Fairness in rationing during a severe pandemic: Public perspectives

In 2009 we led extensive public engagement activities to elicit ethical objectives that should guide state decision-makers in rationing health-related resources in a severe pandemic. Participants reacted strongly—pro and con—to the inclusion of a fairness objective. Many participants in large community forums felt that saving the most lives and preserving critical infrastructures should be the core rationing objectives, and they disagreed that fairness should be included. They considered fairness to be unachievable in ordinary circumstances, much less in a crisis. Some participants said fairness is about the way objectives are met, and differs in this respect from the core objectives. A smaller number of participants passionately disagreed, arguing that fairness should be the overarching objective— the one all other objectives serve. Participants in nine small group engagements delved into the fairness issue more deeply. As with the community forums, while many small group participants embraced fairness as a concept useful to guide rationing, many others reacted strongly and negatively. The small groups revealed, though, that those who reacted negatively nonetheless embraced particular strategies that derived from fairness (e.g., they agreed rationing shouldn't be based on quality of life or unfairly discriminate according to race, ethnicity, gender or sexual preference). Important insights into communication challenges emerged. The presentation will describe participants' varied ways of interpreting the concept of fairness as a policy objective, reflect on how these differences might inform commitments to social justice in health policy, and describe how final recommendations were revised to reflect public input.