Elsevier

The Lancet

Volume 373, Issue 9661, 31 January–6 February 2009, Pages 423-431
The Lancet

Department of Ethics
Principles for allocation of scarce medical interventions

https://doi.org/10.1016/S0140-6736(09)60137-9Get rights and content

Summary

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.

Section snippets

Simple allocation principles

Eight simple ethical principles for allocation can be classified into four categories, according to their core ethical values: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness (table 1). We do not regard ability to pay as a plausible option for the scarce life-saving interventions we discuss.

Some people wrongly suggest that allocation can be based purely on scientific or clinical facts, often using the term “medical need”.

Assessing principles: allocation systems

Which principles best embody morally relevant values? First-come, first-served is flawed in practice because it unwittingly allows irrelevant considerations, such as wealth, to affect allocation decisions, whereas a lottery is insufficient but not flawed. Similarly, sickest-first allocation is inherently flawed, whereas the youngest-first principle, though insufficient, recognises the important value of priority to the worst-off. Both utilitarian principles—maximising lives saved and

The complete lives system

Because none of the currently used systems satisfy all ethical requirements for just allocation, we propose an alternative: the complete lives system. This system incorporates five principles (table 2): youngest-first, prognosis, save the most lives, lottery, and instrumental value.5 As such, it prioritises younger people who have not yet lived a complete life and will be unlikely to do so without aid. Many thinkers have accepted complete lives as the appropriate focus of distributive justice:

Legitimacy

As well as recognising morally relevant values, an allocation system must be legitimate. Legitimacy requires that people see the allocation system as just and accept actual allocations as fair. Consequently, allocation systems must be publicly understandable, accessible, and subject to public discussion and revision.92 They must also resist corruption, since easy corruptibility undermines the public trust on which legitimacy depends. Some systems, like the UNOS points systems or QALY systems,

Conclusion

Ultimately, none of the eight simple principles recognise all morally relevant values, and some recognise irrelevant values. QALY and DALY multiprinciple systems neglect the importance of fair distribution. UNOS points systems attempt to address distributive justice, but recognise morally irrelevant values and are vulnerable to corruption. By contrast, the complete lives system combines four morally relevant principles: youngest-first, prognosis, lottery, and saving the most lives. In pandemic

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