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Allocating Scarce Life-Sustaining Resources in a Disaster

Eric Toner, MD, August 18, 2017

During a catastrophe, healthcare providers may face difficult questions about who will receive limited life-saving resources. My colleagues and I at Johns Hopkins just published the results of a multi-year study examining the public’s values regarding how scarce mechanical ventilators should be allocated during an influenza pandemic.1

Deliberative Democracy Forums

We conducted 15 half-day community engagement forums with the general public and health-related professionals around the state of Maryland using “deliberative democracy” practices. Deliberative democracy is a methodology to engage the public in facilitated small group discussions around potentially contentious social issues. A total of 324 individuals participated in the forums. 

Some Divergence from Expert Guidance

Most participants indicated a preference for approaches that prioritize short- and long-term survival—that is, giving priority to those most likely to survive the immediate illness in order to maximize the number of life-years saved. This is consistent with previously issued recommendations made by groups of experts. But the participants also indicated that these should not be the only factors driving decision making during a crisis. Fairness and social justice, for example, were also very important to many participants. Qualitative analysis identified 10 major themes that emerged. Many, but not all, themes were consistent with the views of experts. The most important difference with experts’ views related to withholding versus withdrawing ventilator support. Expert groups have suggested that these are ethically equivalent actions; however, the majority of both lay participants and healthcare providers in our forums did not agree and felt that withdrawal of a life-sustaining resource from a lower priority person in order to reallocate it to someone of a higher priority is much more fraught than not providing it in the first place. 

Policy Implications

The values expressed by the public and frontline clinicians sometimes diverge from expert guidance in important ways, including in ethically challenging life-and-death situations. Awareness of these differences should inform policymaking. 



  1. Biddison ELD, Gwon HS, Schoch-Spana M, Regenberg AC, Juliano C, Faden RR, Toner ES. Scarce resource allocation during disasters: a mixed-method community engagement study. CHEST 2017. doi: 10.1016/j.chest.2017.08.001. Accessed August 16, 2017.