3 February 2009 PUSH Post

Public United for Savings in Healthcare

E-Economics

Principles for allocation of

scarce medical interventions
Persad G, Wertheimer A, Emanuel EJ
The Lancet, Volume 373, Issue 9661,
Pages 423 - 431, 31 January 2009

"In health care, as elsewhere,

scarcity is the mother of allocation.
... the scarcity of many specific
interventions—including beds in
intensive care units, organs, and
vaccines during pandemic
influenza—is widely
acknowledged. ... We evaluate
eight simple allocation principles
that can be classified into four Allocation of scarce medical resources can be made on the basis of four
principles, each of which can again be considered from two perspectives. The
categories: treating people equally,
authors recommend a system that "combines four morally relevant principles: youngest-
favouring the worst-off, first, prognosis, lottery, and saving the most lives. In pandemic situations, it also allocates
maximising total benefits, and scarce interventions to people instrumental in realising these four principles."
promoting and rewarding social
usefulness. No single principle is The authors do not make any distinction between situations that are perennially
sufficient to incorporate all present - ICU beds, organ transplantation and such - and those that are episodic -
morally relevant considerations infectious epidemics. The former can be handled a little more leisurely, with time for
and therefore individual the formation of expert committees and for examining the evidence. The real
principles must be combined into challenge lies in handling unplanned epidemics and disasters where there is seldom
multiprinciple allocation systems." time to establish rules and implement them.

Dr Arjun Rajagopalan
 PUSH Post 3 February 2009

While on the topic of resource allocation it is worthwhile

taking a quick look at another paper that examined the
priorities for spending for common healthcare
problems. Using an opinion poll questionnaire, the
authors of this report surveyed 253 health professionals
from six countries, asking them to rank ten health
interventions in order of priority for spending from most
important (rank 1) to least important (rank 10). A
summary of the intervention rankings, pooled across
countries, is shown in the chart alongside.

The key values on which this ranking was based

emerged as follows:

1. Fair innings. At the top (most important priority for

spending), participants favoured giving priority in
spending to children.

2. Prevention. The strongest and most consistently

shared value across countries was a general preference
for preventive health care over curative care.

3. Individual responsibility. Typically, smokers were

"blamed" for their cancer and were regarded as the
least deserving of health-care spending.

4. Rule of rescue. Participants were willing to invoke

the "rule of rescue" —the moral imperative to save the
life of an identified individual who would otherwise die.

What drives health-care spending priorities? An

international survey of health-care professionals PLoS Much more at:
Med 4(2): e94Salkeld G, Henry D, Hill S, et al

Dr Arjun Rajagopalan