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to have a deep interest in critically reflecting on toughallocation problems, we ought to have a deeper and moreabiding interest in reflecting on why, at any given moment,background conditions force us into these dilemmas inthe first place. Sometimes they will be unavoidable, butmany times they are not but for our own collective will.I especially worry when theorists feel comfortable takingideas like the modified youngest-first principle andapply them to least advantaged populations in poorerparts of the world. There can be no denying that, in suchplaces, resources are frighteningly scarce, but there also can be no denying that our complacency towards first-order

issues of social injustice contributes to their ongoingscarcity.

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 ResourcesDorothy E. Vawter, Minnesota Center for Health Care EthicsJ. 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 advancingthe scholarly debate about which principles should guidethe allocation of scarce health care resources and for theirinsightful 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 multi-ple principles and that two core principles for any alloca-tion scheme include saving the most lives and saving themost life-years. They agree that infants and young childrenshould be de-prioritized. And they seem to agree that theprinciple of first-come, first-served should be rejected. Thesimilarities soon end, however.

Kerstein and Bogner raise at least four major concernswith Persad and colleagues analysis. First, they maintainthat Persad and colleaguesmistakenlyreject theprinciple ofthe sickest first. Second, they believe Persad and colleaguesshould have considered differences in quality of life. Third,

they disagree with Persad and colleagues defense of prior-itizing older children and young adults ahead of other agegroups. Fourth, they fault Persad and colleagues proposedsystem because it offers insufficient guidance on how to bal-ancethe often competing principlesof saving the most lives,

Address correspondence to Dorothy E. Vawter, Minnesota Center for Health Care Ethics, 1890 Randolph Avenue, St. Paul, MN 55105,USA. E-mail: [email protected]

saving the most life-years, and prioritizing older childrenand young adults ahead of other age groups.

In a nutshell, Kerstein and Bogner argue that the com-plete lives system is incomplete, includes a mistaken prin-

ciple concerning age-based rationing, and fails to providesufficient practical guidance. They suggest additional prin-ciples and considerations (noting that any final frameworkneeds to include even more yet-to-be-specified principles)and propose a baseline method for adjudicating betweensaving the most lives and saving the most life-years whenthese principles direct conflicting allocations.

Both sets of authors seek a primary set of allocationprinciples for such diverse resources and circumstances asvaccines in a pandemic and intensive care unit (ICU) bedsand organ transplants in times of no pandemic. In contrast,theMinnesota Pandemic EthicsProject concludes it is wrongto assume that a single allocation framework is sufficient toguide therationing of sucha broad range of resources under

varying conditions (Vawter et al. 2010).

THE MINNESOTA PANDEMIC ETHICS PROJECT

The project, which involved approximately 600 Min-nesotans and included informed public deliberation,

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yielded multiple ethical frameworks to guide statewide ra-tioningof health-related resourcesduring a severe influenzapandemic. These pandemic-specific frameworks differ inimportant ways from those by Persad and colleagues andKerstein and Bogner. We next highlight a few of the mostsignificant substantive differences.

Sickest FirstMinnesotas project participants would agree that Persadand colleagues too quickly conclude that giving to the sick-estfirst is an inherentlyflawedprinciple forallocating scarceresources (Kerstein and Bognar 2010). Participants in theMinnesota project recommended a form of the principlesickest persons first, that is, prioritize persons at high riskof flu-related mortality and serious morbidity who have anacceptable response to the resource.

Maximize Life-Years

Both sets of authors consider maximizing life-years(or max-imizing the life-years of persons with the capacities to

set ends and to form, act on, and revise plans for attain-ing them) as undeniably relevant to allocating resources.Minnesotas project participants, on the other hand, con-cluded that during a severe pandemic, allocating resourcesto maximize life-years would be unfair, exacerbate healthdisparities, be impractical, and cause distrust of the statesallocation system. First and foremost, relying on actuarialdata aboutdifferentdemographicgroups wouldunfairly fa-vor healthier, wealthier, and more empowered groups overgroups systematically left behind.For instance, the principleunfairly allows 40-year-old white women living in high-income areas routinely to be prioritized over 40-year-oldmen of color living in low-income areas for the simple rea-son that the former have a longer life expectancy. Moreover,

the principle relies on unreasonable assumptions about theaccuracy of predictions that a particular person will livedecades into the future. It is infeasible during a severe pan-demic for clinic staff to have detailed health histories abouteveryone seeking a pandemic flu vaccine, treatment antivi-rals, and the like. Finally, the principle gives patients andclinicians incentive to hide health histories and importantcomorbidities that might otherwise contraindicate the pa-tients receipt of resources.

The most closely related recommendation offered bythe Minnesota project is that persons be de-prioritized fromreceiving resources if they are known to be imminentlyand irreversibly dyingfor example, if they are known tohave a comorbidity incompatible with life beyond a short

timeframe. De-prioritizing imminently dying personsmax-imizes the number of lives saved; it is not concerned withmaximizing the number of life-years saved.

Quality of Life

Minnesotas project participants would reject Kerstein andBogners recommendation that persons with specific psy-chological capacities be prioritized to receive resources be-

fore those lacking those capacities, including all infantsand young children. Project participants explicitly recom-mended that resources not be rationed based on perceiveddifferences in quality of life, regardless of the definition ormethod used to define it. Quality-of-life judgments are no-toriously subjective and difficult to implement consistently.Such judgments are likely to result in unacceptable discrim-ination and to exacerbate health disparities.

(Modified) Youngest-First

Kerstein and Bogner raise several valid concerns aboutPersadand colleaguesmodified principle of prioritizing theyoungest first, including its inconsistency with competingprinciples. The Minnesota Pandemic Ethics Project providessomesupport for rejecting the principle of prioritizing olderchildren and young adults over other age groups. ManyMinnesotans believe that during a severe influenza pan-demic it can be justified under some limited circumstancesto prioritize younger before older persons, and especiallychildren before adults. They explicitly rejected the notion ofprioritizing younger children before older children or vice

versa.Project participants recommendations regarding chil-

dren stand in stark contrast with the recommendationsof Persad and colleagues and Kerstein and Bogner. Thesetwo sets of authors recommend de-prioritizing infants andyoung children relative to older children and young adults.They base their recommendations on different rationales,both of which are not only inconsistent with the MinnesotaPandemic Ethics Projects recommendations, but also ex-pressly rejected as unfair.

An exhaustive review of the conflicting age-based rec-ommendations is beyond the scope of this commentary.It is worth observing, however, that the recommendationsof the Minnesota Pandemic Ethics Project were developed

from a statewide public health perspective in which it wasassumed that many of the pandemic resources are publicgoods. It is perhaps not unexpected that persons design dif-ferent allocation frameworks depending on the perspectivebrought to the task. Persad and colleagues ask, Assumingthat 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 corequestion: In a severe pandemic, how would you adviseyour states department of health to ration health resourcesfairly to protect the publics health? Project participantsfrequently observed that decisions they might make aboutallocating scarce resources within their families or at theirplace 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 resourcesis clear. Fortunately, an increasing number of groups aretackling this challenging task. Particularly encouragingare the efforts that actively engage a diverse range ofprofessionals and laypersons. The differences between

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various proposed allocation schemes suggest an urgentagenda of ethical issues in resource allocation deservingadditional 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 goodof us

all:Ethically rationinghealth resources in Minnesotain a severe influenza

pandemic. Final report. St. Paul, MN: Minnesota Center for Health

Care Ethics and University of Minnesota Center for Bioethics.

2010.

Balancing Relevant Criteria inAllocating Scarce Life-Saving

InterventionsErik Nord, Norwegian Institute of Public Health and the University of Oslo

Persad, Wertheimer, and Emanuel (2009) review a num-ber of possible principles for allocating scarce life-savinginterventions like organ transplants and vaccines. Whiletheir discussion is useful, I agree with Kerstein and Bog-nar (2010) that several of the Persad and colleagues claimsregarding what are relevant and what are flawed criteriaare open to debate, if not clearly incorrect. For instance,it is difficult to follow Persad and colleagues when theyclaim that current degree of sickness is morally completelyirrelevant. Altogether, the Persad and colleagues final selec-tion of relevant criteria for a complete lives system comesacross as one based on their own values and preferences

rather than as one that is firmly established by their priorarguments.

The Persad and colleagues preferred principles are (1)giving priority to adolescents and young adults,(2) favoringthose who stand to gain more life years from the interven-tion in question (referred to as having a better prognosis),and (3) saving as many lives as possible. While the latterprinciple (saving the most lives) is fairly uncontroversial,the two former are not.

Even if there are arguments for giving priority to youngpeople over small children, Kerstein and Bognar show thatthere are good arguments to the contrary in terms of fair-ness. There are also arguments at a more personal, psy-chological 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 anadolescent 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

Address correspondence to Erik Nord, Department of Mental Health, Norwegian Institute of Public Health, Sandakerveien 24c, bygg b,Oslo, 1403, Norway. E-mail: [email protected]

I could never think that my 28- and 26-year-old childrenhave stronger claims on a new heart or liver than my 8-and 6-year-old children, and it would not have made anydifference if the former had been only 18 and 16. In short,Sophies choice would not have been easier if the age dif-ference had been bigger. When Dworkin is not left alonewith his peculiar view, but is actually embraced by Persadand colleagues and not rejected by Kerstein and Bognar onthis particular moral account, I feel disturbed and wonderwhether there are value differences at play here betweenmen and women, philosophers and non-philosophers, aca-demics and non-academics, or even people of different na-

tions that are worth examining more closely.Regarding the Persad and colleagues second criterion

prognosisthe picture is mixed. Persad and colleaguesare skeptical of the quality-adjusted life years (QALY) ap-proach, but their proposal on life years gained is in factconsistent with the QALY model, which assumes that valueis moreor less proportionalto the duration of effect. This as-sumption in the QALY model is not supported by evidenceof societal values in, for instance, Australia, Norway, theUnited Kingdom, and the United States (Olsen 1994; Nordet al. 1996; Murray 1996; Dolan and Cookson 1998). For in-stance, in a focus group study in the United Kingdom, a ceil-ingeffect seemed to come into play at around 10 years: Mostsubjects 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 andcolleaguesdo notpropose to quality adjustgained lifeyears.Kerstein and Bognar find this peculiar. But Persad andcolleagues are correct in noting that strength of interest in

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