The ventilator lottery: rolling the dice in the face of difficult choices

As the winter approaches there has been a surge in the number of cases of swine flu, as well as a number of recent deaths in the UK. Although there is hope that the new vaccine will reduce the impact of the pandemic a number of countries including Canada the UK and the  United States have had to face the possibility that health services will not be able to accommodate the predicted surge in demand. Officials have been contemplating guidelines for deciding who should be prioritised for receiving life saving mechanical ventilation. The hope is that such guidelines will enable doctors to save the greatest number of lives in a pandemic.

But one concern about these guidelines is that they are unfair. Should scarce medical resources such as ventilators be allocated using a lottery instead?

In Australia and New Zealand during the Southern hemisphere’s winter there were 722 intensive care admissions related to H1N1 influenza. 2/3 of admissions required mechanical ventilation. Patients with the flu at some points made up 1/5 of all patients in intensive care. It is unclear just how much demand the pandemic will create during the Northern hemisphere winter. But during a planning exercise 3 years ago officials in New York calculated that a pandemic on the scale of the 1918 pandemic would lead to 18, 000 New Yorkers competing for 1000 ventilators in the peak week of the pandemic. A moderately severe pandemic would still result in a shortfall of more than 1200 ventilators.

There are various ways to allocate scarce medical resources. The New York group developed a system for rationing ventilators based on the numbers of organs that were failing, and patients’ risk of dying. The idea behind it is the utilitarian principle that we should maximise the numbers of lives saved. Others favour including the age of the patient, their previous functional status, and coexisting illnesses, in order to maximise the number of quality-adjusted life years saved.

But these methods of rationing are vulnerable to an objection on the basis of fairness. Certain patients (for example the elderly or those with more severe illness) will be given no chance of having their life saved. The 80 year old with influenza has just as strong a desire that their life be saved as a 20 year old. Their right to life is equal to that of the 20 year old. But they are denied life-saving treatment in such a rationing system.

Some philosophers (for example John Taurek) have argued that when deciding whose life should be saved we should not be accountants. If we have the choice of saving one person or 5 people we should toss a coin since this is the only fair way of arbitrating between the demands of the one (that his life is saved) and the demands of the five. More complicated rationing situations should take place using a lottery. Other philosophers have defended the idea of a weighted lottery that might take into account the relative numbers of patients in different groups. 

So should we adopt some sort of lottery for distributing ventilators in the event of a pandemic overwhelming intensive care capacity? Here are 4 reasons why we might

1. A ventilator lottery would be procedurally transparent and prevent favouritism. Unlike attributions of predicted mortality, or weightings of co-morbidity, a centrally administered lottery would not be open to bias, and would give members of the community confidence that doctors were not preferentially treating friends or colleagues.
2.  A ventilator lottery would give every member of the community an equal chance at a desired and scarce resource. Nobody would be excluded from the lottery.
3. The lottery would prevent discrimination – against the elderly, the disabled or those who are socially disadvantaged (and who may therefore be sicker when they present to hospital).
4. The lottery would take the burden off doctors at the frontline from having to make extremely difficult decisions about the eligibility of patients for life-saving treatment.

There are various different ways of understanding fairness, but the lottery would be more fair than utilitarian rationing in at least these ways.

Of course, the ventilator lottery would also almost certainly result in more deaths from influenza. Then we need to bite the bullet and decide how many lives we are willing to sacrifice for the sake of fairness.

Officials ponder disconnecting ventilators from some patients in severe flu outbreak Seattle Times 23/9/09

Ben Saunders A Defence of Weighted Lotteries in Life Saving Cases Ethical Theory and Moral Practice June 2009

Douglas White Who Should Receive Life Support During a Public Health Emergency?
Using Ethical Principles to Improve Allocation Decisions Ann Intern Med. 2009;150:132-138.

Marcel Verweij Moral Principles for Allocating Scarce Medical Resources in an Influenza Pandemic. Journal of Bioethical Inquiry 2009 6 (2).