics experts. They produced a comprehensive online questionnaire to determine how different people perceive ethical standards concerning the fair allocation of scarce medical resources in three hypothetical situations: donor transplants, the allocation of hospital beds during an epidemic, and an artificial hip replacement to improve a patient’s quality of life.

Respondents had to rate, on a scale from 1 to 7, how fair they thought the criteria were. The 1,267 respondents included lay people, general practitioners, medical students, and other health professionals. The findings appear in the journal PLOS ONE.

In all three hypothetical situations, lay people rate “sickest first” as the fairest option, followed by a waiting list, and a patient’s medical prognosis.

By contrast, medics are rather more discriminating. In the case of organ transplants, medical professionals considered prognosis to be the fairest criterion, followed by the sickest first, and a combination of age, prognosis, and lottery. Unlike lay people, medics say the patient’s age is more important than their position on the waiting list.

“It’s fascinating to discover that lay people consider age to be an unfair criterion for an organ transplant, while both health professionals and ethicists think it is fair to give precedence to young people for this type of operation,” says Pius Krütli of ETH Zurich. Favoring young over old patients is a form of discrimination that lay people apparently consider unfair.

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General practitioners consider the patient’s prognosis to be the fairest criterion for allocating hospital beds in the event of a pandemic, followed by sickest first, and then a combination of criteria. Both general practitioners and lay people think that the “sickest first” principle is the fairest criterion for a hip replacement, since it would improve the patient’s quality of life.

All respondents felt that the principle of “reciprocity,” or rewarding those people who have provided services to society in the past, is an unfair criterion. Both doctors and lay people think that a patient’s willingness to make a monetary contribution towards their care is not a fair principle.

But lay people and the medical profession appear to be very divided when it comes to prioritizing treatment on the basis of individual behavior.

Reality gap

The ratings awarded by ethics specialists to the various fairness criteria varied. There is a particularly big divide when it comes to the two criteria “sickest first” and waiting list. Certain ethicists believe a lottery to be a fair principle, but neither general practitioners nor lay people think a lottery is a fair criterion in any of the hypothetical situations.

Further, not all health professionals and lay people share the opinion of some ethicists that “sickest first” is morally indefensible, since it doesn’t take into consideration the future course of the illness.

“The results of our survey are to some extent diametrically opposed to the current position of various ethicists,” Krütli says. The large gap between the fairness ratings of ethical experts and the general public is in itself not particularly unusual. Ethicists believe that ethical principles cannot be derived from empirical data.

“On the other hand, ethicists cannot simply ignore these empirical findings, or else there is a risk of the gap between moral standards and reality widening to the point where ethical arguments are brushed aside as being divorced from reality. We want to reflect the position of ethicists and produce an empirical study to check how their proposed fairness criteria fit in with the real world.”

The findings clearly show that the standards of ethicists differ—quite significantly in some cases—from prevalent social attitudes, Krütli says.

“Policymakers therefore have to consider whether to give equal weight to ethicists, health professionals, and the general public when developing collective norm.”

The Cogito Foundation funded the work.

Source: ETH Zurich

Original Study DOI: 10.1371/journal.pone.0159086