Blood on Silk: The Violence of Medicine Part VII Being the chosen one or not.

The factors driving the allocation of resources within the medical system is often not obvious or transparent to the outsider, the patient or their family. One area where it is openly acknowledged is in the media coverage of transplant medicine. There it is repeatedly stated that the number of organs donated or supplied is significantly less that the number of patients waiting for a transplant.  Ethical frameworks have been developed to help determine which patient is the preferred recipient. It is not on a first come first served basis. This system based on need, viability and likelihood of success is disrupted when the donation of organs by family members either willingly or under duress is directed to a single recipient who may or may not be usually considered a viable recipient. The resources in all medical cases also includes the required machinery and workforce to undertake the transplant and the care of the patient pre and post operation.

During the Covid19 pandemic the allocation of resources in various countries has become a more obvious issue of concern. While the focus has tended to be on the number of ventilators and the number of beds in ICU, it is as important that there be the number of trained staff to manage the treatment and monitor the interaction between the patient and the machinery. It is also difficult to imagine that when the hospital system becomes totally overwhelmed that there is the time available for the triage staff to allocate the resources according to a robust ethical framework established prior to the pandemic.

The University of Sydney on the second of April 2020 released a document titled ‘An Ethics Framework for Making Resource Allocation Decisions within Clinical Care: Responding to COVID-19.’[1]  In this document it is stated that when determining the allocation of any scarce resource as the availability of that resource becomes less than the demand based on clinical need then  ‘..our primary obligation is to ensure that we gain the best value we possibly can from the expenditure of that resource.’ The term best value appears then to loop around and come back to a medical judgement enmeshed with a value judgement of who is ‘highly likely to recover and would benefit long term from admission to ICU’. While overt discrimination on the basis of age, gender, ethnicity, sexuality, disability, etc is discouraged it is likely that the systemic inequality of higher socio economic groups tending to be associated with higher or more controlled levels of health and previous healthcare would result in their treatment giving the best value in terms of the likelihood of recovery. While this would tend reinforce the status quo the document interestingly puts forward the suggestion that priority in terms of who would benefit long term could expand to include a benefit to the whole community by prioritising First Nations patients as an acknowledgement of previous discrimination and injustice.

Still, however the term ‘best value’ is described it would/could be difficult to be the chosen one who got access to an ICU bed and the subsequent significant levels of intervention possibly leading to a successful outcome. It also would be difficult to be the chosen one making decisions about the allocation of resources.