What is a fair allocation of ventilators?

Why is this a problem?

Whilst the majority of people who catch Covid-19 experience only mild symptoms, some patients do experience difficulties in breathing, and ventilators are a must to keep them alive. In many countries like the US, the demand for ventilators far exceeds the supply of them.[1] Based on estimates, the number of patients who will require these medical devices could range from 1.4 to 31 patients per ventilator.[2] Many countries have unfortunately had to make difficult decisions in an attempt to allocate the use of ventilators fairly.

How are we allocating ventilators?

Different countries have developed different procedures to allocate ventilators. Italy’s system is based on the utilitarian principle[3] of trying to save the most lives and life-years that patients can live after the treatment. Unfortunately, under this prioritisation system, people aged 80 or over may not get access to intensive care and are left to die.[4] America has taken a somewhat similar approach by assessing both short-term and long-term survivability.[5] Some states in the US have relied on scores such as Sequential Organ Failure Assessment (SOFA), which measures the functioning of the body. Patients with high SOFA scores would be less likely to qualify for treatment.[6]

What are the economists recommending?

To tackle this problem, it is important to know what values can or should be considered in allocating ventilators. Emanuel et al have suggested four values that should be given weight:[7]

1. Maximising the effect of ventilators. This can be achieved by maximising the most lives saved or the most life-years by having patients who will likely to survive the longest prioritised.

2. Treating people equally is also important. Equality can be achieved by using first come first serve allocation, or by randomly selecting patients (i.e. by lottery). In a pandemic, first come first serve is an unfair way of allocating ventilators since it would benefit patients who live close to health facilities. It would also disadvantage people who have strictly adhered to government recommendations of self-isolation and social distancing since they will get sick at a later time.

3. Promoting and rewarding instrumental value is also a consideration. Instrumental value can be promoted by giving priority to people who can save others in the future, or to people who have saved others in the past, such as healthcare workers and volunteers for vaccines.

4. Another important value is giving priority to the worst off. This value suggests that priority should be given to the sickest.

These values should not be used alone and a fair allocation requires the use of all principles since one principle alone is not adequate to achieve a fair allocation.[8]

The priority system

One way to think about it is to create a system that incorporates all these values and to assign each patient a number to determine priority – a priority system. For example, for a medical worker, extra 10 points can be added to their priority number to reward instrumental value. This system has been used in hospitals in the US.[9] SOFA is a priority system and is used when considering who gets priority. However, a priority system can lead to unfair allocations.

1. When medical workers receive extra points, all medical workers have higher priority than the general population. It is possible that most ventilators will be used by medical workers, and other groups are denied access.[10]

2. For groups that receive low priority numbers, none of the people from that group will get treatment. They will never get access to ventilators. That is unfair and can be seen as discrimination against a group of patients.[11]

The reserve system

A reserve system can improve unfairness.[12] In a reserve system, ‘patients are identified as members of particular groups – e.g., young or old, frontline health worker or not, very sick or sick.’[13] A patient can fit in multiple categories. According to these categories, ventilators are allocated to each category. This prevents the above problems from occurring. It is impossible for medical workers to occupy all the ventilators and people with low priorities would not be discriminated against by having no ventilators available to them (a small amount can be allocated to such groups).

Whilst a reserve system can offer more flexibility compared to priority systems, it is also prone to issues of unfairness. In a reserve system, processing order of a category matters.[14]

For example, if there are 60 ventilators in total, 30 of them are reserved for medical workers and 30 are unreserved and can be accessed by community members. Access to ventilators is by lottery to reflect the value of equality. Suppose there are 60 medical workers and 60 community members who want access to the ventilators. There are two potential situations:

1. If the medical workers’ reserve is processed first, then all 30 ventilators in their category will be taken. 30 of the unreserved will be taken by 10 medical workers and by 20 community members. Therefore, there are 40 ventilators for medical workers and 20 for community members.

2. If the unreserved category is processed first, medical and community members will get 15 each. All 30 ventilators in the medical reserve will be allocated to medical workers. This will result in medical workers taking 45 in total and community members taking 15.

Consequently, although it may look fair for community members to access the ventilators first, they end up disadvantaged because they were processed first. Designing the reserve system is complex and can lead to unintended problems.

The reserve system may be better, but it’s even better if we don’t run out of ventilators

Clearly, these are tough decisions, with no right or wrong answers, and it is far from a win-win game. Luckily, we seem to have enough supply of ventilators for the moment in Australia.[15] If we can keep the numbers of patients down by practising good social distancing, we won’t have to make painful decisions like this.

[1] Kuchler, H. (2020, April 1). US hospitals face severe ventilator drugs shortage. Financial Times. Retrieved from https://www.ft.com/content/dce3dab6-36e5-4aa6-bff6-fe0b9bf95b71.

[2] Truog, R. D., Mitchell, C., & Daley, G. Q. (2020). The Toughest Triage — Allocating Ventilators in a Pandemic. New England Journal of Medicine. doi:10.1056/NEJMp2005689.

[3] Blasi, E. D. (2020, March 14). Italians over 80 ‘will be left to die’ as country overwhelmed by coronavirus. The Telegraph. Retrieved from https://www.telegraph.co.uk/news/2020/03/14/italians-80-will-left-die-country-overwhelmed-coronavirus/.

[4] At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. (2020). NEJM Catalyst. Retrieved from https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0080.

[5] Mike Baker, S. F. (2020, March 31). At the Top of the Covid-19 Curve, How Do Hospitals Decide Who Gets Treatment? nytimes. Retrieved from https://www.nytimes.com/2020/03/31/us/coronavirus-covid-triage-rationing-ventilators.html.

[6] Ibid.

[7] Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., . . . Phillips, J. P. (2020). Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine. doi:10.1056/NEJMsb2005114.

[8] Ibid.

[9] Mike Baker, S. F. (2020, March 31). At the Top of the Covid-19 Curve, How Do Hospitals Decide Who Gets Treatment? nytimes. Retrieved from https://www.nytimes.com/2020/03/31/us/coronavirus-covid-triage-rationing-ventilators.html.

[10] Fink, S. (2020, March 30). U.S. Civil Rights Office Rejects Rationing Medical Care Based on Disability, Age. The New York Times. Retrieved from https://www.nytimes.com/2020/03/28/us/coronavirus-disabilities-rationing-ventilators-triage.html.

[11] Pathak, P. A., Sönmez, T., Unver, M. U., & Yenmez, M. B. (2020). Triage Protocol Design for Ventilator Rationing in a Pandemic: Integrating Multiple Ethical Values through Reserves. National Bureau of Economic Research Working Paper Series, No. 26951. doi:10.3386/w26951.

[12] Ibid.

[13] Ibid.

[14] Ibid.

[15] Pearce, L. (2020, April 9). Australia has ‘more than enough’ ventilators for COVID-19 patients, says Deputy CMO. 9News. Retrieved from https://www.9news.com.au/national/coronavirus-australia-has-more-than-enough-ventilators-nick-coatsworth/5dd65aad-8dd3-4732-8a89-1ea1a74b47ae.