Ethical Issues and the Allocation of Scarce Resources During a Public Health Emergency

摘要

White and colleagues (1) offer an interesting and useful critique of existing proposals for allocating critical care resources in public health disasters. We comment as drafters of the New York proposal cited by these authors, a group that included numerous ethicists, clinicians, and public health experts and developed an ethical framework to guide allocation principles. The differences in the specific recommendations about allocation are testimony to the difficulty of translating ethical principles into concrete actions in the clinical realm. For instance, we use exclusion criteria before applying a Sequential Organ Failure Assessment (SOFA) score, thus barring patients with severe comorbid conditions from receiving ventilators in a disaster. White and colleagues calculate SOFA scores and then exclude patients with severe comorbid conditions (1). On the basis of these aspects of the allocation process, both proposals will result in similar groups receiving or being denied access to ventilators. One substantive difference between the proposal by White and colleagues and the one from New York is the explicit use of age as a factor that limits ventilator access. We considered and rejected this option because the SOFA score would inherently weigh against elderly persons, who tend to have more comorbid conditions than young persons. However, our own New York state focus group data indicate that community members may prefer a system that enhances ventilator access for young persons.