Distributive Justice: Lessons of a Pandemic

For almost six months, the mass media are delivering round the clock news, reports, and chronicles about the Covid19 pandemics.

Issues about medical problems focus on prevention, by confinement or discovery of a vaccine, but also around treatment by a drug, new or one already existing in the world pharmacopeia, to treat the damages the virus can cause in our bodies.

During the first days and weeks of this pandemic, one of the topics of discussion centered on the shortage of ventilators in Intensive Care Units (ICU) all around the world. It focalized around the bioethical principle of distributive justice.

The contribution of other ethical principles, namely beneficence, non- maleficence, and autonomy, to clarify the ethical problems was not, globally, significant. In the case of informed consent, an advanced directive of life, refusing mechanical ventilation could ease the physician’s decision.

In this context, does the distributive justice tackles clearly and explicitly the problem?

Before any analysis and reflection about the helping hand of this principle, it is elementary to assume two undeniable facts:

In medical practice, of modern times, the role of this principle was mostly restricted to the macroeconomics of health services or micro expenses at the local level. It was never called upon to help in moral judgment of the allocation of a specific resource. Moreover, with a short time to come out with a decision.

Assuming the naked truth, that no country or no national health service can have a ventilator to every citizen, in a situation of a pandemic where the need for ventilators exceeds the offer, how should the resources be allocated?

The principles of distributive justice provide moral guidance for the processes that affect the distribution of benefits and burdens in societies.

It is a crucial ethical principle that applies to the provision of social goods, including public health services. It requires that health services should be accessible to individuals according to need and within the context of resource availability.

It seems clear that in this situation, the allocations of the resources imply well-defined criteria that provide a ventilator for a patient while deny for the other.

Summarizing, what should be the answer to the following questions? Distribution of what, by whom, where, and based on what?

The answer to the first three questions offers, supposedly, no difficulty.

It is providing a ventilator; to a patient in acute or acute on chronic respiratory failure; by the team of physicians in charge of the intensive care unit or, eventually, by the ethics committee of the hospital.

The problem arises with the last question. Based on what?

Can the principles of justice, as understood by most distinguished philosophers or thinkers, guide us in this dilemma of ventilators shortage in the Covid19 pandemics?

Aristotle - equals be treated equally and unequal’s unequally.

Plato - to each his/her due

Marx –from each according to his ability, to each according to his need

Rawls – principles of justice pertain to the assigning of rights and duties and the distribution of benefits and burdens of social cooperation.

In my opinion, the assumptions of these principles cannot and should not be applied since they outline the allocation of resources in a normal situation.

So, what is the solution?

Can a code of conduct, based on the significant risk factors for a favorable outcome, as expressed in the Rockwood Clinical frailty scale, unfold the dilemma?

Is there any chance of an infallible formula for the decision? Or, whatever the criteria, there are always greyish zones.

It is time for all those concerned with ethical principles to think about distributive justice so far as the allocation of resources is concerned, in situations of significant world catastrophes, whether pandemics, earthquakes, chemical or nuclear disasters.

In any of these eventual tragedies, the demands for life saving devices do not meet the disposable resources

The solution, through the distributive justice, is always more suitable if thought and planned than decided in a full-fledged emergency.