Universal DNR Orders, Social Worth, and Life-Years Approaches are Discriminatory and Should Not be Used to Allocate Resources

Philadelphia, PA (April 24, 2020) – Universal do-not-resuscitate (DNR) orders, social worth, and life-years approaches to rationing scarce resources are not fair and conflict with ethical principles, and should not be used during the COVID-19 pandemic or other health catastrophes, write authors affiliated with the American College of Physicians (ACP) Ethics, Professionalism, and Human Rights Committee in an Ideas and Opinions article published today in Annals of Internal Medicine.

The COVID-19 pandemic is novel but the ethical dilemmas it presents are not, say authors Thomas A. Bledsoe, MD, Janet A. Jokela, MD, MPH, Noel N. Deep, MD and Lois Snyder Sulmasy, JD. They say a physician’s responsibility is for the health and welfare of the patient, even as prioritization of resources becomes critical to maximize patient recoveries in a public health crisis. “Prioritization, however, does not mean discrimination against specific groups.”

“Particularly during a widespread pandemic like COVID-19, it’s more critical than ever for physicians and institutions to work together to provide fair, equitable and non-discriminatory care to all patients,  to apply longstanding principles of medical ethics to these emergency circumstances to  guide decisions,” said lead author Thomas Bledsoe, MD, FACP.

The authors state that a universal DNR order goes against a physician’s obligation to avoid harm, act in the patient’s best interest and respect the value of each individual. It is also not consistent with an individualized evidence-based clinical assessment. Social worth determinations are not “ethically defensible” since they entail judgments that some categories of persons are deemed less socially worthy than others. The “life-years” approach systematically discriminates against older patients, the disabled and other groups.

“Fair is fair and means we all have an equal shot at scarce resources under equitable criteria to maximize recovery.  Allocation approaches that  disadvantage older adults, the disabled, or potentially other groups tell all patients that some lives are valued more than others, breeding distrust now andinto the future,“ said Lois Snyder Sulmasy, director, ACP Center for Ethics and Professionalism.

The authors cite the recent ACP policy, “Non-Discrimination in the Stewardship and Allocation of Resources During Health System Catastrophes Including COVID-19” which says resource allocation decisions about, for example, access to ventilators, must not be based on unjust or prejudicial criteria that result in discrimination, but should be made based on patient need, prognosis, and effectiveness, and that allocation of treatment must maximize the number of patients who will recover, not the number of ‘life years.’


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ACP Media Contact: Edward Vassallo, (215) 351-2761​, EVassallo@acponline.org