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Influence of Community and Culture in the Ethical Allocation of Scarce Medical Resources in a Pandemic Situation: Deliberative Democracy Study.

ABSTRACT: BACKGROUND:Stark gaps exist between projected health needs in a pandemic situation and the current capacity of health care and medical countermeasure systems. Existing pandemic ethics discussions have advocated to engage the public in scarcity dilemmas and attend the local contexts and cultural perspectives that shape responses to a global health threat. This public engagement study thus considers the role of community and culture in the ethical apportionment of scarce health resources, specifically ventilators, during an influenza pandemic. It builds upon a previous exploration of the values and preferences of Maryland residents regarding how a finite supply of mechanical ventilators ought to be allocated during a severe global outbreak of influenza. An important finding of this earlier research was that local history and place within the state engendered different ways of thinking about scarcity. OBJECTIVE:Given the intrastate variation in the themes expressed by Maryland participants, the project team sought to examine interstate differences by implementing the same protocol elsewhere to answer the following questions. Does variation in ethical frames of reference exist within different regions of the United States? What practical implications does evidence of sameness and difference possess for pandemic planners and policymakers at local and national levels? METHODS:Research using the same deliberative democracy process from the Maryland study was conducted in Central Texas in March 2018 among 30 diverse participants, half of whom identified as Hispanic or Latino. Deliberative democracy provides a moderated process through which community members can learn facts about a public policy matter from experts and explore their own and others' views. RESULTS:Participants proposed that by evenly distributing supplies of ventilators and applying clear eligibility criteria consistently, health authorities could enable fair allocation of scarce lifesaving equipment. The strong identification, attachment, and obligation of persons toward their nuclear and extended families emerged as a distinctive regional and ethnic core value that has practical implications for the substance, administration, and communication of allocation frameworks. CONCLUSIONS:Maryland and Central Texas residents expressed a common, overriding concern about the fairness of allocation decisions. Central Texas deliberants, however, more readily expounded upon family as a central consideration. In Central Texas, family is a principal, culturally inflected lens through which life and death matters are often viewed. Conveners of other pandemic-related public engagement exercises in the United States have advocated the benefits of transparency and inclusivity in developing an ethical allocation framework; this study demonstrates cultural competence as a further advantage.

SUBMITTER: Schoch-Spana M

PROVIDER: S-EPMC7141421 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Influence of Community and Culture in the Ethical Allocation of Scarce Medical Resources in a Pandemic Situation: Deliberative Democracy Study.

Schoch-Spana Monica M Brunson Emily K EK Gwon Howard H Regenberg Alan A Toner Eric S ES Daugherty-Biddison Elizabeth L EL

Journal of participatory medicine 20200330 1

<h4>Background</h4>Stark gaps exist between projected health needs in a pandemic situation and the current capacity of health care and medical countermeasure systems. Existing pandemic ethics discussions have advocated to engage the public in scarcity dilemmas and attend the local contexts and cultural perspectives that shape responses to a global health threat. This public engagement study thus considers the role of community and culture in the ethical apportionment of scarce health resources, ...[more]

PMID: 33064107

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Project description:Objective. When medical resources are scarce, clinicians must make difficult triage decisions. When these decisions affect public trust and morale, as was the case during the COVID-19 pandemic, experts will benefit from knowing which triage metrics have citizen support. Design. We conducted an online survey in 20 countries, comparing support for 5 common metrics (prognosis, age, quality of life, past and future contribution as a health care worker) to a benchmark consisting of support for 2 no-triage mechanisms (first-come-first-served and random allocation). Results. We surveyed nationally representative samples of 1000 citizens in each of Brazil, France, Japan, and the United States and also self-selected samples from 20 countries (total N = 7599) obtained through a citizen science website (the Moral Machine). We computed the support for each metric by comparing its usability to the usability of the 2 no-triage mechanisms. We further analyzed the polarizing nature of each metric by considering its usability among participants who had a preference for no triage. In all countries, preferences were polarized, with the 2 largest groups preferring either no triage or extensive triage using all metrics. Prognosis was the least controversial metric. There was little support for giving priority to healthcare workers. Conclusions. It will be difficult to define triage guidelines that elicit public trust and approval. Given the importance of prognosis in triage protocols, it is reassuring that it is the least controversial metric. Experts will need to prepare strong arguments for other metrics if they wish to preserve public trust and morale during health crises. Highlights We collected citizen preferences regarding triage decisions about scarce medical resources from 20 countries. We find that citizen preferences are universally polarized. Citizens either prefer no triage (random allocation or first-come-first served) or extensive triage using all common triage metrics, with “prognosis” being the least controversial. Experts will need to prepare strong arguments to preserve or elicit public trust in triage decisions.

Project description:The allocation strategies during challenging situations among the different social groups is based on 9 principles which can be considered either individually: sickest first, waiting list, prognosis, youngest first, instrumental values, lottery, monetary contribution, reciprocity, and individual behavior, or in combination; youngest first and prognosis, for example. In this study, we aim to look into the most important prioritization principles amongst different groups in the Jordanian population, in order to facilitate the decision-making process for any potential medical crisis. We conducted an online survey that tackled how individuals would deal with three different scenarios of medical scarcity: (1) organ donation, (2) limited hospital beds during an influenza epidemic, and (3) allocation of novel therapeutics for lung cancer. In addition, a free-comment option was included at the end of the survey if respondents wished to contribute further. Seven hundred and fifty-four survey responses were gathered, including 372 males (49.3%), and 382 females (50.7%). Five groups of individuals were represented including religion scholars, physicians, medical students, allied health practitioners, and lay people. Of the five surveyed groups, four found "sickest-first" to be the most important prioritization principle in all three scenarios, and only the physicians group documented a disagreement. In the first scenario, physicians regarded "sickest-first" and "combined-criteria" to be of equal importance. In general, no differences were documented between the examined groups in comparison with lay people in the preference of options in all three scenarios; however, physicians were more likely to choose "combination" in both the second and third scenarios (OR 3.70, 95% CI 1.62-8.44, and 2.62, 95% CI 1.48-4.59; p < 0.01), and were less likely to choose "sickest-first" as the single most important prioritization principle (OR 0.57, CI 0.37-0.88, and 0.57; 95% CI 0.36-0.88; p < 0.01). Out of 100 free comments, 27 (27.0%) thought that the "social-value" of patients should also be considered, adding the 10th potential allocation principle. Our findings are concordant with literature in terms of allocating scarce medical resources. However, "social-value" appeared as an important principle that should be addressed when prioritizing scarce medical resources in Jordan.

Project description:Societies are facing medical resource scarcities, inter alia due to increased life expectancy and limited health budgets and also due to temporal or continuous physical shortages of resources like donor organs. This makes it challenging to meet the medical needs of all. Ethicists provide normative guidance for how to fairly allocate scarce medical resources, but legitimate decisions require additionally information regarding what the general public considers to be fair. The purpose of this study was to explore how lay people, general practitioners, medical students and other health professionals evaluate the fairness of ten allocation principles for scarce medical resources: 'sickest first', 'waiting list', 'prognosis', 'behaviour' (i.e., those who engage in risky behaviour should not be prioritized), 'instrumental value' (e.g., health care workers should be favoured during epidemics), 'combination of criteria' (i.e., a sequence of the 'youngest first', 'prognosis', and 'lottery' principles), 'reciprocity' (i.e., those who provided services to the society in the past should be rewarded), 'youngest first', 'lottery', and 'monetary contribution'.1,267 respondents to an online questionnaire were confronted with hypothetical situations of scarcity regarding (i) donor organs, (ii) hospital beds during an epidemic, and (iii) joint replacements. Nine allocation principles were evaluated in terms of fairness for each type of scarcity along 7-point Likert scales. The relationship between demographic factors (gender, age, religiosity, political orientation, and health status) and fairness evaluations was modelled with logistic regression.Medical background was a major predictor of fairness evaluations. While general practitioners showed different response patterns for all three allocation situations, the responses by lay people were very similar. Lay people rated 'sickest first' and 'waiting list' on top of all allocation principles-e.g., for donor organs 83.8% (95% CI: [81.2%-86.2%]) rated 'sickest first' as fair ('fair' is represented by scale points 5-7), and 69.5% [66.2%-72.4%] rated 'waiting list' as fair. The corresponding results for general practitioners: 'prognosis' 79.7% [74.2%-84.9%], 'combination of criteria' 72.6% [66.4%-78.5%], and 'sickest first' 74.5% [68.6%-80.1%); these were the highest-rated allocation principles for donor organs allocation. Interestingly, only 44.3% [37.7%-50.9%] of the general practitioners rated 'instrumental value' as fair for the allocation of hospital beds during a flu epidemic. The fairness evaluations by general practitioners obtained for joint replacements: 'sickest first' 84.0% [78.8%-88.6%], 'combination of criteria' 65.6% [59.2%-71.8%], and 'prognosis' 63.7% [57.1%-70.0%]. 'Lottery', 'reciprocity', 'instrumental value', and 'monetary contribution' were considered very unfair allocation principles by both groups. Medical students' ratings were similar to those of general practitioners, and the ratings by other health professionals resembled those of lay people.Results are partly at odds with current conclusions proposed by some ethicists. A number of ethicists reject 'sickest first' and 'waiting list' as morally unjustifiable allocation principles, whereas those allocation principles received the highest fairness endorsements by lay people and to some extent also by health professionals. Decision makers are advised to consider whether or not to give ethicists, health professionals, and the general public an equal voice when attempting to arrive at maximally endorsed allocations of scarce medical resources.

Project description:COVID-19 is a global pandemic that affected the everyday life activities of billions around the world. It is an unprecedented crisis that the modern world had never experienced before. It mainly affected the economic state and the health care system. The rapid and increasing number of infected patients overwhelmed the healthcare infrastructure, which causes high demand and, thus, shortage in the required staff members and medical resources. This shortage necessitates practical and ethical suggestions to guide clinicians and medical centers when allocating and reallocating scarce resources for and between COVID-19 patients. Many studies proposed a set of ethical principles that should be applied and implemented to address this problem. In this study, five different ethical principles based on the most commonly recommended principles and aligned with WHO guidelines and state-of-the-art practices proposed in the literature were identified, and recommendations for their applications were discussed. Furthermore, a recent study highlighted physicians' propensity to apply a combination of more than one ethical principle while prioritizing the medical resource allocation. Based on that, an ethical framework that is based on Fuzzy inference systems was proposed. The proposed framework's input is the identified ethical principles, and the output is a weighted value (per patient). This value can be used as a rank or a priority factor given to the patients based on their condition and other relevant information, like the severity of their disease status. The main idea of implementing fuzzy logic in the framework is to combine more than one principle when calculating the weighted value, hence mimicking what some physicians apply in practice. Moreover, the framework's rules are aligned with the identified ethical principles. This framework can help clinicians and guide them while making critical decisions to allocate/reallocate the limited medical resources during the current COVID-19 crisis and future similar pandemics.

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Influence of Community and Culture in the Ethical Allocation of Scarce Medical Resources in a Pandemic Situation: Deliberative Democracy Study.

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Influence of Community and Culture in the Ethical Allocation of Scarce Medical Resources in a Pandemic Situation: Deliberative Democracy Study.

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