Allocating scarce medical resources during armed conflict: ethical issues

We describe ethical issues arising in the allocation of civilian medical resources during armed conflict. Three features are significant in the context of allocating scarce resources in armed conflicts: the distinction between continuous and binary medical resources; the risks of armed conflict itself, and the impact of cultural differences on cases of armed conflict. We use these factors to elicit a modified principle for allocating medical resources during armed conflict, using hemodialysis for patients with end-stage renal disease as a case study. © The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Background Armed conflict jeopardizes patient care, inter alia, through shortages in vital medical supplies. When healthcare resources are both scarce and insecure, ethically justified principles for resource allocation are required. These allocation decisions present a challenge for medical ethics in the context of armed conflict. Existing statements on medicine and armed conflict tend to provide conflicting advice on allocation decisions. The World Medical Association Regulations in Times of Armed Conflict and Other Situations of Violence claims “[w]hether civilian or combatant, the sick and wounded must receive promptly the care they need. No distinction shall be made between patients except those based upon clinical need [1].” A joint statement by the International Commission of the Red Cross and Red Crescent, with advice by four other nongovernment organizations, states “in providing the best available care, [health care personnel] shall take into consideration the equitable use of resources [2],” but provides no guidance on what this equity might look like. These statements, however, ignore the realities of armed conflicts and resource scarcity. Clinical need is indeed a defensible principle on which to allocate resources, but it neither the only, nor always the most important principle for allocating scarce resources. Equity is another important principle in resource allocation, but what constitutes equality or equal treatment includes the possibility lotteries or “first come first serve” policies that carry with them numerous ethical and logistical issues [3]. While there exists a literature on allocation and treatment decisions for military healthcare workers and warfighters [4], little scholarship addresses with the ethics of allocating scarce medical resources to civilians operating within warzones. For example, in their description of moral dilemmas faced by staff at the Rambam Medical Center during the Second Lebanon War, Bar-El et al. [5] describe challenges faced in allocating fortified spaces to patients to protect them from potential rocket attacks, but give no guidance on how this challenge was resolved in a principled manner. Literature exists on allocating resources during mass casualty events such as disease pandemics or bioterror [6], and on medical rationing and triage decision for military doctors working with service personnel [7]. None of these, however, provide an account of the principled allocation of scarce medical resources to noncombatant civilians during armed conflicts. In this article, we attempt to redress this neglect by describing general ethical considerations that govern the allocation of scarce medical resources within civilian contexts during armed conflict. We begin by identifying relevant ethical considerations that bear on this context, and how they differ from related situations in which allocation decisions must be made. We then apply our analysis to the illustrative case of hemodialysis among patients Open Access Disaster and Military Medicine *Correspondence: [email protected] 1 University of Massachusetts Lowell, Lowell, MA, USA Full list of author information is available at the end of the article Page 2 of 6 Evans and Sekkarie Disaster and Mil Med (2017) 3:5 suffering from end-stage renal disease (ESRD) in the Syrian armed conflict, now in its seventh year. Resource allocation in armed conflict In armed conflict, many if not most medical supplies—including healthcare workers—experience severe shortages through the destruction of trade routes, manufacturing and storage facilities, and hospitals. During World War One, it was estimated that 800,000 civilians died from a combination of material deprivation crowding and breakdowns in sanitary systems, and shortages of medical care. These deprivations, moreover, had long term effects on mortality for the survivors of war [8]. These shortages are of two kinds. First, shortages in medical supplies, combined with increases in demand for medical care due to civilian casualties of war cause severe scarcity among medical supplies: there simply aren’t enough to go around. Second, difficulties in providing aid to a warzone make the same resources radically insecure. Scarcity and insecurity create a situation where supplies must be allocated in an ethical manner: that is, allocation according a system of consistent and appropriate values. Attempts to allocate scarce medical resources in an ethical manner date back to the first hemodialysis units [9], and have developed for a range of important scenarios that entail situations of scarcity and insecurity [3]. Solid organ are allocated on principles including equality and priority, factoring in the time a candidate is on waiting lists, their medical need, and prognosis. During mass casualty events, in contrast, allocation favors healthcare workers and other critical personnel, in an attempt to save the most lives and maximize the utility of scarce resources (Table 1). Armed conflict share features with the above paradigms. Solid organs are both scarce and insecure resources: there aren’t enough for everyone, and no guarantee on when and where more will emerge [10]. Mass casualty events, on the other hand, share with armed conflict a systemic and widespread set of harms [6, 11]. There, considerations of societal utility—in particular, maintaining critical services in the face of extreme adversity—may outweigh other considerations. However, three features further distinguish armed conflict from other allocation principles. Continuous versus binary resources War is a protracted disaster: the Syrian conflict is in its seventh year. Allocation principles must therefore account for long—potentially indefinite—periods of scarcity and insecurity. This will depend in part on whether resources are binary, or continuous. Binary resources are indivisible for the purpose of care, e.g., any attempt to transplant a fraction of a heart would waste that heart. Pain medication, on the other hand, could conceivably be divided during extended shortages to produce clinically meaningful if non-ideal outcomes. Some resources, such as antibiotics, may be divided only to a certain therapeutic threshold, after which subtherapeutic doses fail to provide meaningful clinical outcomes. This distinction has implications for resource allocation in armed conflict. When continuous supplies are scarce, there is a case to be made for ensuring sufficient, albeit sub-optimal care is provided to the greatest number of patients. When supplies are radically insecure, providing a level of care ensures continued supply of resources for patients until replacement occurs. This consideration will need to be balanced against other considerations: if differential increases in some patient dosages frees up a scarce resource—if, for example, a high dose of a life saving drug given to some patients will free up beds in an overloaded hospital it may be, all other things being equal, justified to give small number of patients higher doses of a scarce drug to benefit a large set of other patients. As a baseline, however, in times of extreme scarcity and insecurity, scarce medical resources should be allocated in a way that maximizes the length of time a patient population can continue to receive clinically meaningful care. Risks from armed conflict Armed conflict generates substantial risks for patients. First, civilians attempting to reach medical centers or hospitals may have to travel through active combat zones. Second, medical centers—and healthcare workers—may be targeted as strategic resources, sources of supplies, or in reprisal for perceived support of the opposition [12]. In October 2015, a hospital in Kunduz, Afghanistan, was allegedly hit by a US airstrike targeted using mistaken intelligence [13]. Even worse, health care facilities and providers in Syria may be deliberately targeted for looting or reprisals by armed groups [14, 15]. These risks may at times outweigh the benefits of clinical care in a way that, say, the risks a patient takes in a major US city in getting to a clinic for treatment do not. While there is always a small but nontrivial risk involved in transport for clinical care, in peacetime scenarios this is arguably always outweighed by the benefits of clinical care. In some cases, the risks of open movement in armed conflict may outweigh the benefits of clinical care. Moreover, healthcare workers themselves are scarce resources during armed conflict [8, 16]. Providing guidance to patients to reduce time in care facilities, where communication infrastructure is not so broken as to make such communication counterproductive [17], will help maintain supplies for a community and protect patients against a range of risks beyond those of their care. Page 3 of 6 Evans and Sekkarie Disaster and Mil Med (2017) 3:5 Ta bl e 1 M on st ic p ri nc ip le s fo r a llo ca ti ng s ca rc e re so ur ce s. A da pt ed fr om P er sa d et a l. [3 ] A llo ca tio n pr in ci pl e A dv an ta ge s D is ad va nt ag es Ex am pl es o f u se Tr ea tin g pe op le e qu al ly L ot te ry H ar d to c or ru pt ; l itt le in fo rm at io n ab ou t r ec ip ie nt s ne ed ed Ig no re s ot he r r el ev an t p rin ci pl es M ili ta ry d ra ft ; s ch oo ls ; v ac ci na tio n F irs tco m e, fi rs tse rv ed Pr ot ec ts e xi st in g do ct or -p at ie nt re la tio ns hi ps ; l itt le in fo rm at io n ab ou t r ec ip ie nt s ne ed ed Fa vo rs w ea lth y; p ow er fu l, an d w el l-c on ne ct ed ; i gn or es ot he r r el ev an t p rin ci pl es In te ns iv e Ca re U ni t ( IC U ) b ed s; pa rt o f o rg an a llo ca tio n Fa vo rin g th e w or st -o ff : p rio rit ia ria ni sm S ic ke st fi rs t A id s th os e w ho a re s uff er in g rig ht n ow ; a pp ea ls to “ru le o f r es cu e” ; m ak es s en se in te m po ra ry s ca rc ity ; pr ox y fo r b ei ng w or st o ff ov er al l Su rr ep tit io us u se o f p ro gn os is ; i gn or es n ee ds o f t ho se w ho w ill b ec om e si ck in fu tu re ; m ig ht fa ls el y as su m e te m po ra ry s ca rc ity ; l ea ds p eo pl e re ce iv in g in te rv en tio ns o nl y af te r p ro gn os is d et er io ra te s; ig no re s ot he r re le va nt p rin ci pl es Em er ge nc y ro om s; pa rt o f o rg an a llo ca tio n Y ou ng es t fi rs t Be ne fit s th os e w ho h av e ha d le as t l ife ; p ru de nt p la nne rs h av e an in te re st in li vi ng to o ld a ge U nd es ira bl e pr io rit y to in fa nt s ov er a do le sc en t a nd yo un g ad ul ts ; i gn or es o th er re le va nt p rin ci pl es N ew N at io na l V ac ci ne A dv is or y Co m m itt ee /A dv is or y Co m m itt ee o n Im m un iz at io n Pr ac tic es (N VA C /A C IP ) pa nd em ic fl u va cc in e pr op os al M ax im iz in g to ta l b en efi t: ut ili ta ria ni sm N um be r o f l iv es s av ed Sa ve s m or e liv es , b en efi tin g th e gr ea te st n um be r; av oi ds n ee d fo r c om pa ra tiv e ju dg m en ts a bo ut q ua lity o r o th er a sp ec ts o f l iv es Ig no re s ot he r r el ev an t p rin ci pl es Pa st A C IP /N VA C p an de m ic fl u va cc in e; b io te rr or is m re sp on se p ol ic y; d is as te r t ria ge P ro gn os is o r l ife -y ea rs sa ve d M ax im iz es li fe -y ea rs p ro du ce d Ig no re s ot he r r el ev an t p rin ci pl es , p ar tic ul ar ly d is tr ib ut e pr in ci pl es Pe ni ci lli n al lo ca tio n; tr ad iti on al m ili ta ry tr ia ge (p ro gn osi s) a nd d is as te r t ria ge (l ife -y ea rs s av ed ) Pr om ot in g an d re w ar di ng s oc ia l u se fu ln es s In st ru m en ta l v al ue H el ps p ro m ot e ot he r i m po rt an t v al ue s; fu tu re or ie nt ed Vu ln er ab le to a bu se th ro ug h ch oi ce o f p rio rit iz ed oc cu pa tio ns o r a ct iv iti es ; c an d ire ct re so ur ce s aw ay fro m h ea lth n ee ds Pa st a nd c ur re nt N VA C /A C IP p an de m ic fl u va cc in e