How Should We Allocate Scarce Medical Resources?
Who should get a ventilator if there aren’t enough to go around? Research on decision making leads to three concrete guidelines that policy-makers and physicians can use to make fair choices when allocating scarce, life-saving resources. They key to making fair and ethical choices is to assure that decisions are made through an impartial process.
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Physicians around the world must make daunting decisions in the face of the Covid-19 crisis. Chief among their concerns is that there might not be enough of a scarce resource, such as ventilators, ICU beds, or vaccines, for all of the patients who need them. This isn’t a theoretical dilemma. Doctors in Italy faced horrifying choices about which patients should get a ventilator and which they should let die. Fortunately, major U.S. cities have thus far escaped that calamity, but this remains an important concern for the months ahead as we wait to see whether the virus slows down or resurges.
Globally, the situation remains challenging as the virus spreads to regions with fewer resources. Confronted with impossible choices, hospitals need workable guidelines that reflect society’s deepest understanding of fairness. Research on moral decision making, and our own experiments asking ordinary people what choices they would make, offers some guidance.
Who should get a ventilator if there aren’t enough to go around? Many medical ethicists adopt a philosophical perspective called utilitarianism. The idea is simple – you should seek to minimize overall harm and maximize well-being across society. Writing in the New England Journal of Medicine, for instance, bioethicist Ezekiel Emanuel and colleagues argue for prioritizing the lives of health care providers – providing them first with testing, ventilators, treatments and vaccines – to assure that they can remain on the job or return quickly to it if they become sick. “These workers should be given priority not because they are somehow more worthy,” they write, “but because of their instrumental value: they are essential to pandemic response.” Utilitarianism likewise endorses the traditional “triage” of battlefield medicine, where resources are directed toward those whose lives hang in the balance and away from those who will surely live or surely die.
Yet, utilitarianism’s willingness to confront seemingly impossible choices head on makes many people uncomfortable. Roger Severino, the director of the Office for Civil Rights at the U.S. Department of Health and Human Services, for example, announced that there would be investigations of those who institute utilitarian policies during the crisis. But, Severino failed to provide any alternative guidance for making such tragic choices.
One especially controversial feature of utilitarianism is that in life-or-death decisions it favors the young over the old, because doing so can be expected to save more years of life. But when ventilators are scarce, isn’t it immoral to explicitly favor the young?
To shed light on the question of whether hospitals should take a utilitarian perspective in these challenging times we set out to understand the perspectives of American citizens about how they would want physicians to prioritize care. In a recent experiment, we instructed one group of participants to imagine a doctor deciding whether to give the last available ventilator to the 65-year-old patient who arrived first or to the 25-year-old patient who arrived moments later. Participants were told to assume that whichever patient is saved will live to age 80, and that the ventilator is equally capable of saving either patient. About half of these participants thought that it would be moral to give the ventilator to the younger person. Perhaps not surprisingly, their answers were strongly associated with their age; 66% of people between 18 and 30 considered it moral to give the ventilator to the younger person, but only 33% of people 60 or older agreed.
But we saw an interesting shift when we asked participants to look at this dilemma from an impartial stance. Applying philosopher John Rawls’ veil of ignorance perspective, which argues that a fair decision is equivalent to a selfish decision, provided that you don’t know who you will be among those affected, we presented another group of participants with the same situation. However, we first asked them to put themselves into the equation, imagining that they had a 50% chance of being the older patient, with 15 years left to live if saved, and a 50% chance of being the younger patient, who will live 55 years if saved. About three quarters said they would want the doctor to follow the utilitarian principle, favoring the younger patient.
More interestingly, after thinking through what they would want under the veil of not knowing whether they were the younger or older patient, when we then asked whether they thought that it would be moral to give the ventilator to the younger person, a much higher percentage (62%) now found the utilitarian course of action more ethical. This increase in the proportion of people favoring the younger patient occurred principally because most of the older respondents, imagining themselves with an equal chance of being young or old, now chose to save the younger patient. The change in moral assessment when the veil of ignorance obscured which patient they were — young or old — was strongest for those over 60.
Their preferences tell us something about fairness principles. “First come, first served” is a morally plausible principle. So is “Save the most years of life.” Which rule is fairer in the current moment? When participants put themselves in the shoes of both patients, the majority indicated that saving more life-years is fairer: It’s what they would want for themselves if they did not know whom they were going to be.
Our most important conclusion is not that the young should be favored over the old, or that any group should be favored over any other, but rather that decisions should be made through an impartial process. Research on decision making provides three concrete guidelines that policymakers and physicians can use to make fair choices when allocating scarce, life-saving resources:
First, it can be helpful to try to use Rawls’ veil of ignorance. Our current work applied Rawls’ idea and found that assuming a veil of ignorance shifts judgment toward saving more life years. We’ve seen this same effect in previous research that looked at people’s instinct to save the most lives in scenarios involving self-driving cars, charitable giving, and health care decisions.
Second, decisions can be improved when making comparative rather than one-off choices. Our research (with Iris Bohnet and Alexandra van Geen) shows that when people evaluate job candidates one at a time, they make stereotype-based decisions, such as hiring men for mathematical tasks and women for verbal tasks. By contrast, when people compare two applicants at the same time, they focus more on job-relevant criteria and make more ethical, less sexist hiring choices. In other research (with Chia-Jung Tsay and Fiery Cushman), we found that considering two moral dilemmas at the same time promotes consistency in moral decision-making. Similarly, comparing multiple options for saving lives when resources are limited should lead to better, more ethical decisions than evaluating options one at a time. Thus, rather than make case-by-case decisions when patients in critical need arrive at a hospital, doctors should consider multiple options or policies for how they would allocate limited resources.
Third, it’s important to pre-commit to evaluative standards. Our ongoing research (with Linda Chang, Mina Cikara, and Iris Bohnet) shows that that when employers first think through the criteria that define a good employee before considering a specific candidate, they make less discriminatory decisions and hire better-quality employees. Likewise, when physicians and administrators think through their goals when planning how to allocate limited medical resources, they will reach decisions that are more aligned with their values.
Just as surgeons aim to use the best available tools when operating, those at the front lines of the pandemic need the best decision-making tools available to allocate scarce resources fairly. That means moving beyond intuitive thinking, harnessing their deliberative cognitive capacities — and empowering them to make these tragic decisions as ethically as possible.
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Max H. Bazerman is the Jesse Isidor Straus Professor of Business Administration at Harvard Business School and the author of Better, Not Perfect: A Realist’s Guide to Maximum Sustainable Goodness (Harper Business, 2020).
Regan Bernhard is a Postdoctoral College Fellow in the Department of Psychology at Harvard University.
Joshua Greene is Professor of Psychology and a member of the Center for Brain Science faculty at Harvard University. He is the author of Moral Tribes: Emotion, Reason, and the Gap Between Us and Them.
Karen Huang is a Ph.D. Candidate in Organizational Behavior at Harvard Business School, and incoming Assistant Professor at Georgetown University’s McCourt School of Public Policy
Netta Barak-Corren is an Assistant Professor of Law at the Hebrew University of Jerusalem.
How Should We Allocate Scarce Medical Resources?
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