Pediatric Patients Should Be Prioritized When Rationing COVID-19 Treatments, Report Argues

Pediatric patients should receive priority when rationing life-saving treatments during the COVID-19 pandemic, according to an ethics roundtable discussion.

In a recent survey, 68% of U.S. pediatric extracorporeal membrane oxygenation (ECMO) directors responded that pediatric patients should get priority when such treatment must be allocated.

Dr. John D. Lantos of Children's Mercy Hospital, in Kansas City, Missouri, and a panel of experts in critical care, end-of-life care, bioethics and health policy consider whether age should guide rationing decisions during the COVID-19 pandemic in their roundtable discussion, published in Pediatrics.

Any consideration of rationing should begin with prognosis, they agree. Patients likely to die even if they are treated with the scarce resource should not receive it.

When two or more patients with an identical prognosis need the same resource, rationing decisions should be based on what lives can be saved, not on whose life is worth saving, so social worth should not be the basis for such decisions.

Prioritizing younger patients for scarce resources is justifiable based on a framework previously described as the "complete lives system," which aims to allow more people to live complete lives.

Pediatric prioritization is also consistent with the World Health Organization's suggestion that allocation "should rely on broad life stages, rather than ranking individuals based on differences of only a few years."

With these considerations in mind, the experts favor a rationing approach that first considers prognosis and whether a patient will benefit from ECMO.

Next, age should be considered as a tiebreaker, because younger patients have more to lose when the arc of their life is threatened to be cut short, and thus they have a greater claim to treatment on the basis of need, according to the authors.

Finally, when two or more patients both stand to benefit from the intervention and are roughly the same age, a random lottery can be used to determine who gets treatment, the team says.

"We all deserve to live a full life and to experience all of life's stages," writes Dr. Lantos and colleagues. "Thus, prioritizing younger patients for scarce resources is not just ethically permissible; it is the epitome of fairness."

Arnav Mahurkar, a graduate student at Erasmus University Rotterdam's department of health economics, policy and law, in the Netherlands, recently examined rationing decisions in the setting of COVID-19 (https://bit.ly/3gVqeQn). He told Reuters Health by email, "Broadly speaking, a complete life approach that focuses on 'completing lives' appears to be a reasonable basis for rationing scarce ECMO resources. Although the complete life approach focuses on age, it does not ignore social preferences."

He noted that several hurdles stand in the way of implementing any fair system of allocating resources, including "difficulties in establishing consensus among all the stakeholders; time constraints in measuring the preferences of the relevant actors in establishing an acceptable rationing policy; problems in measuring the intensity of preferences among the stakeholders; (and) issues in ensuring transparency in the decision making process."

Dr. Lantos did not respond to a request for comments.

—Will Boggs MD

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