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• Ethical challenges in Scarce Resources Allocation in COVID-19 pandemic: Western and Islamic views
  Hassan Chamsi-Pasha, Majed Chamsi-Pasha and Mohammed .A. Albar
  Published on: 29 June 2020

• Published on: 29 June 2020

  Ethical challenges in Scarce Resources Allocation in COVID-19 pandemic: Western and Islamic views

  • Hassan Chamsi-Pasha, Consultant Cardiologist King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
  • Other Contributors:
    • Majed Chamsi-Pasha, Senior Registrar, Internal Medicine
    • Mohammed .A. Albar, Director of Medical Ethics Center, Department of Medical Ethics

  We read with great interest the article of Solnica et al entitled “Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective”. (1)
  The Coronavirus Disease 2019 (COVID-19) pandemic raises unique ethical dilemmas. The implications of scarce resources allocation are devastating. Physicians must deal with decisions about the allocation of scarce resources which may eventually cause severe moral distress. (2)
  During the process of allocating resources, physicians are prioritizing those most likely to survive over those with remote chances of survival. The news that prioritization criteria were being applied in Italian hospitals in relation to the current outbreak sparked widespread controversy, aroused great resentment, and triggered an intense debate, at both public and institutional levels, about the right of every individual to access healthcare. (3)
  Since equals should be treated equally, it is unequal to treat unequals equally. Although there is a right for everyone to be treated, it is not feasible to ignore contingent medical and biological characteristics that, inevitably, make one patient different from the other. Prioritization does not mean that one life is more valuable than another, as all lives are equally valuable. But when resources are not enough to save all those in need, prioritization involves allocating resources such that they are more likely to save the most lives. (3,4)
  Priority for limited resource...

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  We read with great interest the article of Solnica et al entitled “Allocation of scarce resources during the COVID-19 pandemic: a Jewish ethical perspective”. (1)
  The Coronavirus Disease 2019 (COVID-19) pandemic raises unique ethical dilemmas. The implications of scarce resources allocation are devastating. Physicians must deal with decisions about the allocation of scarce resources which may eventually cause severe moral distress. (2)
  During the process of allocating resources, physicians are prioritizing those most likely to survive over those with remote chances of survival. The news that prioritization criteria were being applied in Italian hospitals in relation to the current outbreak sparked widespread controversy, aroused great resentment, and triggered an intense debate, at both public and institutional levels, about the right of every individual to access healthcare. (3)
  Since equals should be treated equally, it is unequal to treat unequals equally. Although there is a right for everyone to be treated, it is not feasible to ignore contingent medical and biological characteristics that, inevitably, make one patient different from the other. Prioritization does not mean that one life is more valuable than another, as all lives are equally valuable. But when resources are not enough to save all those in need, prioritization involves allocating resources such that they are more likely to save the most lives. (3,4)
  Priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life. Saving more lives and more years of life is a consensus value across expert reports. (4) It is consistent both with utilitarian ethical perspectives that emphasize population outcomes and with nonutilitarian views that emphasize the paramount value of each human life. (5)
  Withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for physicians and some doctors might refuse to do so. For patients with similar prognoses, equality should be invoked and operationalized through random allocation, such as a lottery, rather than a first-come, first-served allocation process. (6)
  The National Institute for Health and Care Excellence in the UK published on 20 March 2020 the Guideline with clinical decision-making. The basis of the Guideline is to maximize patient safety and appropriate use of resources. Admission to an intensive care unit is based on some assessment of frailty, comorbidities and likeliness to recover from the intensive treatment.
  Solnica et al described the Jewish ethical prospective on medical triage in in the allocation of scarce resources. Utilitarian principles should be the basis for such decision. The difficulty, however, arises when it is impossible to triage patients based solely on utilitarian considerations.
  The Jewish tradition also recognizes the utilitarian approach but there is disagreement between the rabbis whether human discretion has any role in the allocation of scarce resources and triage decision-making. (1)
  In response to the COVD-19 pandemic, three Fatwas (decrees) were issued by major Islamic Jurisprudence authorities. The first was issued by the Assembly of Muslim Jurists of America which stated that what is to be considered in prioritizing patients over others is the degree of need; so the one in greater need should be prioritized. If they have the same need, the one with a greater likelihood of recovery, based on clinical tools, should be given precedence. If such likelihood is equal, then those with the longer life expectancy should be given precedence. When applicable, service should be provided on a first come, first served basis. If all previous considerations do not give precedence to some over the others, resorting to lottery is a principle that is endorsed by the Islam. (8)
  The second decree was issued on 28.3.2020 by the European Council for Fatwa and Research (ECFR) on managing scarce resources during this pandemic. It states: “Muslim physicians are committed to the regulations of the hospitals they work in. If the matter is assigned to the physicians, they must utilize medical, ethical and humanitarian standards. Withdrawal of life-saving equipment in order to treat a patient arriving later is not permitted. If the physician has no choice but to choose between two patients, then the former is offered the ventillator, unless he is deemed futile; the one in need of urgent treatment over the one whose condition allows delay, and the patient whose successful treatment is more likely.” (9)
  The third recommendation was issued by The International Islamic Fiqh Academy which held a symposium on 16th April 2020 discussing the ethical implications of COVID-19 and stated that “Physicians should adhere to the medical and ethical standards. In case of excessive number of patients requiring ventilators with the lack of adequate devices, it is left to the discretion of the physician who prioritizes the one who deserves prioritization, and when they are equal, he resorts to lottery between patients”. (10)
  The Islamic law permits withdrawal of futile treatment on the basis a clear medical decision by at least three physicians. (11) In futile cases, many Fatwas (decrees) stated that while life support treatment is permissible to stop, ancillary treatment including nutrition, hydration, pain control, and antibiotics should continue. (12)

  References
  1. Solnica A, Barski L, Jotkowitz A.Allocation of Scarce Resources During the COVID-19 Pandemic: A Jewish Ethical Perspective. J Med Ethics .2020 Apr 10. doi: 10.1136/medethics-2020-106242.
  2. Khoo EJ, Lantos JD. Lessons learned from the COVID-19 pandemic [published online ahead of print, 2020 Apr 14]. Acta Paediatr. 2020;10.1111/apa.15307. doi:10.1111/apa.15307
  3. Mannelli C. Whose Life to Save? Scarce Resources Allocation in the COVID-19 Outbreak. J Med Ethics. Epub ahead of print: doi:10.1136/medethics-2020-106227
  4. Zucker H, Adler K, Berens D, et al. Ventilator allocation guidelines. Albany: New York State Department of Health Task Force on Life and the Law, November 2015 (https://www .health
  .ny .gov/ regulations/ task_force/ reports_publications/ docs/ventilator_guidelines .pdf).
  5. Kerstein SJ. Dignity, disability, and lifespan. J Appl Philos 2017; 34: 635-50.
  6. Emanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19 [published online ahead of print, 2020 Mar 23]. N Engl J Med. 2020;10.1056/NEJMsb2005114. doi:10.1056/NEJMsb2005114
  7. National Institute for Health Care Excellence. COVID-19 rapid guideline: critical care in adults. NICE guideline 2020;25.
  8. www.amjaonline.org/fatwa/en/87747/
  9. www.e-cfr.org
  10. http://www.iifa-aifi.org/5254.html
  11. Al-Bar MA, Chamsi-Pasha H. Contemporary bioethics: Islamic perspective. New York (NY): Springer; 2015.http://link.springer.com/book/10.1007/978-3-319-18428-9
  12. Mohiuddin A, Suleman M, Rasheed S, Padela AI. When can Muslims withdraw or withhold life support? A narrative review of Islamic juridical rulings. Glob Bioeth. 2020;31(1):29‐46. Published 2020 Mar 22. doi:10.1080/11287462.2020.1736243

  Competing interests: No competing interests

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  Conflict of Interest:
  None declared.

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