Healthcare resource allocation during the COVID-19 pandemic: a Christian ethical perspective
This is a short summary of a briefing paper – please read the full version for a more thorough consideration of the issues.
As doctors based in the United Kingdom’s National Health Service (NHS), a well-resourced healthcare system, we approach the subject of healthcare rationing with a degree of humility. However, as the COVID-19 pandemic progresses, resource allocation is becoming increasingly challenging for all nations. We seek to consider how, as Christians, we can begin to address some of the difficult ethical challenges facing our healthcare systems.
When asked, what is the greatest commandment:
Jesus replied: ‘“Love the Lord your God with all your heart and with all your soul and with all your mind.” This is the first and greatest commandment. And the second is like it: “Love your neighbour as yourself.”’ [1]
Loving our neighbour may look quite different from one person to the next, based on clinical need and health status. Yet love must remain at the heart of all our decisions.
The demand for intensive life-saving resources from seriously unwell patients is rising rapidly. Managing this demand has involved measures such as testing, contact tracing, quarantining and social distancing. There are many examples in scripture of increasing the supply of resources in times of challenge through faith and prayer,[2] recruiting more workers,[3] training and releasing new leaders.[4]
Despite efforts to increase capacity, we are still facing the potential for a shortage of resources. Using Beauchamp and Childress’ four pillars of medical ethics[5] as a framework, let us consider a Christian response.
Respect for patient autonomy
If a patient has capacity and refuses escalation in care, this cannot be forced on them, even if this seems unwise. [6] Similarly, if a patient insists that they should be for full escalation of treatment, it may still be clinically appropriate to withhold certain treatments that are unlikely to be of benefit [7] or cause harm. Some patients, particularly those frail and elderly, might choose to stay at home (ideally with the support of high-quality palliative care), to allow a more natural death in the company of those they love.
Beneficence – maximising benefit with good stewardship of resources
As Christian healthcare workers, we are called to be good stewards of our resources.[8] However, utilitarianism[9] – ‘the greatest good for the greatest number’ – often makes us deeply uncomfortable. The COVID-19 crisis is an example of an extreme circumstance with an overwhelming need and limited resources, where a soft utilitarian ethic may be justified.
Where resources are insufficient, it seems reasonable to prioritise access to intensive interventions for those who are most likely to benefit. However, the application of this principle is challenging, as our knowledge about COVID-19 is patchy but expanding.
The overarching priority when deciding who should receive treatment during this crisis is: how likely a person is to survive and the speed of anticipated benefit. Relevant factors include:
- Severity of acute illness
- Presence and severity of comorbidity
- Frailty or, where clinically relevant, age [10]
We must acknowledge that rationing in the context of a pandemic will cause moral distress to healthcare teams and should look to model what it means to promote wellbeing in our colleagues, as well as our patients.
The Word of God repeatedly commands us to be compassionate, just as our Heavenly Father is compassionate:
Finally, all of you, be like-minded, be sympathetic, love one another, be compassionate and humble.[11]
Despite increasing stress and pressure in this time, the command remains. We should seek the compassion and comfort of the Lord, so that we may pass it on to those around us.[12]
Distributive justice – ensuring impartiality, equality and fairness
As Christians, we affirm that all people have intrinsic value and significance, being made in the very image of God,[13] and are equally worthy of care. That all people are equal does not mean they should all receive the same treatments.
However, justice becomes corrupted if it discriminates in favour of some lives over other lives. Throughout scripture, we see that all people are of equal worth, and we should not favour individuals based on their social,[14] financial,[15] or other status – our God abhors favouritism and loves impartiality.[16] Indeed, we are called to be advocates of the vulnerable.[17]
We must also consider the access of non-COVID-19 patients to scarce healthcare resources. How do we care for those requiring other urgent treatments when our hospital resources are close to exhaustion? These are very difficult challenges and we need to pray for wisdom.
Non-maleficence – minimising harm
During this COVID-19 crisis, decisions around withdrawal of treatment (such as invasive ventilation) may, out of necessity, occur sooner than would happen under normal circumstances, and on grounds of resources. Withdrawal of treatment is not morally equivalent to intentional killing.[7] In those circumstances, death is already in the room, and allowing a death to take place is not the same as causing death.
Nonetheless, these kinds of existentially burdensome decisions, in addition to potential legal ramifications,[18] will be emotionally, morally and spiritually distressing for those clinicians having to make them. Complex decisions around rationing may be best made in discussion with a second opinion, and even by committee.[19]
Conclusion
This COVID-19 pandemic provides a clarion call to pray for clinicians, managers, politicians, and all involved in the response. We should pray for new solutions, innovations and technologies to support healthcare delivery and an end to this challenging crisis.
Ultimately, we should seek wisdom from the Lord.[20] We, our families, and our wider Church family all across the world, are praying for you and other healthcare professionals all around the globe. We must endeavour to be good stewards, whilst also lobbying for sufficient resources. We must strive to affirm that compassion is key, all people are equal, and all are worthy of care.
Dr Melody Redman – Paediatric Trainee & Leadership Fellow, Sheffield, UK
Dr James Haslam – Consultant in Anaesthesia & Intensive Care Medicine, Salisbury, UK
References
- Matthew 22:37-39
- Matthew 14:19; 2 Kings 4:1-7
- Matthew 9:37-38
- Numbers 11:16-17; Luke 10:1
- Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th edition. New York: Oxford University Press, 2001
- Treatment and care towards the end of life: good practice in decision making. General Medical Council, July 2010. bit.ly/2UG7g7C [accessed 5 April 2020]
- Haslam J. Withdrawing and withholding medical treatment. CMF File 62, 2017. cmf.li/2HUkFCG [accessed 5 April 2020]
- Matthew 25:14-30 15
- Bentham J. An introduction to the principles of morals and legislation (1789). Garden City, NJ: Doubleday, 1961
- Coulson-Smith P, Lucassen A. Clinical ethics guidance during the COVID-19 pandemic. University Hospital Southampton (UHS) Clinical Ethics Committee, 30th March 2020 (unpublished)
- 1 Peter 3:8
- 2 Corinthians 1:3-4
- Genesis 1:27
- Galatians 3:28
- James 2:1-9
- Proverbs 24:23; Romans 2:11; Luke 14:13-14
- Proverbs 31:8-9
- Statement on legal liabilities of clinicians as individuals during Coronavirus Pandemic. Intensive Care Society. bit.ly/2QYRQJG [accessed 5 April 2020]
- Truog RD, et al. The toughest triage – allocating ventilators in a pandemic. NEJM, 2020. DOI:10.1056/NEJMp2005689
- James 1:5
Thanks for this, some questions those of us in resource limited settings are reflecting on are more on distributive justice
In rural areas for the poor – anyone above 65 – to 70 with multiple co-morbidities are usually not offered critical care due to limited facilities and financial issues – and so decisions for COVID19 will not be different than for any other illnesses
In urban for the poor the issue will be same as above,
For the middle class, and the well off and politically connected people – they will try to abuse the system to get their well of elderly parents or those with multiple co-morbidities, which will block off the limited facilities – so we will need to develop much more stricter onboarding criteria for critical care.
But principles will be the same as you shared.