Ethical Challenges in Ventilator Allocation during COVID-19 Crisis Level Care in a Low-Resource Setting, Subtitle: Who gets the last ventilator?

Abstract

Health crisis-level situations, such as the COVID-19 pandemic, has brought the challenge of ethical allocation of scarce life-saving resources (e.g. mechanical ventilator) in the face of sudden demand by critically ill patients. The problem is heightened in low-resource countries with limited number of ventilators. This article analyzes the ethical challenges in mechanical ventilator allocation during the COVID-19 pandemic in low to middle-income countries (LMIC), such as the Philippines. Among the three rationing principles of substantive justice, maximizing the benefit of the limited and vital resource for the most in society is acknowledged by majority of public health experts to be the prevailing principle to guide resource allocation. In low-resource settings, such as low to middleincome countries, with pre-existing health inequities in health care resources and absence of legal framework supporting advance directives, the principle of maximizing benefit is tempered with proportionate need focused on the vulnerable population sectors that may have suffered from inequities even before the COVID-19 crisis. The procedural aspect of the allocation decision formulation and implementation should ensure community engagement with solidarity, openness, veracity, transparency and accountability as values to be consistently manifested. Painful decisions will still be made at the frontline on who will receive the life-saving ventilator or not, but, as long as there is transparency and community participation in these decisions, then the decision-makers will be able to live with these decisions without undue burden on their conscience.