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Munthe et al 1 argue for an asymmetry between positive and negative dynamics that justifies a new sustainability principle among the operational principles for ethical healthcare resource allocation. The purported asymmetry is that while positive dynamics are ‘taken into account in present applications of the operational principles…, negative dynamics are not’.1 Positive dynamics occur when allocations in the present lead to there being more healthcare resources per health need in the future (than are available in the present), whereas negative dynamics occur when present allocations lead to there being less future healthcare resources per health need.i Munthe et al 1 are correct that we have ethical reason to reduce negative dynamics—all other things being equal, having less future healthcare resources per health need is worse than having more. Furthermore, this ethical reason ought to be accounted for by operational principles. However, using current examples from the COVID-19 response, I argue that allocation policies guided by existing operational principles already take into account negative dynamics and thus obviate the need for a new sustainability principle. Nevertheless, Munthe et al 1 make a valuable contribution to the literature by opening up new lines of important research regarding the mitigation of allocation policies’ negative dynamics.
As Munthe et al 1 cogently argue, existing healthcare allocation policies (eg, of vaccines) take positive dynamics into account. However, when they do so, they also often implicitly or …
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Contributors Single author with acknowledgements to others for feedback and suggestions on earlier versions of this commentary.
Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.
↵I use the authors’ definition in the text from page 3. This is the clearest of a number of definitions the authors provide. For example, this definition is distinct from the “Total value of met health needs possible to generate” mentioned in figure 2 because the former definition makes no reference to total value but instead just to the resources themselves. As Munthe et al correctly note, because available healthcare resources do not always contribute to such value (eg, empty ICU beds), it is important to distinguish resources from such value. Nevertheless, my arguments apply mutatis mutandis to this ‘total value’ definition. There is another definition of positive dynamics on page 3 that makes no reference to need and instead invokes intertemporal consistency in the use of principles: “a resource allocation according to the operational principles positively affects the available outcome value possible to generate through a future resource allocation that uses these principles”. Given that Munthe et al believe that one can change the principles (eg, by adding a sustainability principle) and that different allocators over time (even in the same health system) may use different principles, including intertemporal consistency of use is not practically useful to incorporate into the definition of positive dynamics.