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Incorporating Stakeholder Perspectives on Scarce Resource Allocation: Lessons Learned from Policymaking in a Time of Crisis

Published online by Cambridge University Press:  25 March 2021

BETHANY BRUNO ,
HEATHER MCKEE HURWITZ ,
MARYBETH MERCER ,
HILARY MABEL ,
LAUREN SANKARY ,
GEORGINA MORLEY ,
PAUL J. FORD ,
CRISTIE COLE HORSBURGH  and
SUSANNAH L. ROSE
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Abstract

The coronavirus disease (COVID-19) crisis provoked an organizational ethics dilemma: how to develop ethical pandemic policy while upholding our organizational mission to deliver relationship- and patient-centered care. Tasked with producing a recommendation about whether healthcare workers and essential personnel should receive priority access to limited medical resources during the pandemic, the bioethics department and survey and interview methodologists at our institution implemented a deliberative approach that included the perspectives of healthcare professionals and patient stakeholders in the policy development process. Involving the community more, not less, during a crisis required balancing the need to act quickly to garner stakeholder perspectives, uncertainty about the extent and duration of the pandemic, and disagreement among ethicists about the most ethically supportable way to allocate scarce resources. This article explains the process undertaken to garner stakeholder input as it relates to organizational ethics, recounts the stakeholder perspectives shared and how they informed the triage policy developed, and offers suggestions for how other organizations may integrate stakeholder involvement in ethical decision-making as well as directions for future research and public health work.

Keywords

organizational ethicsstakeholder inputscarce resource allocationpandemic planning
Type
Departments and Columns
Information
Cambridge Quarterly of Healthcare Ethics , Volume 30 , Issue 2 , April 2021 , pp. 390 - 402
Copyright
© The Author(s), 2021. Published by Cambridge University Press

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Footnotes

This CQ section will address ethical challenges arising in the actions and decisions made by health care institutions or a health care system. Organizational ethics articles shift the focus from individual patients to the broader context of the organization, including its mission, values, financial management and health care delivery practices. Readers are invited to contact Bill Nelson to propose a submission at: william.a.nelson@dartmouth.edu.

*

Bethany Bruno, Heather Mckee Hurwitz are co-first authors.

Acknowledgments: We thank the following for their contributions: G. Deadwyler, R.C. Langley, M. Michalski, M. Nall, V. Nall, C. Reeves, J. Szabo, D. Easton, R. Field, K. Flowers, J. Gorecki, R. Hosler, C. Leigh, K. Lichman, A. Markert, Y. Mauer, B. O’Neill, J. Ramsey, J. Toski Welsh, C. Turner, J. Jankowski, S. Feldman, A. Boissy, and D. Klein.

References

Notes

1. Berlinger, N, Wynia, M, Powell, P, Hester, M, Milliken, A, Fabi, R, et al. Ethical framework for health care institutions & guidelines for institutional ethics services responding to the coronavirus pandemic: Managing uncertainties, safeguarding communities, and guiding practice. Hastings Center; 2020 Mar 16; available at https://www.thehastingscenter.org/ethicalframeworkcovid19/ (last accessed 6 Apr 2020).Google Scholar

2. Berlinger, N, Wynia, M, Milliken, A, Cohn, F, Guidry-Grimes, LK, Bruce, L, et al. Responding to Covid-19 as a regional public health challenge: Preliminary guidelines for regional collaboration involving hospitals. Hastings Center; 2020 Apr 29; available at https://www.thehastingscenter.org/covid19-regional-ethics-guidelines (last accessed 2 July 2020).Google Scholar

3. Cookson, R, Dolan, P. Principles of justice in health care rationing. Journal of Medical Ethics 2000;26(5):323–9.CrossRefGoogle ScholarPubMed

4. Danis, M, Hurst, SA. Developing the capacity of ethics consultants to promote just resource allocation. American Journal of Bioethics 2009;9(4):37–46.CrossRefGoogle ScholarPubMed

5. Daugherty Biddison, EL, Gwon, HS, Schoch-Spana, M, Regenberg, AC, Juliano, C, Faden, R, et al. Scarce resource allocation during disasters: A mixed-method community engagement study. Chest 2018;153(1):187–95.CrossRefGoogle Scholar

6. Gibson, JL. Organizational ethics: No longer the elephant in the room. Healthcare Management Forum 2012;25(1):37–9.CrossRefGoogle ScholarPubMed

7. Schoch-Spana, M, Brunson, EK, Gwon, H, Regenberg, A, Toner, ES, Daughtery Biddison, EL. Influence of community and culture in the ethical allocation of scarce medical resources in a pandemic situation: Deliberative democracy study. Journal of Participatory Medicine 2020;12(1):e18272.CrossRefGoogle Scholar

8. Wall, S. Organizational ethics, change, and stakeholder involvement: A survey of physicians. HEC Forum 2007;19(3):227–43.CrossRefGoogle ScholarPubMed

9. Werhane, PH. Business ethics, stakeholder theory, and the ethics of healthcare organizations. Cambridge Quarterly of Healthcare Ethics 2000;9(2):169–81.CrossRefGoogle ScholarPubMed

10. Cavallo, JJ, Donoho, DA, Forman, HP. Hospital capacity and operations in the coronavirus disease 2019 (COVID-19) pandemic—Planning for the nth patient. JAMA Health Forum 2020;1(3):e200345.CrossRefGoogle Scholar

11. Emanuel, EJ, Persad, G, Upshur, R, Thome, B, Parker, M, Glickman, A, et al. Fair allocation of scarce medical resources in the time of Covid-19. New England Journal of Medicine 2020;382(21):2049–55.CrossRefGoogle ScholarPubMed

12. Iserson, KV. Healthcare ethics during a pandemic. Western Journal of Emergency Medicine. 2020;21(3);477–483. available at https://westjem.com/articles/healthcare-ethics-during-a-pandemic.html (last accessed 2 July 2020).CrossRefGoogle ScholarPubMed

13. Morley, G. COVID-19 and the moral community: A nursing ethics perspective. In BMJ Medical Ethics Blog [Internet]. London: BMJ; 2020; available at https://blogs.bmj.com/medical-ethics/2020/03/25/covid-19-and-the-moral-community-a-nursing-ethics-perspective/ (last accessed 2 July 2020).Google Scholar

14. Morley, G, Grady, C, McCarthy, J, Ulrich, CM. Covid-19: Ethical challenges for nurses. Hastings Center Report 2020;50(3):35–9.CrossRefGoogle ScholarPubMed

15. Sokol, D, Gray, B. Should we give priority care to healthcare workers in the Covid-19 pandemic? In BMJ Opinion [Internet]. London: BMJ; 2020; available at https://blogs.bmj.com/bmj/2020/04/01/should-we-give-priority-care-to-healthcare-workers-in-the-covid-19-pandemic/ (last accessed 2 Jul 2020).Google Scholar

16. White, DB, Lo, B. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. Journal of the American Medical Association 2020;323(18):1773–4.CrossRefGoogle ScholarPubMed

17. Degeling, C, Carter, SM, Rychetnik, L. Which public and why deliberate? A scoping review of public deliberation in public health and health policy research. Social Science & Medicine 2015;131:114–21.CrossRefGoogle ScholarPubMed

18. See note 6, Gibson 2012, at 37–9.

19. Ritvo, P, Perez, DF, Wilson, K, Gibson, JL, Guglietti, CL, Tracy, CS, et al. Canadian national surveys on pandemic influenza preparations: Prepandemic and peripandemic findings. BMC Public Health 2013;13:271.CrossRefGoogle Scholar

20. Mabel, H, Riaz, S, Augustine, ML, Jankowski, J. Gaps in ethics consultation support for patients and families & practical guidance for future research or quality work involving these stakeholders. American Journal of Bioethics 2020;20(6)75–7.CrossRefGoogle ScholarPubMed

21. Bruce, CR, Smith, ML, Hizlan, S, Sharp, RR. A systematic review of activities at a high-volume ethics consultation service. Journal of Clinical Ethics 2011;22(2):151–64.Google Scholar

22. Rose, S, Hizlan, S, Smith, M, Crites, J. Developing an Ethics Consultation Database as a Clinical Tool and Outcomes Research Resource. Washington, DC: American Society for Bioethics and Humanities; 2016.Google Scholar

23. Sabin, JE, Cochran, D. Confronting trade-offs in health care: Harvard Pilgrim health care’s organizational ethics program. Health Affairs 2007;26(4):1129–34.CrossRefGoogle ScholarPubMed

24. Gallagher, JA, Goodstein, J. Fulfilling institutional responsibilities in health care: Organizational ethics and the role of mission discernment. Business Ethics Quarterly 2002;12(4):433–50.CrossRefGoogle ScholarPubMed

25. Boissy, A. Editor’s letter. Journal of Patient Experience 2018;5(3):159.CrossRefGoogle ScholarPubMed

26. Cosgrove, T. The Cleveland Clinic Way. New York: McGraw Hill Education; 2013.Google Scholar

27. Moody, L, Nicholls, B, Shamji, H, Bridge, E, Dhanju, S, Singh, S. The person-centered care guideline: From principle to practice. Journal of Patient Experience 2018;5(4):282–8.CrossRefGoogle Scholar

28. Scaife, C. SWSC 2019 presidential address “putting patients first”. American Journal of Surgery 2019;218(6):1035–9.CrossRefGoogle ScholarPubMed

29. See note 4, Danis, Hurst 2009, at 37–46.

30. See note 8, Wall 2007, at 227–43.

31. See note 9, Werhane 2000, at 169–81.

32. Bensimon, CM, Smith, MJ, Pisartchik, D, Sahni, S, Upshur, RE. The duty to care in an influenza pandemic: A qualitative study of Canadian public perspectives. Social Science & Medicine 2012;75(12):2425–30.CrossRefGoogle Scholar

33. See note 5, Daugherty et al. 2018, at 187–95.

34. Gale, NK, Heath, G, Cameron, E, Rashid, S, Redwood, S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology 2013;13(117);1–8. available at https://doi.org/10.1186/1471-2288-13-117 (last accessed 2 July 2020).CrossRefGoogle ScholarPubMed

35. Baum, NM, Gollust, SE, Goold, SD, Jacobson, PD. Looking ahead: Addressing ethical challenges in public health practice. Journal of Law, Medicine and Ethics 2007;35(4):657–7.CrossRefGoogle ScholarPubMed

36. See note 11, Emanuel et al. 2020, at 2049–55.

37. Persad, G, Wertheimer, A, Emanuel, EJ. Principles for allocation of scarce medical interventions. The Lancet 2009;373(9661):423–31.CrossRefGoogle ScholarPubMed

38. See note 32, Baum et al. 2007, at 657–7.

39. See note 11, Emanuel et al. 2020, at 2049–55.

40. See note 37, Persad et al. 2009, at 423–31.

41. See note 37, Persad et al. 2009, at 423–31.

42. See note 37, Persad et al. 2009, at 423–31.

43. The perspectives of eight caregivers represented the instrumental value rationale: two reciprocity rationale and two both rationales. One caregiver did not provide a rationale; one caregiver voiced he/she/they would not be able to decide resource allocation.

44. Caregivers and patients were asked to consider different scenarios. Caregivers’ conversations addressed increasing interventions from preventing infection with PPE and vaccines, to treating infection, and to providing life-sustaining ventilators and intensive care. Patients’ conversations considered the difference between prioritization generally versus providing life-sustaining ventilators and intensive care.

45. The survey referenced essential worker groups defined in our state government’s March 2020 stay-at-home orders.

46. Gibson, JL. Organizational ethics and the management of healthcare organizations. Healthcare Management Forum 2007;20(1):32–4.CrossRefGoogle Scholar

47. See note 6, Gibson 2012, at 37–9.

48. See note 24, Gallagher, Goodstein 2002, at 433–50.