Resource allocation in intensive care units: Three arguments against prematurely discharging one patient to admit another who can benefit more

Drew Carter1, Andrew McGee2, Annette Braunack-Mayer3, Adam M. Deane4

1 School of Public Health, University of Adelaide, SA, 5005, drew.carter@adelaide.edu.au
2 Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD, 4001
3 School of Public Health, University of Adelaide, SA, 5005
4 Discipline of Acute Care Medicine, University of Adelaide, SA, 5005

Intensivists routinely discharge patients only when they judge that a patient no longer has the capacity to benefit from intensive care. However, some ethicists and clinicians are advocating change, arguing that ICUs ought to maximise aggregated benefits (for example, save as many lives as possible) by discharging a patient early when the resources freed up by doing this can be allocated to another patient with a greater capacity to benefit. Under pain of being simplistic, proposals to transform ICU practices ought to reflect serious consideration of three arguments that we develop.

First, premature discharge indicates a type of care that is highly conditional. To avoid this, namely to uphold what it means to accept a patient into one’s care, we should be willing to forego some aggregated benefits.

Second, justice is better served by considering, not how to maximise aggregated benefits, but instead what we are each morally prepared to do for, and ask of, one another.

Finally, it is morally worse to withdraw beneficial treatment than to withhold it.  This is because withdrawing beneficial treatment from one patient to provide it to another involves upturning a first-come-first-served arrangement, and such an arrangement ought not to be upturned insofar as it constitutes an exercise in procedural justice.  Furthermore, to withdraw beneficial treatment is to act against a patient’s best interests.  It therefore violates the doctor-patient relationship and, in particular, the implicit promise and trust that partly comprise it.  The idea that withdrawing and withholding treatment are morally equivalent has been dubbed the Equivalence Thesis.  We thus explain why the Equivalence Thesis is false in the case of beneficial treatment.


Biography

Drew Carter is a moral philosopher and health services researcher who works mostly at the interface of ethics and health economics. He is particularly interested in identifying what is important besides gaining the maximum possible health for a population. Philosophically, he works to extend and apply insights made by the philosophers Ludwig Wittgenstein, Iris Murdoch, Raimond Gaita, and Christopher Cordner. He teaches ethics to medicine and public health students at the University of Adelaide, along with a short course open to the public: https://health.adelaide.edu.au/public-health/short-courses/ethics.

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