Ethical allocation of resources in paediatrics — viva

Stem

Examiner-led viva on a surge and a cost-based allocation scenario. [3]

Examiner: Two children need the last PICU bed. On what principle do you frame the decision? [1]

Strong answer: I frame it on distributive justice, because the question is fair distribution of a scarce resource across the population, not the best interests of one child. I then operationalise it with the four allocation principles from Persad, Wertheimer and Emanuel — maximise benefits, treat people equally, prioritise the worst off, and recognise instrumental value — and I ground the decision in accountability for reasonableness. [1]

Examiner: Name the conditions of accountability for reasonableness. [2]

Strong answer: Publicity, so the criteria are open; relevance, so they are relevant to stakeholders; appeals, so there is a revision and appeal pathway; and enforcement, so the process is actually followed and improved. The point is that a community can accept a painful outcome if it can see how the decision was made. [2]

Examiner: How do you classify this scarcity, and what does that mean for who decides? [3]

Strong answer: This is absolute scarcity — demand exceeds any conceivable supply — so the defensible step is to invoke the pre-agreed paediatric-aware triage protocol and separate the triage officer from the treating team. If this had been a cost-based scarcity, such as the gene therapy, the locus would be the macro-level funding body using explicit criteria, not the bedside clinician. [3] [6]

Examiner: A registrar wants to rank the children by cognitive ability. How do you respond? [8]

Strong answer: I reject it. Disability, cognitive ability, weight, socioeconomic status, family influence, race, indigeneity and migrant status must never rank children. A protocol that discounts disabled children on quality-of-life grounds is discriminatory. I read any quality-adjusted-life-year logic alongside equity precisely because it can otherwise disadvantage disabled children whose life-years count equally. [8]

Examiner: The family of the child who did not get the bed asks what happens now. What do you tell them? [8]

Strong answer: I tell them the decision reflects scarcity, not a judgement that their child's life is worth less, and that allocation withdraws only the specific intervention — never care. Their child still receives active comfort care, family presence and symptom relief, and they have an appeal pathway through the documented protocol and the ethics committee. [8]

Examiner: One key pitfall to avoid in cost-based allocation? [9]

Strong answer: Covert bedside rationing by an individual clinician, with no transparent policy or appeal pathway. Cost-based allocation belongs at macro or meso level with explicit criteria, and my role is to advocate for the child within that transparent system, not to gatekeep silently. [9] [2]