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to have a deep interest in critically reecting on tough allocation problems, we ought to have a deeper and more abiding interest in reecting on why, at any given moment, background conditions force us into these dilemmas in the rst place. Sometimes they will be unavoidable, but many times they are not but for our own collective will. I especially worry when theorists feel comfortable taking ideas like the modied youngest-rst principle and apply them to least advantaged populations in poorer parts of the world. There can be no denying that, in such places, resources are frighteningly scarce, but there also can be no denying that our complacency towards rst-order

issues of social injustice contributes to their ongoing scarcity.

REFERENCES
Harris, J. 1999. The concept of the person and the value of life. Kennedy Institutue of Ethics Journal 9(4): 293308. Kerstein, S., and G. Bognar. 2010. Complete lives in the balance. American Journal of Bioethics 10(4): 3745. Persad, G., A. Wertheimer, and E. J. Emanuel. 2009. Principles for the allocation of scarce medical interventions. Lancet 373: 423431.

Dueling Ethical Frameworks for Allocating Health Resources

Dorothy E. Vawter, Minnesota Center for Health Care Ethics J. Eline Garrett, Minnesota Center for Health Care Ethics Karen G. Gervais, Minnesota Center for Health Care Ethics Angela Witt Prehn, Minnesota Center for Health Care Ethics Debra A. DeBruin, University of Minnesota Center for Bioethics
We commend Kerstein and Bognar (2010) for advancing the scholarly debate about which principles should guide the allocation of scarce health care resources and for their insightful analysis of Persad, Wertheimer, and Emanuels (2009) complete lives system. Kerstein and Bogner agree with Persad and colleagues that coherent allocation frameworks must attend to multiple principles and that two core principles for any allocation scheme include saving the most lives and saving the most life-years. They agree that infants and young children should be de-prioritized. And they seem to agree that the principle of rst-come, rst-served should be rejected. The similarities soon end, however. Kerstein and Bogner raise at least four major concerns with Persad and colleagues analysis. First, they maintain that Persad and colleagues mistakenly reject the principle of the sickest rst. Second, they believe Persad and colleagues should have considered differences in quality of life. Third, they disagree with Persad and colleagues defense of prioritizing older children and young adults ahead of other age groups. Fourth, they fault Persad and colleagues proposed system because it offers insufcient guidance on how to balance the often competing principles of saving the most lives, saving the most life-years, and prioritizing older children and young adults ahead of other age groups. In a nutshell, Kerstein and Bogner argue that the complete lives system is incomplete, includes a mistaken principle concerning age-based rationing, and fails to provide sufcient practical guidance. They suggest additional principles and considerations (noting that any nal framework needs to include even more yet-to-be-specied principles) and propose a baseline method for adjudicating between saving the most lives and saving the most life-years when these principles direct conicting allocations. Both sets of authors seek a primary set of allocation principles for such diverse resources and circumstances as vaccines in a pandemic and intensive care unit (ICU) beds and organ transplants in times of no pandemic. In contrast, the Minnesota Pandemic Ethics Project concludes it is wrong to assume that a single allocation framework is sufcient to guide the rationing of such a broad range of resources under varying conditions (Vawter et al. 2010). THE MINNESOTA PANDEMIC ETHICS PROJECT The project, which involved approximately 600 Minnesotans and included informed public deliberation,

Address correspondence to Dorothy E. Vawter, Minnesota Center for Health Care Ethics, 1890 Randolph Avenue, St. Paul, MN 55105, USA. E-mail: vawter@mnhealthethics.org

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yielded multiple ethical frameworks to guide statewide rationing of health-related resources during a severe inuenza pandemic. These pandemic-specic frameworks differ in important ways from those by Persad and colleagues and Kerstein and Bogner. We next highlight a few of the most signicant substantive differences. Sickest First Minnesotas project participants would agree that Persad and colleagues too quickly conclude that giving to the sickest rst is an inherently awed principle for allocating scarce resources (Kerstein and Bognar 2010). Participants in the Minnesota project recommended a form of the principle sickest persons rst, that is, prioritize persons at high risk of u-related mortality and serious morbidity who have an acceptable response to the resource. Maximize Life-Years Both sets of authors consider maximizing life-years (or maximizing the life-years of persons with the capacities to set ends and to form, act on, and revise plans for attaining them) as undeniably relevant to allocating resources. Minnesotas project participants, on the other hand, concluded that during a severe pandemic, allocating resources to maximize life-years would be unfair, exacerbate health disparities, be impractical, and cause distrust of the states allocation system. First and foremost, relying on actuarial data about different demographic groups would unfairly favor healthier, wealthier, and more empowered groups over groups systematically left behind. For instance, the principle unfairly allows 40-year-old white women living in highincome areas routinely to be prioritized over 40-year-old men of color living in low-income areas for the simple reason that the former have a longer life expectancy. Moreover, the principle relies on unreasonable assumptions about the accuracy of predictions that a particular person will live decades into the future. It is infeasible during a severe pandemic for clinic staff to have detailed health histories about everyone seeking a pandemic u vaccine, treatment antivirals, and the like. Finally, the principle gives patients and clinicians incentive to hide health histories and important comorbidities that might otherwise contraindicate the patients receipt of resources. The most closely related recommendation offered by the Minnesota project is that persons be de-prioritized from receiving resources if they are known to be imminently and irreversibly dyingfor example, if they are known to have a comorbidity incompatible with life beyond a short time frame. De-prioritizing imminently dying persons maximizes the number of lives saved; it is not concerned with maximizing the number of life-years saved. Quality of Life Minnesotas project participants would reject Kerstein and Bogners recommendation that persons with specic psychological capacities be prioritized to receive resources be-

fore those lacking those capacities, including all infants and young children. Project participants explicitly recommended that resources not be rationed based on perceived differences in quality of life, regardless of the denition or method used to dene it. Quality-of-life judgments are notoriously subjective and difcult to implement consistently. Such judgments are likely to result in unacceptable discrimination and to exacerbate health disparities. (Modied) Youngest-First Kerstein and Bogner raise several valid concerns about Persad and colleagues modied principle of prioritizing the youngest rst, including its inconsistency with competing principles. The Minnesota Pandemic Ethics Project provides some support for rejecting the principle of prioritizing older children and young adults over other age groups. Many Minnesotans believe that during a severe inuenza pandemic it can be justied under some limited circumstances to prioritize younger before older persons, and especially children before adults. They explicitly rejected the notion of prioritizing younger children before older children or vice versa. Project participants recommendations regarding children stand in stark contrast with the recommendations of Persad and colleagues and Kerstein and Bogner. These two sets of authors recommend de-prioritizing infants and young children relative to older children and young adults. They base their recommendations on different rationales, both of which are not only inconsistent with the Minnesota Pandemic Ethics Projects recommendations, but also expressly rejected as unfair. An exhaustive review of the conicting age-based recommendations is beyond the scope of this commentary. It is worth observing, however, that the recommendations of the Minnesota Pandemic Ethics Project were developed from a statewide public health perspective in which it was assumed that many of the pandemic resources are public goods. It is perhaps not unexpected that persons design different allocation frameworks depending on the perspective brought to the task. Persad and colleagues ask, Assuming that you will live a normal life span, at what life-stage(s) would you prefer to have the greatest access to (life-saving) resources? Contrast this with the Minnesota projects core question: In a severe pandemic, how would you advise your states department of health to ration health resources fairly to protect the publics health? Project participants frequently observed that decisions they might make about allocating scarce resources within their families or at their place of employment should not necessarily be the same as decisions made by state government on behalf of all. CONCLUSION The need for ethical frameworks for allocating resources is clear. Fortunately, an increasing number of groups are tackling this challenging task. Particularly encouraging are the efforts that actively engage a diverse range of professionals and laypersons. The differences between

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various proposed allocation schemes suggest an urgent agenda of ethical issues in resource allocation deserving additional professional and public consideration. REFERENCES
Kerstein, S., and G. Bognar. 2010. Complete lives in the balance. American Journal of Bioethics 10(4): 3745.

Persad, G., A. Wertheimer, and E. J. Emanuel. 2009. Principles for the allocation of scarce medical interventions. Lancet 373: 423431. Vawter, D. E., J. E. Garrett, K. G. Gervais, et al. 2010. For the good of us all: Ethically rationing health resources in Minnesota in a severe inuenza pandemic. Final report. St. Paul, MN: Minnesota Center for Health Care Ethics and University of Minnesota Center for Bioethics. 2010.

Balancing Relevant Criteria in Allocating Scarce Life-Saving Interventions

Erik Nord, Norwegian Institute of Public Health and the University of Oslo
Persad, Wertheimer, and Emanuel (2009) review a number of possible principles for allocating scarce life-saving interventions like organ transplants and vaccines. While their discussion is useful, I agree with Kerstein and Bognar (2010) that several of the Persad and colleagues claims regarding what are relevant and what are awed criteria are open to debate, if not clearly incorrect. For instance, it is difcult to follow Persad and colleagues when they claim that current degree of sickness is morally completely irrelevant. Altogether, the Persad and colleagues nal selection of relevant criteria for a complete lives system comes across as one based on their own values and preferences rather than as one that is rmly established by their prior arguments. The Persad and colleagues preferred principles are (1) giving priority to adolescents and young adults, (2) favoring those who stand to gain more life years from the intervention in question (referred to as having a better prognosis), and (3) saving as many lives as possible. While the latter principle (saving the most lives) is fairly uncontroversial, the two former are not. Even if there are arguments for giving priority to young people over small children, Kerstein and Bognar show that there are good arguments to the contrary in terms of fairness. There are also arguments at a more personal, psychological level. I was surprised, to put it mildly, to read Ronald Dworkins claim, quoted by Persad and colleagues, that most people think that it is more terrible when an adolescent dies than when a three year old child dies. Norwegian mothers would fail to understand such a claim, and so would most fathers. To be very concrete, personally I could never think that my 28- and 26-year-old children have stronger claims on a new heart or liver than my 8and 6-year-old children, and it would not have made any difference if the former had been only 18 and 16. In short, Sophies choice would not have been easier if the age difference had been bigger. When Dworkin is not left alone with his peculiar view, but is actually embraced by Persad and colleagues and not rejected by Kerstein and Bognar on this particular moral account, I feel disturbed and wonder whether there are value differences at play here between men and women, philosophers and non-philosophers, academics and non-academics, or even people of different nations that are worth examining more closely. Regarding the Persad and colleagues second criterion prognosisthe picture is mixed. Persad and colleagues are skeptical of the quality-adjusted life years (QALY) approach, but their proposal on life years gained is in fact consistent with the QALY model, which assumes that value is more or less proportional to the duration of effect. This assumption in the QALY model is not supported by evidence of societal values in, for instance, Australia, Norway, the United Kingdom, and the United States (Olsen 1994; Nord et al. 1996; Murray 1996; Dolan and Cookson 1998). For instance, in a focus group study in the United Kingdom, a ceiling effect seemed to come into play at around 10 years: Most subjects did not think that people who could gain 20 years should have priority over people who could gain 10 years (Dolan and Cookson 1998). On the other hand, Persad and colleagues do not propose to quality adjust gained life years. Kerstein and Bognar nd this peculiar. But Persad and colleagues are correct in noting that strength of interest in

Address correspondence to Erik Nord, Department of Mental Health, Norwegian Institute of Public Health, Sandakerveien 24c, bygg b, Oslo, 1403, Norway. E-mail: erik.nord@fhi.no

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