, Volume 6, Issue 2, pp 159-169
Date: 26 May 2009

Moral Principles for Allocating Scarce Medical Resources in an Influenza Pandemic

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One of the societal problems in a new influenza pandemic will be how to use the scarce medical resources that are available for prevention and treatment, and what medical, epidemiological and ethical justifications can be given for the choices that have to be made. Many things may become scarce: personal protective equipment, antiviral drugs, hospital beds, mechanical ventilation, vaccination, etc. In this paper I discuss two general ethical principles for priority setting (utility and equity) and explain how these principles will often point in diverging directions. Moreover, each of these principles can be understood in different, again often competing, ways. Notwithstanding these controversies and conflicts, in the context of pandemic response there are at least some points of convergence: several policies can be justified by appeal to different ethical principles and theories. Convergence may be found with respect to a focus on saving the most lives (instead of other aggregative accounts); giving priority antiviral prophylaxis and therapy for life-saving pandemic responders; and, partly depending on epidemiology of the pandemic, to prioritise vaccination of children. Although decision-making about access to intensive care will involve choices with immediate tragic implications, the ethical complexity of these choices is relatively modest (although decisions will not be easy): there are persuasive moral reasons for giving priority to patients who are expected to benefit most within the shortest time. Finally, in the last section I tentatively argue that constraints on people’s freedom, as necessary for an effective public health approach, may support giving somewhat more weight to saving the most lives, than to concerns of equity.

This paper is largely based upon a background report I wrote for the World Health Organization (Verweij 2008). The report was used as input for a WHO consultation process that lead to ethical guidance for influenza pandemic preparedness and response plans (WHO 2007). In preparing my report I benefited from comments from numerous persons at the WHO and members of a working group of whom I would like to mention especially Andreas Reis, Dan Brock, Iwao Hirose, and Clement Adebamowo. I am also grateful to Michael Selgelid for some very fruitful comments on my tentative argument in the last section of this paper.