lunedì, maggio 25, 2020

Should those in charge get priority treatment in a pandemic?

In a previous blog I discussed an article published in the New England Journal of Medicine (NEJM) that debates certain principles for allocating scarce medical resources during a pandemic.

The authors propose four main values that can be useful when there is a shortage of resources. They are: 1. Maximize the benefits; 2. Treat people equally; 3. Promote and reward instrumental value; and 4. Give priority to the worst off.

I have already discussed three of them and now I will concentrate on “promote and reward instrumental value”.

We value things intrinsically, for their own sake, or instrumentally, for the sake of something else. For instance, a banknote has little intrinsic value, it is just a piece of paper, but when it is a legal tender it also has an instrumental value because it can be used to pay for something. We employ it instrumentally for something else, to carry out a particular function.

Similarly, we can value human beings for what they are, in themselves, or for what they do, instrumentally. If I need a plumber, for instance, I will choose the one that suits me best. I treat him as an instrument for my purposes (do the job being paid for) and there is nothing wrong with it as this is the nature of a commercial transaction.

But when we need to evaluate who has priority in accessing medical resources, should we treat patients for their intrinsic value, simply as members of the human family, or also for some instrumental value, such as their utility to society?

In normal circumstances, we treat them according to their needs. Their past or their future, their role in society, their usefulness should not matter.

We give should give the opportunity to access the same treatment to an important doctor and to someone who has injured himself behaving recklessly, or to someone who is in prison. We value patients not from the point of view of society, but intrinsically, for what they are and not according to their history because even the worst human being deserves care.

Nonetheless, this general equality principle does not apply in exceptional circumstances.

For instance, if there is a health emergency on a ship with hundreds of people, it is morally acceptable to prioritise those who are in charge of the ship over the rest, because if they die, everyone else will also die. The instrumental value prevails in this case.

How this apply to our circumstances?

The NEJM article says: “Instrumental value could be promoted by giving priority to those who can save others, or rewarded by giving priority to those who have saved others in the past”.

Using a technical term, I will call those “diachronic criteria” as they associate value to time, to what someone did in the past or will do in the future.

I maintain that, in allocating medical resources, diachronic instrumental value should not apply retrospectively. Obviously, those who have made relevant contributions should be recognised and rewarded but this should not count as a criterion to select who should have access to ICU beds, ventilators, etc.  Nonetheless, treatments are not awards based on past merit but they are remedies offered according to actual needs. The focus in on the present.

And what about future usefulness or utility? Does it matter? It does but as an ultimate measure and only for the limited time of the in exceptional circumstances. (Think of the previous example of the ship).

The NEJM article says: “Critical Covid-19 interventions – testing, PPE, ICU beds, ventilators, therapeutics, and vaccines – should go first to front-line health care workers and others who care for ill patients and who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace. These workers should be given priority not because they are somehow more worthy, but because of their instrumental value: they are essential to pandemic response”.

They have a higher instrumental value because saving them we will also save other lives. Special considerations will be beneficial to them directly and to others indirectly. So, all things being equal, it is morally acceptable to favour them because of their indispensable role for society.

This kind of thinking seemed to be dominant in March when hospitals were outbidding care homes for PPE and staff leaving them in very short supply at great cost. Almost two-thirds of Covid-related deaths have occurred in care homes and, in the end, the hospitals were never overwhelmed with Covid-patients or anything close to it.

I don’t believe we have anywhere reached such an exceptional level of emergency that the survival of large part of the population depends on few health professionals, but this is an evaluation that has to be performed locally.

In any case, the main point is that “promote and reward instrumental value” should not be interpreted retrospectively. Diachronic instrumental criteria are valid only exceptionally, for a limited period of time, and for the actual benefit of others.

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