Table 2.

Principles and values guiding resource allocation decision-making in the context of KF care, with examples of their limitations^a

Avoiding futility: ensuring resources are used only where they will provide a benefit.

Maximizing utility: allocating resources to produce the greatest benefits overall for a given population.

▪Futility estimates may determine whether to offer dialysis to patients with COVID-19 who are admitted to an ICU given the high rate of mortality in patients with COVID-19 on ventilators and whether to admit patients with existing KF to an ICU if they are COVID-19 positive given their low survival rates. ▪Futility must be defined with respect to specific goals and often involves qualitative judgments that may be prone to bias. Decision aids should be used to promote objectivity when evaluating futility.

▪Utility—or benefits—is often defined by the number of lives or (quality-adjusted) life-years saved by an intervention; thus, allocation decisions may be informed by estimates of patient survival if they receive a share of resources. ▪If applied in isolation, this principle tends to disadvantage those with existing ill health and comorbidities who have poorer chances of longer-term survival (such as many patients with KF), thus potentially reinforcing existing inequities.

Reciprocity and solidarity: helping those who are necessary for the provision of care and/or who contribute to the common good.

“Fair innings”: focus on allowing all people to live a “normal” life span.

▪Health care workers and others who contribute to efforts to provide care for patients with COVID-19, and/or more widespread efforts to support societal well-being during the pandemic, may be prioritized in the allocation of scarce resources in recognition of their contributions and because protecting these workers is beneficial for all. Reciprocity may also encourage prioritization of care for people who have previously contributed to society in other ways. ▪Promoting reciprocity and solidarity is often difficult when there are insufficient resources, for example, of PPE. Prioritization of health care worker safety, for example, may be in tension with professional obligations to care for patients, necessitating systemic interventions to ensure that workers are not forced to choose between their own safety and patient well-being.

▪Often considered in the context of utilitarian analyses, the “fair innings” approach encourages prioritization of lifesaving treatment for younger patients over those who have already enjoyed a normal, or close to normal, life span. ▪If used in isolation, this principle thus systematically discriminates against older persons and effectively devalues the lives of older patients, who are notably more likely to have KF.

Prioritarianism: providing first for the worst off.

Equality: respecting fundamental right to health.b

▪Often interpreted as prioritizing those most likely to die without treatment, those who have already suffered significant disadvantage (such as long-standing ill health or poor quality of life), and/or those for whom death due to the lack of treatment might be considered a greater harm (e.g., those who have not yet lived a full life—see “fair innings” above). ▪Although consideration of prioritarianism may help address existing inequities, if used in isolation it may lead to outcomes that arguably waste vital resources, for example, if those prioritized have a poor prospect of survival even with treatment.

▪Underpins justice in resource allocation, and prohibits discrimination on irrelevant grounds such as race, religion, sex, or politics; strategies used to promote equality may include use of lottery (random chance) or a “first come, first served” approach, or the setting of common limits on care for all (e.g., limited trials of dialysis for those with COVID-19–related AKI). •Although respect for an inherent equal right to health is fundamental for any resource allocation framework, it provides limited guidance for the allocation of resources when these are insufficient to meet all needs and when needs are different within or between groups.

AKI, acute kidney injury; COVID-19, coronavirus disease 2019; KF, kidney failure; ICU, intensive care unit.

^aThese highlight the need for use of allocation frameworks that engage with a range of considerations pertinent to distributive justice.

^bNotably may be interpreted as promoting equality of health outcomes, opportunities to access care, or shares of resources.