FINITE RESOURCES, IMPERFECT SYSTEMS:

WE NEED THIS BED

What is the emotional experience of being unable to provide everything you want to provide—or know how to provide—for every patient? What does it feel like to be "stuck" in what you can give and do as a clinician?

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“We live in a world in which need is boundless but resources are not—and medicine is not immune to the consequences of this reality" (1).


Any semblance of "rationing" in medicine may feel alarming considering the field’s "primary ethical obligation" to help and give (rather than harm or withhold) (2). The truth, however, is that even in resource-rich environments, medical resources are often limited compared to volume and extent of need. The result: denial of “potentially beneficial treatment[s]… on the grounds of scarcity” (1,*). There are only so many ICU beds per state, so many trained care providers, so much transfusable blood. Indeed, allocation of finite resources can be a somberly quotidian problem in medical practice.


Clinicians, however, like most human beings, generally hold a "powerful psychologic impulse to attempt to save those facing death, no matter how expensive or how small the chance of benefit" (1). This so-called "rule of rescue" at the individual level collides forcefully with realities of resource availability at population scale (1). This collision, in turn, creates potential for formidable internal conflict in physicians who, despite institutional guidelines and bioethical guideposts, bear day-to-day responsibility for decisions regarding resource allocation (even if only about time spent with certain patients over others, as a routine example) (1,3-5).


A related yet distinct challenge is the complexity and ultimate subjectivity of such decision making. Recent scholarship has named societal "failure to specify what principle(s) should guide allocation" a "substantial barrier" to management of healthcare resources (1). A range of often competing value-based approaches—from "most lives saved" to "equal treatment"—can plausibly guide distribution decisions (6,7). But it is impossible to accommodate all approaches and uphold all underlying values at once (6). Moreover, given the diversity of guiding values across systems, communities and cultures, decision makers may find their approaches—however sound in their own personal worldviews—in conflict with the values of patients, families, coworkers, or even employers (6). Such conflict only enhances the potential for "emotional turmoil" in clinicians, casting a shadow over medical practice as providers strive to give all patients "a full measure of service and devotion" (1,3,8,9).

*While the concepts of "rationing, futility, and inappropriate treatments are often interwoven," we do not address notions of medical futility or inappropriate treatment here. By definition, futile treatments are those that "should never be provided, regardless of the availability of the resources or the values of the clinicians, patient, or family" because, physiologically-speaking, they "do not work" (5). Inappropriate treatments are those that may theoretically work in some unique scenarios, but are generally considered unsuitable in settings where "either the goal of treatment is considered unreasonable (e.g., the continued vital existence of a patient diagnosed as brain dead) or the goal is reasonable but the chance of achieving that goal is unreasonably small” (5). While these areas are of critical importance—and can absolutely cause providers internal strife—here, we discuss only healthcare resource rationing/allocation defined as "the best distribution of limited resources…in situations in which all of the treatments are desired and may have some value in improving the health of the patients involved" (5).


Separately, we also do not address COVID times specifically. The pandemic overlays an entirely additional set of resource-related concerns and considerations out of the scope of this discussion.

Illustrative scenario:

A physician working in the ICU must decide whether to transfer one of his patients to a lower-acuity floor in order to make room for a new admission from the Emergency Department. The physician realizes, however, that his current patient could potentially benefit from ICU-level care and observation for a couple more days.


 

References

  1. Scheunemann LP and White DB. The Ethics and Reality of Rationing in Medicine. Chest. 2011;140(6):1625–1632.

  2. Allocating Limited Health Care Resources. Code of Medical Ethics Opinion 11.1.3. AMA. https://www.ama-assn.org/delivering-care/ethics/allocating-limited-health-care-resources

  3. Ransom H and Olsson JM. Allocation of Health Care Resources: Principles for Decision-making. Pediatr Rev. 2017;38(7):320–329.

  4. Sinuff T, Kahnamoui K, Cook DJ et al. Rationing critical care beds: a systematic review. Crit Care Med. 2004;32(7):1588-97.

  5. Rubin MA and Truong RD. What to Do When There Aren’t Enough Beds in the PICU. AMA J Ethics. 2017;19(2):157-163.

  6. Rawlings A, Brandt L, Ferreres A et al. Ethical considerations for allocation of scarce resources and alterations in surgical care during a pandemic. Surg Endosc. 2020:1–6.

  7. Bazerman MH, Bernhard R, Greene J et al. How Should We Allocate Scarce Medical Resources? HBR. April 29, 2020.

  8. Jonsen AR and Edwards KA. Resource Allocation. UW Medicine Department of Bioethics and Humanities.

  9. Access to Care and Allocating Scarce Resources - Module 1. Miller School of Medicine Bioethics Institute. https://bioethics.miami.edu/education/ethics-curricula/geriatrics-and-ethics/access-to-care-and-allocating-scarce-resources/index.html