Who should be prioritized for scarce medical assistance?

This post is a preview of a presentation for the Baruch A. Brody Lecture in Bioethics. Want to learn more about this topic? Tune into the lecture Feb 1 at 12 p.m. CT.  Register here.

As we enter 2022, the challenge of fairly allocating scarce medical capacity in response to the COVID-19 pandemic continues. New oral antivirals are available, but in short supply. The omicron variant has heightened the scarcity of monoclonal antibodies as two other frequently used antibody therapies are ineffective against it. And medical personnel are overstretched.

When there is not enough to go around, who should be prioritized for scarce medical assistance? In my 2022 Baruch A. Brody Award Lecture, I will discuss:

• The ethical objectives allocation should consider;
• How strategies for achieving these objectives might differ across interventions; and
• How allocation strategies can be effectively implemented.

Building on earlier work, allocation should emphasize benefiting people and preventing harm and mitigating health inequities. Given that many people have taken reasonable precautions to protect themselves through vaccination, and many others have contributed to stemming the pandemic through frontline work and volunteering in clinical trials, reciprocity is relevant as well.

Optimal allocation would prioritize groups in a way that aligns objectives. For instance, it would prioritize people who face harm if not helped, have good prospects of benefit if helped, are on the short end of health inequities and perhaps have claims of reciprocity as well.

To see how these ethical objectives might be achieved in practice, consider an antiviral therapy in short supply, Paxlovid. To benefit people and prevent harm, allocation should prioritize people at high risk of severe COVID-19 if infected, but not so ill (e.g. terminally ill patients) that they will fare badly even if they receive treatment. It should also prioritize people to produce indirect benefit and prevent harm: for instance, those who are essential to COVID-19 response, such as scarce health workers.

What puts someone at high risk? Here, scientific considerations inform—but do not determine—ethical analysis. Some potential risk factors include being immunocompromised, being older, and being unvaccinated. To prioritize among these, objectives other than benefiting people and preventing harm may matter as well.

Being immunocompromised often exposes one to disadvantage, and most immunocompromising conditions, such as organ transplant, are correlated with other forms of disadvantage and are not easily preventable. Being older, meanwhile, is certainly not preventable, but living longer is correlated with being more advantaged: prioritizing people over 75, for instance, will disproportionately exclude those who are less likely to survive to 75 due to health inequities.

What about unvaccinated adults? Early in the vaccine rollout, being unvaccinated was correlated with disadvantage and access barriers, but this is less true now. Additionally, unvaccinated status (unlike immunocompromise or older age) is now easily reversible by reasonable precautions for everyone except the very few who are medically ineligible. While prioritizing some or all of these high-risk groups treats people unequally, it is nevertheless consistent with equal concern because the unequal treatment is based on relevant differences.

What about indirect benefit? We know that health workers are the scarcest resource at this point in the pandemic. Health worker scarcity worsens medical outcomes for all patients, and especially hurts those who more often need medical assistance, who are often those on the short end of health inequities. Benefiting people and preventing harm would therefore support prioritizing scarce health workers if antiviral treatment can enable them to return more quickly to work and mitigating health inequities may do so as well, particularly for groups like nurses who are more likely to be disadvantaged themselves.

In light of these factors, one might conclude that both immunocompromised people and health workers should be prioritized for Paxlovid. I will argue that a compelling way of doing this is to use what I and others have called a categorized priority system: for instance, prioritizing 25% of available treatments for immunocompromised people and 25% for health workers, with the remainder open to others at risk. Within these groups, one might prioritize if needed using other factors, like older age or high-risk conditions.

Many of these factors are particular to Paxlovid: for interventions that reduce disease transmission (like vaccines) or that are unlikely to enable health workers to return to work quickly (like ECMO), priorities may differ.

Another advantage of articulating ethical objectives is that they illuminate the basis for disagreements. Some understand equal concern as requiring identical treatment and assign it overriding priority, calling for scarce interventions to be allocated by lottery even if this means more people will die.

Others argue that we should treat unvaccinated people identically to vaccine-ineligible people, even though the former could have taken reasonable precautions. These all depend on differing interpretations of, and weights attached to, relevant ethical values: for instance, whether equal concern requires identical treatment or only the equal treatment of equals, and whether reciprocity should be relevant when allocating scarce treatments.

By Govind Persad, J.D., Ph.D., assistant professor at the University of Denver Sturm College of Law and a Greenwall Foundation Faculty Scholar in Bioethics, Recipient of the 2021-2022 Baruch A. Brody Award & Lecture in Bioethics sponsored by the Baylor College of Medicine Center for Medical Ethics and Health Policy, Houston Methodist and the Rice University Department of Philosophy.