COVID-19 Ethics: Rethinking Resource Allocation in Times of Crisis
Jacob Appel
October 11, 2020
Jacob Appel is a physician, lawyer, psychiatrist, bioethicist, and author, with more masters degrees than you can count on one hand, even if you’ve got six fingers.
His talk was about rethinking resource allocation in this time of pandemic, highlighting all the ethical conundrums. He posited three categories of scarce resources: 1) “hard scarcity” (like organs for transplant); 2) “soft scarcity” (with some wiggle room, like funds for health care); and 3) “evaporating or conservable” resources (like antibiotics, where too much use impairs effectiveness).
The big picture, which he called “macro-allocation,” concerns how overall societal resources get allocated – Appel pointed to our nation spending 17-18% of GDP on health care, versus about 6% on education. Our health spending is considerably higher than in other advanced countries, with different systems. Appel noted that ours, dominated by employer-provided insurance, grew out of WWII wage controls, preventing companies from competing for workers on salary, so they competed instead on fringe benefits. [Which are deductible as businesses expenses, and constitute non-taxable income to employees – FSR.]
Also at issue is what specific things we choose to fund. For example, work on HIV/AIDS and cancer is over-funded in comparison to mental health. Appel noted that sickle cell disease (associated with Blacks) is under-funded compared to Cystic Fibrosis (associated with whites). And he said we’ve way underfunded pandemic preparation, undermining what might have been our response to Covid-19.
The health care funding realm presents fundamental ethical dilemmas. We don’t like the idea of “rationing” health care, but resources are never infinite, so we have to make choices. Appel illustrated this with the Slim Watson case – this guy had a rare condition treatable only at great expense. The question being whether to keep him alive and thus effectively deny funding for other things that could actually save many more lives. We have trouble with such issues because they pit “visible victims” (like Watson) against “invisible victims.”
It’s a really acute issue because about 30% of total Medicare spending goes on patients in the last year of life; a third of that in the final month. Is this worth it, compared with what health improvements that money could buy if spent on other people? Appel also pointed to the 1983 “Orphan Drug Act,” incentivizing work on rare diseases. Seemingly altruistic, but there are numerous such illnesses affecting small populations, and treating them all would cost trillions.
Mentioned too was an Oregon attempt at rationally allocating health care, aimed at saving the most lives for a given sum of money. Thus not spending it on cancer patients deemed to have a small chance of recovery. Another example here was the allocation of limited dialysis machines, with a committee established to vet applications from patients seeking their use. Appel presented an actual transcript from the committee’s deliberations, trying to figure out which patients best merited the limited dialysis capability. The excruciating ethical conundrums were obvious.
Of course similar issues can apply regarding ventilators in this time of covid, and who makes the decisions. It may be unethical to put them in the laps of health care workers on the spot. Another option is a “blinded committee” like the one described above (with all the problems that entails). Appel also noted that standards vary greatly from state to state, so identically situated patients can get treated very differently.
Vaccination presents such issues too. Development can be speeded by trials with volunteers exposed to covid after getting a trial vaccine. Is that ethical? Then, who gets a vaccine first? The most vulnerable versus frontline health workers, for example? And should government make vaccination compulsory? Appel suggested that winning public “buy-in” would work better.