Fair priority setting is based on morally sound criteria. Still, there will be cases when these criteria, our primary considerations, are tied and therefore do not help us in choosing one allocation over another. It is sometimes suggested that such cases can be handled by tiebreakers. In this paper, we discuss two versions of tiebreakers suggested in the literature. One version is to preserve fairness or impartiality by holding a lottery. The other version is to allow secondary considerations, considerations that (...) are not part of our primary priority setting criteria, to be decisive. We argue that the argument for preserving impartiality by holding a lottery is sound, while the argument for using tiebreakers as secondary considerations is not. Finally, we argue that the instances where a tiebreaker seems necessary are precisely the situations where we have strong reasons for preferring a lottery. We conclude that factors that we consider valuable should all be included among the primary considerations, while ties should be settled by lotteries. (shrink)

Background The prioritization protocols for accessing adult critical care in the extreme pandemic context contain tiebreaker criteria to facilitate decision-making in the allocation of resources between patients with a similar survival prognosis. Besides being controversial, little is known about the public acceptability of these tiebreakers. In order to better understand the public opinion, Quebec and Ontario’s protocols were presented to the public in a democratic deliberation during the summer of 2022. Objectives (1) To explore the perspectives of Quebec and Ontario (...) citizens regarding tiebreakers, identifying the most acceptable ones and their underlying values. (2) To analyze these results considering other public consultations held during the pandemic on these criteria. Methods This was an exploratory qualitative study. The design involved an online democratic deliberation that took place over two days, simultaneously in Quebec and Ontario. Public participants were selected from a community sample which excluded healthcare workers. Participants were first presented the essential components of prioritization protocols and their related issues (training session day 1). They subsequently deliberated on the acceptability of these criteria (deliberation session day 2). The deliberation was then subject to thematic analysis. Results A total of 47 participants from the provinces of Quebec (n = 20) and Ontario (n = 27) took part in the online deliberation. A diverse audience participated excluding members of the healthcare workforce. Four themes were identified: (1) Priority to young patients - the life cycle - a preferred tiebreaker; (2) Randomization - a tiebreaker of last resort; (3) Multiplier effect of most exposed healthcare workers - a median acceptability tiebreaker, and (4) Social value – a less acceptable tiebreaker. Conclusion Life cycle was the preferred tiebreaker as this criterion respects intergenerational equity, which was considered relevant when allocating scarce resources to adult patients in a context of extreme pandemic. Priority to young patients is in line with other consultations conducted around the world. Additional studies are needed to further investigate the public acceptability of tiebreaker criteria. (shrink)

There is a long-standing debate concerning the eligibility of patients suffering from alcohol-related end-stage liver disease (ARESLD) for deceased donor liver transplantation. The question of retrospective and/or prospective responsibility has been at the center of the ethical discussion. Several authors argue that these patients should at least be regarded as partly responsible for their ARESLD. At the same time, the arguments for retrospective and/or prospective responsibility have been strongly criticized, such that no consensus has been reached. A third option was (...) proposed as a form of compromise, namely that responsibility should only be used as a tiebreaker in liver allocation. The present study provides an ethical investigation of this third option. First, we will provide an overview of the main arguments that have been offered for and against the use of responsibility as an allocation criterion. Second, we will explore the concept of responsibility as a tiebreaker in detail and discuss several types of situations, in which responsibility could be used as a tiebreaker, as well as the main ethical challenges associated with them. As we will show, an ethical justified use of responsibility as a tiebreaker is limited to a very restricted number of cases and is associated with a number of ethical concerns. For this reason, waiting time should be preferred as a tiebreaker in liver allocation, even though the criterion of waiting time, too, raises a number of equity-related concerns. (shrink)

Tiebreak rules are necessary for revealing indifference in non- sequential decisions. I focus on a preference relation that satisfies Ordering and fails Independence in the following way. Lotteries a and b are indifferent but the compound lottery f, 0.5b> is strictly preferred to the compound lottery f, 0.5a>. Using tiebreak rules the following is shown here: In sequential decisions when backward induction is applied, a preference like the one just described must alter the preference relation between a and b at (...) certain choice nodes, i.e., indifference between a and b is not stable. Using this result, I answer a question posed by Rabinowicz (1997) concerning admissibility in sequential decisions when indifferent options are substituted at choice nodes. (shrink)

On March 11, 2020 the World Health Organization classified COVID‐19, caused by Sars‐CoV‐2, as a pandemic. Although not much was known about the new virus, the first outbreaks in China and Italy showed that potentially a large number of people worldwide could fall critically ill in a short period of time. A shortage of ventilators and intensive care resources was expected in many countries, leading to concerns about restrictions of medical care and preventable deaths. In order to be prepared for (...) this challenging situation, national triage guidance has been developed or adapted from former influenza pandemic guidelines in an increasing number of countries over the past few months. In this article, we provide a comparative analysis of triage recommendations from selected national and international professional societies, including Australia/New Zealand, Belgium, Canada, Germany, Great Britain, Italy, Pakistan, South Africa, Switzerland, the United States, and the International Society of Critical Care Medicine. We describe areas of consensus, including the importance of prognosis, patient will, transparency of the decision‐making process, and psychosocial support for staff, as well as the role of justice and benefit maximization as core principles. We then probe areas of disagreement, such as the role of survival versus outcome, long‐term versus short‐term prognosis, the use of age and comorbidities as triage criteria, priority groups and potential tiebreakers such as ‘lottery’ or ‘first come, first served’. Having explored a number of tensions in current guidance, we conclude with a suggestion for framework conditions that are clear, consistent and implementable. This analysis is intended to advance the ongoing debate regarding the fair allocation of limited resources and may be relevant for future policy‐making. (shrink)

Most ethics guidelines for distributing scarce medical resources during the coronavirus pandemic seek to save the most lives and the most life‐years. A patient’s prognosis is determined using a SOFA or MSOFA score to measure likelihood of survival to discharge, as well as a consideration of relevant comorbidities and their effects on likelihood of survival up to one or five years. Although some guidelines use age as a tiebreaker when two patients’ prognoses are identical, others refuse to consider age for (...) fear of discriminating against the elderly. In this paper, I argue that age is directly relevant for maximizing health benefits, so current ethics guidelines are wrongly excluding or deemphasizing life‐stage in their triage algorithms. Research on COVID‐19 has shown that age is a risk factor in adverse outcomes, independent of comorbidities. And limiting a consideration of life‐years to only one or five years past discharge does not maximize health benefits. Therefore, based on their own stated values, triage algorithms for coronavirus patients ought to include life‐stage as a primary consideration, along with the SOFA score and comorbidities, rather than excluding it or using it merely as a tiebreaker. This is not discriminatory because patients ought to have equal opportunity to experience life‐stages. The equitable enforcement of that right justifies unequal treatment based on age in cases when there is a scarcity of life‐saving resources. A consideration of life‐stage would thus allow healthcare workers to responsibly steward public resources in order to maximize lives and life‐years saved. (shrink)

When the Covid‐19 pandemic reached the United States in spring 2020, many states and hospitals announced crisis standards of care plans that used age as a categorical exclusion criterion. Such age choosing was quickly flagged as discriminatory, and so some states and hospitals shifted to embedding age as a tiebreaker deeper in their plans. Different rationales were given for using age as a tiebreaker: that younger patients were more likely to survive than older patients, that saving younger patients would save (...) more life years, and that younger patients deserved a chance to live through life's stages. We provide a critical analysis of these three rationales, noting the differences between them, and then questioning the ethical and legal justifications for such age choosing. (shrink)

We propose a new single-winner voting system using ranked ballots: Stable Voting. The motivating principle of Stable Voting is that if a candidate A would win without another candidate B in the election, and A beats B in a head-to-head majority comparison, then A should still win in the election with B included (unless there is another candidate A' who has the same kind of claim to winning, in which case a tiebreaker may choose between such candidates). We call this (...) principle Stability for Winners (with Tiebreaking). Stable Voting satisfies this principle while also having a remarkable ability to avoid tied outcomes in elections even with small numbers of voters. (shrink)

Sometimes we ought to aggregate lesser harms to many such that they outweigh greater harms to a few, and sometimes we ought not to. This seems self-evident, but it has proven surprisingly difficult to construct a coherent moral theory out of this basic observation. In particular, it is difficult to explain (in a principled way) when we ought to aggregate. Relevance views attempt to solve this problem by arguing that sufficiently lesser harms are irrelevant to greater harms and thus should (...) not be taken into consideration. My thesis develops and defends a new relevance view. The first half of the thesis focuses on when lesser harms can aggregate and outweigh stronger harms. I start by solving a ‘fatal’ dilemma for all relevance views. I show that one horn of the dilemma is fatal but avoidable, whilst the other is unavoidable but not fatal, and that the dilemma rests on a faulty assumption of weak-additivity. I then develop a new relevance view based around the principle that we ought to balance harms by similarity (i.e., we ought to balance greater harms against similarly great harms and lesser harms against other lesser harms) before deciding whether lesser harms are relevant to greater harms. The second half focuses on when lesser harms can aggregate and tiebreak between stronger harms. First, I show that relevance views cannot capture our intuition that sufficiently lesser harms should not tiebreak between greater harms, without forfeiting our intuitions in other important cases. Secondly, I demonstrate that relevance views are sometimes inappropriately insensitive to the number of harms in tiebreaking cases. To solve these problems, I distinguish between two types of relevance, and I introduce Broomean fairness into my account. Doing so allows my view to capture all our intuitions about when lesser harms can tiebreak between stronger harms. (shrink)

Objectives To characterize the prevalence and content of pediatric triage policies.Methods We surveyed and solicited policies from U.S. hospitals with pediatric intensive care units. Policies were analyzed using qualitative methods and coded by 2 investigators.Results Thirty-four of 120 institutions (28%) responded. Twenty-five (74%) were freestanding children’s hospitals and 9 (26%) were hospitals within a hospital. Nine (26%) had approved policies, 9 (26%) had draft policies, 5 (14%) were developing policies, and 7 (20%) did not have policies. Nineteen (68%) institutions shared (...) their approved or draft policy. Eight (42%) of those policies included neonates. The polices identified 0 to 5 (median 2) factors to prioritize patients. The most common factors were short- (17, 90%) and long- (14, 74%) term predicted mortality. Pediatric scoring systems included Pediatric Logistic Organ Dysfunction-2 (12, 63%) and Score for Neonatal Acute Physiology and Perinatal Extensions-II (4, 21%). Thirteen (68%) policies described a formal algorithm. The most common tiebreakers were random/lottery (10, 71%) and life cycles (9, 64%). The majority (15, 79%) of policies specified the roles of triage team members and 13 (68%) precluded those participating in patient care from making triage decisions.Conclusions While many institutions still do not have pediatric triage policies, there appears to be a trend among those with policies to utilize a formal algorithm that focuses on short- and long-term predicted mortality and that incorporates age-appropriate scoring systems. Additional work is needed to expand access to pediatric-specific policies, to validate scoring systems, and to address health disparities. (shrink)

In a recent paper, Charles Foster argued that the epistemic uncertainties surrounding prolonged disorders of consciousness make it impossible to prove that the withdrawal of life-sustaining treatment can be in a patient’s best interests and, therefore, the presumption in favour of the maintenance of life cannot be rebutted. In the present response, I argue that, from a legal perspective, Foster has reached the wrong conclusion because he is asking the wrong question. According to the reasoning in two leading cases —Bland (...) and James —the principle of respect for autonomy creates a persuasive presumption against treatment without consent. Therefore, it is the continuation of treatment that requires justification, rather than its withdrawal. This presumption also works as the tiebreaker determining that treatment should stop if there is no persuasive evidence that its continuation is in the best interests of the patient. The presumption in favour of the maintenance of life, on the other hand, should be understood as an evidential presumption on a factual issue that is assumed to be true if unchallenged. However, the uncertainties regarding PDOC actually give reasons for displacing this evidential presumption. Consequently, decision-makers will have to weigh up the pros and cons of treatment having the presumption against treatment without consent as the tiebreaker if the evidence is inconclusive. In conclusion, when the right question is asked, Foster’s argument can be turned on its head and uncertainties surrounding PDOC weigh in to justify the interruption of treatment in the absence of compelling contrary evidence. (shrink)

When life-saving medical resources are scarce and not everyone can be saved, is the only relevant goal saving the most lives? Or can other factors be considered, at least as tiebreakers, such as how early in life the people we don't save will die or how much future life they are likely to lose? This commentary defends a multiprinciple allocation approach that considers objectives in addition to saving more lives, including preventing early death and preventing harm in the form of (...) lost future life. Particularly compared to an arbitrary, coin-flip tiebreaker, this multiprinciple approach more effectively prevents harm, prioritizes the worst-off, mitigates socioeconomic and racial health disparities, and tracks public values regarding allocation under scarcity—and is legally sound. -/- . (shrink)

Age-based rationing remains highly controversial. This question has been paramount during the Covid-19 pandemic. Analyzing the practices, proposals, and guidelines applied or put forward during the current pandemic, three kinds of age-based rationing are identified: an age-based cut-off, age as a tiebreaker, and indirect age rationing, where age matters to the extent that it affects prognosis. Where age is allowed to play a role in terms of who gets treated, it is justified either because this is believed to maximize benefits (...) from scarce resources or because it is believed to be in accordance with the value of fairness understood as (a) fair innings, where less priority is given to those who have lived a full life or (b) an egalitarian concern for the worse off. By critically assessing prominent frameworks and practices for pandemic rationing, this article considers the balance the three kinds of age-based rationing strike between maximizing benefits and fairness. It evaluates whether elements in the proposals are, in fact, contrary to the justifications of these measures. Such shortcomings are highlighted, and it is proposed to adjust prominent proposals to care for the worse off more appropriately and better consider whether the acquired benefits befalls the young or the old. (shrink)

In this Correspondence, I argue that given that scarcity has existed both for critical care resources and for vaccines, allocating critical care resources to prioritize the prevention of early COVID-19 deaths (i.e. COVID-19 deaths among younger patients) could valuably counterbalance the disproportionate exclusion of minority patients and those with life shortening disabilities that age-based vaccine allocation produces. -/- Covid-19 deaths early in life have overwhelmingly befallen minorities and people with life-shortening disabilities. Policies preventing early deaths prevent an outcome widely recognized (...) as worse—dying earlier in one’s life rather than later—while counteracting intersecting forms of injustice. Ultimately, prohibiting the use of age as a tiebreaker in critical care allocation, as Brown et al. propose, will worsen disparities and is not mandated by law. (shrink)

Seidenfeld (Seidenfeld, T. [1988a], Decision theory without 'Independence' or without 'Ordering', Economics and Philosophy 4: 267-290) gave an argument for Independence based on a supposition that admissibility of a sequential option is preserved under substitution of indifferents at choice nodes (S). To avoid a natural complaint that (S) begs the question against a critic of Independence, he provided an independent proof of (S) in his (Seidenfeld, T. [1988b], Rejoinder [to Hammond and McClennen], Economics and Philosophy 4: 309-315). In reply to (...) my (Rabinowicz, W. [1995], To have one's cake and eat it too: Sequential choice and expected-utility violations, The Journal of Philosophy 92: 586-620), in which I argue that the proof is invalid, Seidenfeld (Seidenfeld, T. [2000], Substitution of indifferent options at choice nodes and admissibility: A reply to Rabinowicz, Theory and Decision 48: 305–310 this issue) submits that I fail to give due consideration to one of the underlying assumptions of his derivation: it is meant to apply only to those cases in which the agent's preferences are stable throughout the sequential decision process. The purpose of this note is to clarify the notion of preference stability so as meet this objection. (shrink)

A general criterion for distinguishing between epistemic and non-epistemic values is that the former promotes the attainment of truth whereas the latter does not. Daniel Steel is a proponent of this criterion, although it was initially proposed by McMullin. There are at least two consequences of this criterion; it always prioritizes epistemic values over non-epistemic values in scientific research, and it overlooks the diverse aims of science, especially the aims of regulatory or policy-oriented science. This criterion assumes the lexical priority (...) of truth or lexical priority of evidence. This paper attempts to show a few inadequacies of this assumption. The paper also demonstrates why epistemic priority over non-epistemic values is a problematic stance and how constraining the role of non-epistemic values as ‘tiebreakers’ may undermine the diverse aims of science. (shrink)

A general criterion for distinguishing between epistemic and non-epistemic values is that the former promotes the attainment of truth whereas the latter does not. Daniel Steel is a proponent of this criterion, although it was initially proposed by McMullin. There are at least two consequences of this criterion; it always prioritizes epistemic values over non-epistemic values in scientific research, and it overlooks the diverse aims of science, especially the aims of regulatory or policy-oriented science. This criterion assumes the lexical priority (...) of truth or lexical priority of evidence. This paper attempts to show a few inadequacies of this assumption. The paper also demonstrates why epistemic priority over non-epistemic values is a problematic stance and how constraining the role of non-epistemic values as ‘tiebreakers’ may undermine the diverse aims of science. (shrink)