Krütli Pius, Rosemann Thomas, Törnblom Kjell Y, Smieszek Timo
Transdisciplinarity Lab (TdLab), Department of Environmental Systems Science, ETH Zurich, Switzerland.
Institute of Primary Care, University of Zurich, Switzerland.
PLoS One. 2016 Jul 27;11(7):e0159086. doi: 10.1371/journal.pone.0159086. eCollection 2016.
Societies are facing medical resource scarcities, inter alia due to increased life expectancy and limited health budgets and also due to temporal or continuous physical shortages of resources like donor organs. This makes it challenging to meet the medical needs of all. Ethicists provide normative guidance for how to fairly allocate scarce medical resources, but legitimate decisions require additionally information regarding what the general public considers to be fair. The purpose of this study was to explore how lay people, general practitioners, medical students and other health professionals evaluate the fairness of ten allocation principles for scarce medical resources: 'sickest first', 'waiting list', 'prognosis', 'behaviour' (i.e., those who engage in risky behaviour should not be prioritized), 'instrumental value' (e.g., health care workers should be favoured during epidemics), 'combination of criteria' (i.e., a sequence of the 'youngest first', 'prognosis', and 'lottery' principles), 'reciprocity' (i.e., those who provided services to the society in the past should be rewarded), 'youngest first', 'lottery', and 'monetary contribution'.
1,267 respondents to an online questionnaire were confronted with hypothetical situations of scarcity regarding (i) donor organs, (ii) hospital beds during an epidemic, and (iii) joint replacements. Nine allocation principles were evaluated in terms of fairness for each type of scarcity along 7-point Likert scales. The relationship between demographic factors (gender, age, religiosity, political orientation, and health status) and fairness evaluations was modelled with logistic regression.
Medical background was a major predictor of fairness evaluations. While general practitioners showed different response patterns for all three allocation situations, the responses by lay people were very similar. Lay people rated 'sickest first' and 'waiting list' on top of all allocation principles-e.g., for donor organs 83.8% (95% CI: [81.2%-86.2%]) rated 'sickest first' as fair ('fair' is represented by scale points 5-7), and 69.5% [66.2%-72.4%] rated 'waiting list' as fair. The corresponding results for general practitioners: 'prognosis' 79.7% [74.2%-84.9%], 'combination of criteria' 72.6% [66.4%-78.5%], and 'sickest first' 74.5% [68.6%-80.1%); these were the highest-rated allocation principles for donor organs allocation. Interestingly, only 44.3% [37.7%-50.9%] of the general practitioners rated 'instrumental value' as fair for the allocation of hospital beds during a flu epidemic. The fairness evaluations by general practitioners obtained for joint replacements: 'sickest first' 84.0% [78.8%-88.6%], 'combination of criteria' 65.6% [59.2%-71.8%], and 'prognosis' 63.7% [57.1%-70.0%]. 'Lottery', 'reciprocity', 'instrumental value', and 'monetary contribution' were considered very unfair allocation principles by both groups. Medical students' ratings were similar to those of general practitioners, and the ratings by other health professionals resembled those of lay people.
Results are partly at odds with current conclusions proposed by some ethicists. A number of ethicists reject 'sickest first' and 'waiting list' as morally unjustifiable allocation principles, whereas those allocation principles received the highest fairness endorsements by lay people and to some extent also by health professionals. Decision makers are advised to consider whether or not to give ethicists, health professionals, and the general public an equal voice when attempting to arrive at maximally endorsed allocations of scarce medical resources.
社会正面临医疗资源短缺的问题，这主要归因于预期寿命的增加、健康预算的有限，以及诸如供体器官等资源在特定时期或持续存在的实际短缺。这使得满足所有人的医疗需求具有挑战性。伦理学家为如何公平分配稀缺医疗资源提供规范性指导，但要做出合理决策还需要了解公众认为何为公平的额外信息。本研究的目的是探讨外行人、全科医生、医学生和其他卫生专业人员如何评估十种稀缺医疗资源分配原则的公平性：“病情最严重者优先”“排队等候”“预后”“行为因素”（即不应优先考虑从事危险行为的人）“工具性价值”（例如，在疫情期间应优先照顾医护人员）“标准组合”（即“最年轻者优先”“预后”和“抽签”原则的顺序组合）“互惠原则”（即过去为社会提供过服务的人应得到回报）“最年轻者优先”“抽签”和“金钱贡献”。
1267名在线问卷受访者面临关于（i）供体器官、（ii）疫情期间医院病床以及（iii）关节置换的稀缺假设情况。针对每种稀缺类型，沿着7点李克特量表评估九种分配原则的公平性。使用逻辑回归对人口统计学因素（性别、年龄、宗教信仰、政治倾向和健康状况）与公平性评估之间的关系进行建模。
医学背景是公平性评估的主要预测因素。虽然全科医生在所有三种分配情况下表现出不同的反应模式，但外行人的反应非常相似。外行人将“病情最严重者优先”和“排队等候”列为所有分配原则中的首选——例如，对于供体器官，83.8%（95%置信区间：[81.2%-86.2%]）认为“病情最严重者优先”是公平的（“公平”由量表得分5-7表示），69.5%[66.2%-72.4%]认为“排队等候”是公平的。全科医生对于供体器官分配的相应结果为：“预后”79.7%[74.2%-84.9%]，“标准组合”72.6%[66.4%-78.5%]，“病情最严重者优先”74.5%[68.6%-80.1%]；这些是供体器官分配中评分最高的分配原则。有趣的是，只有44.3%[37.7%-50.9%]的全科医生认为在流感疫情期间分配医院病床时“工具性价值”是公平的。全科医生对于关节置换的公平性评估结果为：“病情最严重者优先”84.0%[78.8%-88.6%]，“标准组合”65.6%[59.2%-71.8%]，“预后”63.7%[57.1%-70.0%]。两组都认为“抽签”“互惠原则”“工具性价值”和“金钱贡献”是非常不公平的分配原则。医学生的评分与全科医生相似，其他卫生专业人员的评分与外行人相似。
研究结果部分与一些伦理学家目前提出的结论不一致。一些伦理学家拒绝将“病情最严重者优先”和“排队等候”作为道德上不合理的分配原则，而这些分配原则在外行人以及一定程度上在卫生专业人员中获得了最高的公平性认可。建议决策者在试图达成对稀缺医疗资源的最大程度认可的分配方案时，考虑是否给予伦理学家、卫生专业人员和公众平等的话语权。
