Ethical allocation of resources in paediatrics — formative SAQs

SAQ 1 — Principles, scarcity and the locus of decision (10 marks)

A regional paediatric service is funded to offer a one-off, multimillion-dollar gene therapy for spinal muscular atrophy to only a small number of children each year. Several infants could benefit. The treating team is divided about how to choose. [3] [9]

Questions

1. Name the four allocation principles and the procedural framework that should govern the decision. (5 marks) [1] [2]
2. Classify this scarcity and state the correct locus for the decision, and why. (3 marks) [3]
3. State two biases that must be excluded and one safeguard that must accompany any such decision. (2 marks) [8]

Model answer

Principles and framework (5). The four allocation principles set out by Persad, Wertheimer and Emanuel are: maximise benefits (most lives or life-years saved), treat people equally (lottery or first-come among comparables), prioritise the worst off (sickest and youngest), and promote instrumental value. The procedural framework is Daniels and Sabin's accountability for reasonableness, whose conditions are publicity (criteria are public), relevance (relevant to stakeholders), appeals (a revision and appeal pathway exists) and enforcement. A defensible decision is one a reasonable person can accept even when they disagree with the outcome. [1] [2]

Classification and locus (3). This is cost-based scarcity — a beneficial therapy is too expensive to offer to all who could benefit. The correct locus is a macro or meso funding body, such as a health-technology-assessment organisation, using explicit criteria including cost-effectiveness, equity and budget impact. The bedside clinician's role is to advocate for the child within the transparent system, not to gatekeep silently, because covert bedside rationing is ethically perilous. [3] [9]

Biases and safeguard (2). Two biases that must be excluded are disability (quality-of-life or QALY bias against disabled children whose life-years count equally) and socioeconomic status or family influence. A safeguard that must accompany the decision is a documented, appealable rationale plus audit of who receives the resource by disadvantage, so systematic inequity is corrected over time. [8]

SAQ 2 — Pandemic surge triage and the drug-shortage parallel (10 marks)

A pandemic overwhelms the service: demand for critical care far exceeds supply, and a separate national shortage of a life-saving chemotherapy agent affects the oncology service. [6] [7]

Questions

1. Outline the first steps and the structural safeguard you would invoke for surge triage, and why improvisation is dangerous. (4 marks) [6] [7]
2. Distinguish this absolute scarcity from the everyday relative scarcity of a full PICU. (3 marks) [12]
3. Describe how the scarce chemotherapy should be allocated, and what must be guaranteed for children who do not receive the scarce resource in either scenario. (3 marks) [9] [8]

Model answer

Surge triage (4). Invoke the pre-agreed paediatric-aware triage protocol immediately, and separate the triage officer from the treating team so that no single clinician carries both patient advocacy and population logic. Apply validated prognostic scoring to reduce individual bias, and document each decision against the protocol. Improvisation is dangerous because it produces inconsistent, undocumented, biased decisions that families cannot scrutinise or appeal, and it deepens staff moral distress. [6] [7]

Absolute versus relative scarcity (3). Absolute scarcity is demand that exceeds any conceivable supply, requiring a shift from best care for each child to best care for the population under a triage protocol. Relative scarcity is the everyday reality of constrained beds, staff and sub-specialty time, managed by coordination, bed management and transparent escalation rather than survival triage. Treating a fixable process failure as a triage is itself an allocation error. [12]

Chemotherapy allocation and the guarantee (3). The scarce chemotherapy should be allocated by clinical priority and equipoise, with institutional ethics input and transparent documentation — never by quiet clinician preference or ability to pay. In both scenarios, allocation withdraws only the specific scarce intervention; every child who does not receive the resource still receives active comfort care, family presence and symptom relief. Allocation never withdraws care. [9] [8]