Public attitudes toward pandemic triage: Evidence from conjoint survey experiments in Switzerland

Public voices on tie-breaking criteria and underlying values in COVID-19 triage protocols to access critical care: a scoping review

Background

To reduce the arbitrariness in the allocation of rare resources in intensive care units (ICU) in the context of the pandemic, tiebreakers were considered in some COVID-19 triage algorithms. They were also contemplated to facilitate the tragic decisions of healthcare workers when faced with two patients with similar prognosis and only one ICU bed available. Little is known about the public's perspective on tiebreakers.

Objectives

To consolidate the available scientific literature on public consultations, particularly on tiebreakers and their underlying values. Also, to obtain an overview of the key arguments presented by the participating public and to identify potential gaps related to this topic.

Methods

The steps described by Arksey and O'Malley was the preferred method to our approach. Seven electronic databases were searched from January 2020 to April 2022, using keywords for each database: PubMed, Medline, EMBASE, Web of Science, PsycINFO, EBM reviews, CINAHL complete. We also searched in Google and Google Scholar, and in the references of the articles found. Our analysis was mainly qualitative. A thematic analysis was performed to consider the public's perspectives on tiebreakers and their underlying values, according to these studies.

Results

Of 477 publications found, 20 were selected. They carried out public consultations through various methods: surveys (80%), interviews (20%), deliberative processes (15%) and others (5%) in various countries: Australia, Brazil, Canada, China, France, Germany, India, Iran, Italy, Japan, Korea, Netherlands, Portugal, Spain, Switzerland, Thailand, United Kingdom, and United States. Five themes emerged from our analysis. The public favored the life cycle (50%) and absolute age (45%) as a tiebreaker. Other values considered important were reciprocity, solidarity, equality, instrumental value, patient merit, efficiency, and stewardship. Among the new findings were a preference for patient nationality and those affected by COVID-19.

Conclusions

There is a preference for favoring younger patients over older patients when there is a tie between similar patients, with a slight tendency to favor intergenerational equity. Variability was found in the public's perspectives on tiebreakers and their values. This variability was related to socio-cultural and religious factors. More studies are needed to understand the public's perspective on tiebreakers.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44250-023-00027-9.

Prioritization preferences for COVID-19 vaccination are consistent across five countries

Vaccination against COVID-19 is making progress globally, but vaccine doses remain a rare commodity in many parts of the world. New virus variants require vaccines to be updated, hampering the availability of effective vaccines. Policymakers have defined criteria to regulate who gets priority access to the vaccination, such as age, health complications, or those who hold system-relevant jobs. But how does the public think about vaccine allocation? To explore those preferences, we surveyed respondents in Brazil, Germany, Italy, Poland, and the United States from September to December of 2020 using ranking and forced-choice tasks. We find that public preferences are consistent with expert guidelines prioritizing health-care workers and people with medical preconditions. However, the public also considers those signing up early for vaccination and citizens of the country to be more deserving than later-comers and non-citizens. These results hold across measures, countries, and socio-demographic subgroups.

The importance of citizenship for deserving COVID-19 treatment

Immigrant non-citizens are often considered less deserving than citizens of welfare and other public services. The logic is that valuable and scarce public resources must be limited somehow, and the club of citizens is one way of drawing a boundary. In this paper, we examine how far that boundary extends, by analyzing the extent to which Germans prioritize citizens over non-citizens for access to life-saving healthcare. We implement a conjoint experiment to elicit preferences in the context of the COVID-19 pandemic. The data were collected between April 2020 and March 2021, in 23 waves of an online rolling cross-sectional survey with roughly 17,000 respondents. Our main finding is that citizens are viewed as more deserving of healthcare than non-citizen immigrants, a relationship that is sizeable and robust. Our findings have implications for debates about social boundaries and how to allocate resources in Western Europe.

The citizen preferences-positive externality trade-off: A survey study of COVID-19 vaccine deployment in Japan

Objective

Medicine is a scarce resource and a public good that benefits others by bettering patients’ health. COVID-19 vaccines in shortage are, 1) a scarce resource and 2) a public good with the positive externality of building herd immunity. These features are expected to drive citizens’ attitudes in opposite directions, exclusionist and inclusionist, respectively. Scarcity would drive citizens’ exclusionism, while the positive externality might mitigate exclusionism.

Setting and design

We recruited 15,000 Japanese adults and asked them to rank, in the context of a COVID-19 vaccine shortage, the deservingness of hypothetical vaccine recipients who differed according to 1) citizenship status, 2) visa type and duration of stay (if foreign), 3) occupation, 4) age, 5) whether they lived with a child, and 6) whether they lived with an elderly individual. Citizenship options were Japanese, Chinese, Taiwanese, South Korean, American, or European. The occupations were healthcare, education, other employed, self-employed, or not employed. The 6 attributes were randomly combined, and respondents were shown 3 hypothetical vaccine recipients: one was Japanese, and the others were foreigners.

Treatments

First, through a conjoint design, we created hypothetical vaccine recipients whose attributes were randomized except for the benchmark citizenship, Japanese national. Second, we randomly presented two scenarios for vaccination payments: 1) billed at cost or 2) fully subsidized by the government.

Results

1) Whether the vaccines were billed at cost or fully subsidized did not affect the rankings of deservingness. 2) Japanese citizenship was prioritized. 3) The penalty for being a foreigner was higher for individuals from nations with which Japan has geopolitical tensions. 4) Working in health or education reduced the penalty on foreigners, indicating that the positive externality related to occupation amplifies the positive externality associated with vaccination and mitigates exclusionist attitudes.

Conclusions

The positive occupational externalities that amplify the positive externality of vaccination substantially allay the foreigner penalty.