A Personalist Approach to the Just Allocation of Resources in the Midst of a Pandemic

Abstract

This paper examines the ethical implications of healthcare resource allocation during the first wave of COVID-19 in Italy, from 21 February to 31 May 2020, with a focus on the utilitarian principles that prioritized age-based resource allocation. By comparing this approach to an ontological personalist bioethics framework, the study aims to offer a more equitable strategy for healthcare allocation applicable to any pandemic. Data from governmental reports, healthcare policies, and ethical guidelines were analyzed, revealing that Italy’s utilitarian method led to significant ethical concerns, particularly regarding age discrimination. In contrast, the ontological personalist approach emphasizes the dignity and intrinsic worth of each individual, irrespective of age or health condition. The findings demonstrate that this personalist framework fosters a more balanced and fair allocation of resources, respecting human dignity and offering a universally applicable alternative to age-based prioritization. Ultimately, the study suggests that integrating ontological personalist principles into healthcare policies could enhance ethical decision-making in future pandemics, ensuring that resource allocation practices align more closely with human rights and individual dignity.

1. Introduction

During Italy’s first wave of COVID-19, spanning from 21 February 2020 to 31 May 2020, the allocation of ventilators was reportedly determined exclusively by age. This approach has sparked significant debate over the ethics of age-based resource distribution in a public health crisis. This paper investigates whether using age as the sole criterion for ventilator allocation is ethically justifiable and explores the broader implications of this practice.

The analysis begins with a critical examination of why age was chosen as the determining factor in Italy’s resource allocation strategy. What were the underlying reasons for prioritizing age, and how did this criterion influence decision-making? From a utilitarian perspective, why does age play such a pivotal role in this context? By addressing these questions, the paper aims to evaluate the ethical soundness of the age-based framework and consider alternative approaches to resource allocation that might be more equitable. In this context, Catholic Social Teaching will be employed as a critical lens to evaluate utilitarianism, particularly in its implications for human dignity and ethical decision-making.

The discussion will also address the notion that age-based policies, while controversial, are not inherently unjust or unlawful. For instance, legal frameworks like Australia’s Age Discrimination Act 2004 (Cth) permit age-based distinctions in certain contexts, such as superannuation (s 38), social security (s 41), migration (s 43), insurance (s 37), and taxation (s 40); things performed in observance of territory and state laws (s 39); specific employment and health programs (ss 41A & 42); or youth wages (s 25). Thus, age-related decisions in healthcare settings should be scrutinized within a broader legal and ethical context.

By analyzing Italy’s ventilator allocation practices, this paper seeks to develop a universal framework for making ethical decisions regarding resource distribution during pandemics. This framework aims to provide guidance for handling similar crises globally, ensuring that ethical considerations are effectively integrated into resource allocation strategies.

Ultimately, the paper will critically assess the ethical framework used in Italy’s decision-making process, focusing on whether excluding individuals over 75 years of age from receiving ventilators was justified. This evaluation will offer insights into how resource allocation can be approached more equitably in future public health emergencies.

2. Context and Application of Age-Based Resource Allocation in Italy During COVID-19

The first person-to-person transmission (‘Transmission’) of this virus was identified on 21 February 2020, with Italy becoming the world’s second most affected country in fifteen days from the date of Transmission [1]. Regarding the age profile of COVID-19, while the virus itself does not discriminate among those who become infected, it is evident that severe illness and mortality are significantly more prevalent among individuals over the age of seventy-five [2]. Given that COVID-19 disproportionately affects older individuals compared to younger ones, this raises an important question: Even under these conditions, is it justifiable to adopt an age-based approach to resource allocation?

In the context of COVID-19 treatment during times of scarcity, while age is a relevant factor, it should not be the sole criterion for resource allocation. Between 3 January 2020 and 16 August 2021, the availability of Intensive Care Unit (‘ICU’) beds and ventilators was one of the major public health concerns in Italy, guiding doctors to apply an age-based cut-off to allocate ventilators (‘Problem’) [3]. The Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care (‘SIAARTI’) was a key body in determining this decision. SIAARTI is a body of physicians that, amongst other things, develops and issues guidelines, behavioral clinical protocols, and work directions in resuscitation and anesthesia [4].

SIAARTI were approached by numerous physicians requiring ethical counsel on how to deal with issues of resource scarcity [3]. In response, SIAARTI provided recommendations under the management of Marco Vergano, the chair of SIAARTI’s Ethics Section [1]. Vergano stated that SIAARTI’s ethical committee advocated for a utilitarian approach concerning resource scarcity [3] (p. 1874).

Vergano, in his co-authored article titled An ethical algorithm for rationing life-sustaining treatment during the COVID-19 pandemic wrote that ‘the first ethical principle for allocation aims to maximize the numbers of lives saved… According to utilitarianism, resources should be distributed to bring about the most good: the greatest good to the greatest number… We should save more lives rather than fewer, other things being equal. We can call this the moral requirement to save the greatest number. It should be a universal requirement of rationing’ [5]. Furthermore, SIAARTI recommended that the scarce resources should be put aside for those ‘who have a much greater probability of survival and life expectancy, in order to maximize the benefits for the largest number of people’ [1].

Although the recommendations provided by the SIAARTI are not binding and approaches to resource scarcity vary within each hospital, some hospitals [1] followed a similar approach to the recommendations provided [6]. Hospitals have discretion in applying the SIAARTI guidelines, allowing for alternative allocation methods. For example, Dr. Rosenbaum notes that one hospital lowered its age cut-off from 80 to 75 to broaden resource distribution among younger patients [3] (pp. 1874–1875). This approach would be considered ageist, as it allocates resources based on age. For purposes of this paper, the term ‘ageism’ is understood as follows:

• [a] process of systematic stereotyping or discrimination against people because they are old, just as racism and sexism accomplish with skin color and gender [7].

Given the use of ageist policies in some hospitals in Italy during the COVID-19 pandemic, this paper focuses on the treatment of human dignity in the context of resource allocation, viewing it as the antidote to ageism. By grounding the discussion in ontological personalism, this analysis underscores the inherent value of each individual, regardless of age, and advocates for resource allocation that respects and upholds human dignity.

Human dignity, as understood from the Catholic theological perspective, is a crucial aspect of this discussion. According to paragraph 357 of the Catechism of the Catholic Church, human dignity can be understood as ‘being in the image of God’ in which ‘the human individual possesses the dignity of a person, who is not just something, but someone’ [8]. Furthermore, quoting Gaudium et Spes, the Compendium on Catholic Social Doctrine states that ‘since something of the glory of God shines on the face of every person, the dignity of every person before God is the basis of the dignity of man before other men’ [8]. This is the ultimate foundation of the radical equality and brotherhood among all people, regardless of their race, nation, sex, origin, culture, or class [9].

One might add to this that it is also regardless of their age, noting the obligation of special protection towards the most vulnerable. The Compendium further argues that a society can only become just when it is founded upon ‘the respect of the transcendent dignity of the human person’ [9]. This is because the human person, though not entirely, symbolizes the vital end of society. The human person actually is the end of society. Society is there for human persons and it is composed of communities of persons.

Therefore, social order and its progression must consistently work to benefit the human person (in so far as these benefits are not futile), not vice versa [9]. Human dignity can be defined ‘as the particular cultural understandings of the inner moral worth of the human person and his or her proper political relations with society’ [10]. This definition emphasizes that a theo-centric approach is not necessary to recognize the importance and characteristics of human dignity. By framing human dignity in this way, it can be demonstrated that its significance can be appreciated across diverse cultural and philosophical contexts, allowing for a broader discourse that is not limited to religious frameworks.

From the perspective of ontological personalism, Juan Manuel Burgos notes that men and women are beings who contain an inherent perfection that differentiates them from the natural world and ‘this perfection has a specific name: dignity’ and dignity possessed in a ‘radical sense’ [11]. This perception of dignity has numerous practical applications for philosophical anthropology; human dignity is both constitutive and intrinsic, and human beings cannot be seen or treated simply as a ‘means to an end’ because human dignity is absolute. Human dignity forms the foundation of human rights, and each individual is ‘unrepeatable and unsubstitutable’ [12].

Irrespective of which view one holds, all three views agree that human dignity is not something that can be bestowed, but is inherent and not contingent upon a certain characteristic such as age. The inherent dignity of each person is highlighted and protected by numerous human rights treaties. The ratification of the treaties enshrining human rights on the basis of human dignity shows the universal concept of the importance and significance of human dignity—a part of the human person that warrants protection, both domestically and internationally. The UN Convention on the Rights of the Child, the International Covenant on Civil and Political Rights, and the International Covenant on Economic, Social, and Cultural Rights, all refer to ‘the inherent dignity… of all members of the human family [as] the foundation of freedom, justice and peace in the world’.

The dignity of human beings does not decline with age and thus using age as the sole determining factor to allocate resources implies that the dignity of the elderly is not considered to be equal to those who are younger. Sitting beneath that is the idea that, as finite creatures, we have a limited time to be alive. Therefore, any discrimination is about the length of someone’s life—someone younger with a shortened life expectancy would be treated the same way as someone older. Allocating resources on the basis of this framework is an unethical act. This sheds some light on an approach to the handling of the situation in Italy, which was addressed by providing preferential treatment to those under the age of 75. Those who did not meet this age cut-off were not provided with ventilators and consequently died.

The ethics of the ageist framework used can be contested by examining this case in light of the concept of human dignity, which is central to the philosophical framework of ontological personalism. However, it should be clarified that the SIAARTI recommendations also noted that the ‘criteria for allocation [of resources] should be flexible and adapted locally in response to available resources’. However, an age limit for ICU may ultimately need to be set, which it was. Furthermore, along with age, the functional status and comorbidities of the patient should be sensibly assessed [13]. Thus, for those under the age of 75, the comorbidities and functional status of any critically ill patient were evaluated.

Applicability

The proposed framework offers a universally applicable approach to evaluating the allocation of medical resources. There have been numerous proposed frameworks, for instance, implemented in the State of New South Wales (‘NSW’), Australia, with regards to the allocation of resources in a pandemic that are based upon utilitarian principles [14], while others also seem to take a personalist approach by stating that allocating medical resources should be performed fairly, ‘according to medical need and each patient’s capacity to benefit’ [15]. However, it is important to recognize that the ontological personalist framework should not be applied dogmatically, as practical considerations and other factors may influence its feasibility.

For instance, the time in which a health practitioner must allocate a resource between two competing patients may be of the essence and they may not be able to apply this framework adequately as there is insufficient time to obtain the relevant information. Therefore, the proposed framework should be seen as a guide, not a mandate, and should only be used in circumstances that allow for its implementation. For instance, two patients, both infected with COVID-19, are admitted to hospital for respiratory failure. If either patient does not receive a ventilator within the next few minutes, they will die. However, given time constraints, there is not enough time to undertake proper medical due diligence of each patient to check for any comorbidities. In this instance, this framework cannot be adequately applied.

3. Assessing Ethical and Legal Dimensions of Resource Allocation in Healthcare

While numerous frameworks are employed for resource allocation [16], this analysis will specifically critique the utilitarian approach, which was applied in Italy during the scenario discussed above. It will then propose an alternative personalist framework to address the Problem. There have been numerous journal articles both critically citing Italy as a case study and favoring their methodology for resource allocation amid a pandemic [17], but none have used Italy as the central case study while analyzing, critiquing, and offering an alternative approach to resource allocation. However, there have been some articles written focusing on criteria that take age as an arbitrary criterion and have offered an alternative approach [18]. This alternative approach will enforce a personalist position to medical ethics, endorsing an ontological personalist [1] framework that is based on the primary ethical principle that all human beings deserve respect [19].

Respect can mean different things to different people, because it can be difficult to define [20]. Beach et al. note that a physician shows respect to their patients when respecting the autonomy of patients [21]; respect is given independent of a patient’s idiosyncrasies, is shown equally to all patients, believing that patients have ‘value’ [21] and acting in harmony with this conviction. This account of respect is the ‘recognition of the unconditional value of patients as persons’ [21].

A study undertaken by Dickert and Kass highlights that a patient’s perspective of what constitutes respect is not dissimilar to the aforementioned view. Dickert and Kass undertook a qualitative study with eighteen survivors of sudden cardiac death and concluded that patients believed that respect involves seven elements: dignity, attention to needs, autonomy, empathy, care, recognition of individuality, and information provision [22]. Approaching a similar conclusion, the Auckland District Health Board surveyed 2838 inpatients where they stated that respect contained (a) being treated with compassion and care; (b) being polite and courteous; (c) having their dignity and privacy actively respected; and (d) having their perspectives listened to and taken into account [23]. However, being provided with respect does not mean that the practitioner must provide the patient with the treatment they desire. This proposed framework balances respecting the patient and their autonomy while also simultaneously respecting the freedom of the practitioner to make a conscientious objection. This principle will be discussed later.

Like the notion of respect, there are various forms of personalism, making it difficult to define [24]. However, this paper will use ontological personalism, a philosophy that demonstrates the objective value of the person based upon the person’s ontological structure [25]. It is acknowledged that age is not entirely excluded from considerations of how and to whom resources should be allocated. However, this paper contends that age should not be used as the sole criterion for making allocation decisions.

This proposed framework incorporates the concept of the futility of care. Consequently, this section will evaluate the issue of the ‘futility’ of treatment from a legal perspective, examining relevant laws and health policies in Australia that may provide guidance for decision-making. The rationale for using Australia as a standard is based on its established legal framework that emphasizes ethical considerations in healthcare, which can offer valuable insights for critiquing Italy’s approach and supporting the framework’s principle of ‘need’. If providing futile treatment is deemed outside the standard duty of care as outlined in applicable laws or policies, this justification supports the framework’s stance on not allocating resources under such conditions. Additionally, critiques of utilitarianism will be framed not only legally but also theologically and philosophically, acknowledging that ontological personalism serves as a philosophical foundation rather than a strictly theological one.

4. Utilitarianism and the Respect for Persons Principle: An Incompatibility Analysis Defining Utilitarianism

The ethical theory of utilitarianism can be understood and applied in a variety of ways. Generally, utilitarianism is the view that the morally correct act is the act that creates the most good. The founder of utilitarianism, Jeremy Bentham, argued that what constitutes a ‘good’ can vary within a utilitarian framework [26]. For instance, the ‘good’ can be seen in terms of pleasure, happiness, freedom, love, fairness or justice, virtue, life, and so on [27]. However, concerning humans, human life, and society, the ‘good’ refers to saving a human life. Therefore, maximizing the number of human lives saved (or the years of human life saved in total), the good, is the desired outcome according to utilitarianism [28]. In other words, ‘act in such a way as to generate the maximum quantum of well-being, happiness, or utility’ [28] (p. 2). Utilitarianism is a form of consequentialism [29], a theory that holds that we should do what has the best consequences [30]. This paper will focus on utilitarian consequentialism, because this was the theory used when allocating resources in Italy.

Advocates for this view hold that one must choose the act that produces the most good for all persons affected by that act. This perspective comes from two connected ideas that are fundamental to utilitarianism. Firstly, an act is correct when, compared to other opposing options, it creates the maximum possible equilibrium of good consequences or the minimum amount of possible bad consequences. Secondly, the ideas of right, responsibility, and duty are secondary to, and are determined by, that which creates the greatest quantity of good [31].

4.1. Italy and Utilitarianism

By implementing an age limit for resource allocation, hospitals in Italy adopted the utilitarian principle of maximizing ‘benefits for the greatest number of people’ [1]. This approach was highlighted by Vergano, who noted that the committee supported ‘clinical reasonableness’ alongside a utilitarian strategy in addressing resource scarcity [3].

The central issue here is why age was selected as a key criterion. Insights from SIAARTI shed light on this decision: they suggested that ‘an age limit for the admission to the ICU may ultimately need to be set. The underlying principle would be to save limited resources which may become extremely scarce for those who have a much greater probability of survival and life expectancy, to maximize the benefits for the largest number of people’ [1]. Although the guidelines did not recommend that age alone should be a factor influencing resource distribution, the committee recognized that an age limit for ICU admission may need to be established [3] (p. 1873). Vergano further explained that the elderly and frail might struggle with the prolonged intubation required to recover from COVID-related pneumonia [3] (p. 1875). As Rosenbaum observed, prioritizing ventilatory support for patients with a low likelihood of survival meant that many others with a better prognosis were denied necessary support [3] (p. 1875). The reasoning can be seen as follows:

P1. Anything that aims to maximize utility for the greatest number of people is a form of utilitarian consequentialism;

P2. The SIAARTI guidelines aim to maximize utility for the greatest number of people;

P3. Therefore, the SIAARTI guidelines are a form of utilitarian consequentialism.

Ultimately, the guidelines used the utilitarian methodology of the maximization of benefit for the greatest amount of people [32].

Grover, McClelland, and Furnham noted that the mortality rates for COVID-19 are greatly elevated for susceptible populations, specifically persons over 80 years of age and those with underlying health issues [33]. As a consequence, due to the scarce supply of ventilators, physicians in some of the hardest-hit regions of Italy prioritized providing younger patients with ventilators, on the basis that their prognosis was more favorable [3] (p. 1873). Therefore, a solely age-based approach was used to allocate resources due to the high probability of the younger patients surviving. In this way, this approach ensures that the resources allocated are used most efficiently because the patients who were provided with the resources had a higher probability of surviving than their elderly counterparts.

Additionally, the use of age as a primary criterion for resource allocation was influenced by the correlation between comorbidities—such as cardiovascular disease, diabetes, and immunocompromising conditions—and higher COVID-19 mortality rates, which are more common among older individuals [34]. Furthermore, the age-based cut-off was justified by the principle of maximizing the years of life saved [35]. Prioritizing younger patients was viewed as a means of granting them the opportunity to experience more of life’s milestones—such as infancy, adolescence, middle age, and old age [36]. The rationale was that these patients, having had less time to live, would benefit more from the resources allocated, not necessarily due to utility or social value but because they had experienced fewer life stages.

Therefore, given the assumption that older patients have a higher COVID-19 mortality rate, providing them with a resource seems counterproductive when incorporating the utilitarian principle of the ‘maximization of benefit for the greatest amount of people’.

4.2. Critique of the Utilitarian Framework for Resource Allocation in Italy

4.2.1. Moving Away from a Deontological Stance

The SIAARTI recommendations were met by strong disapproval by theologians, physicians, journalists, and members of the public [37] because the recommendations moved away from Italy’s medicine’s customary deontological attitude that all lives should be valued and all sick people should be assisted as endorsed by the Italian Medical Association [38]. Deontological ethics, defined as the moral philosophy that emphasizes the inherent value of individuals and their rights to equal access to lifesaving treatment, highlight that each individual is valuable and should have equal access to receiving lifesaving treatment [39].

From a deontological viewpoint, a utilitarian approach in achieving the maximum benefit may lead to infringements of individual rights or discrimination [39]. Therefore, a deontological approach views the age-based criterion to resource allocation, as endorsed by hospitals in Italy, as discriminatory since it ‘views elderly persons as a means to an end rather than individual agents’ [40].

In early April 2020, the Italian National Committee for Bioethics (‘INCB’), Italy’s governmental bioethics body, released a report disagreeing with those provided by SIAARTI [41]. ICNB argued that clinical judgment should be the only suitable criterion for triaging critically ill patients with COVID-19 [42]. Clinical judgment refers to the assessment of the success of the care under consideration—that is, in an instance where a ventilator is required for a patient with respiratory failure, success could be measured on the basis of survivability—and the clinical need of the patient [41]. ICNB went on further to say that triaging on the foundation of a ‘predetermined class’, including social status, gender, age, ethnicity, and disability is discriminatory and ethically intolerable [43].

In April 2020, the ICNB issued an opinion titled Clinical Decision-making in Conditions of Resource Shortage, in which they argued that a particular age-based form of triage can be morally justified only in ‘exceptional’ circumstances. The opinion referred to triage for COVID-19 positive patients as ‘pandemic emergency triage’, to underscore the unique circumstances concerning the right to health and common care as preserved in the Italian Constitution. Article 32 of the Italian Constitution states, ‘the Republic safeguards health as a fundamental right of the individual and as a collective interest, and guarantees free medical care to the indigent’.

On this basis, the ICNB put forward two criteria for deciding how to allocate resources in a pandemic: first, clinical appropriateness, and second, actuality. The first criterion refers to clinical decisions comparative to the effectiveness of the treatment which is under consideration and to the clinical need of each patient. The ICNB stated that clinical appropriateness refers to the gravity of the onset of the pathology and the prognostic possibility of recuperation. The treatment must always be comparable. In other words, treatment must take into consideration the balance of risks and benefits for each patient, reviewed from the perspective of both the objective and subjective clinical aspect (assessment of the intrusiveness of treatments, assessment of pain and suffering, etc.).

The ICNB noted that age is a parameter that is taken into account given the relationship with the current and predictive clinical assessment, but it is not the sole or main factor. Priority should be determined by assessing, based on the aforementioned factors, the patients for whom the treatment can be rationally more effective, in that it ensures ‘the greatest chance of survival’ [42]. The second criterion takes into consideration the revisability of the clinical decision which may be necessary under emergency circumstances [41].

4.2.2. Incompatibility with the Respect for Persons Principle

Utilitarian moral frameworks are frequently criticized for aiming to maximize usefulness at the cost of respecting persons and thus not incorporating the notion of shared accountability [44]. However, there has been some attempt to argue otherwise [44]. For instance, one approach to a utilitarian utilization of the respect for persons principle argues that utilitarianism is a process for cumulative individual preferences and needs that provides the same influence to the claim of each person and treats them with equal concern and respect [44].

Utilitarianism takes into consideration each individual’s claim, but it prohibits any one claim taking priority over others. Instead, a utilitarian approach counts each individual claim ‘for one, and no one for more than one’ [45]. This concept is important because it argues that a utilitarian framework does take each individual claim-need seriously. However, it does not do so at the cost of prioritizing the claim-needs of one over another—to ensure equality and respect. However, this conception of utilitarianism is founded on an impecunious formation of respect for persons. The basic understanding is that we show respect for people by guaranteeing that their interests are treated alike irrespective of whose interests they are [46].

The utilitarian framework used in Italy did not follow the respect for persons principle because it did not take into consideration the claim-need of each patient. Instead, it allocated resources based solely upon an ageist framework. Regardless of the individual health needs of the patient, insofar as a patient did not meet the age criterion set, they did not receive a healthcare resource. Therefore, the claim-needs of those over the age threshold were not considered and thus were not ultimately respected in any meaningful manner.

To assess whether a framework has sufficiently followed the respect for persons principle, two methods can be used. First, how the framework assesses the individual claims made on the available resources can be determined—as briefly outlined earlier—and second, the criteria used to make decisions about resource allocation can be assessed.

Assessing Individual Claim-Needs

A framework that incorporates the respect for persons principle does not take a cumulative approach. A cumulative approach refers to the adding together of morally relevant factors such as well-being, desire satisfaction, claims or reasons into an objective value [47]. This paper will use the term ‘cumulative’ to refer to the accumulation of individuals’ claims into a faction claim. Cumulation is a means of maximizing the good fashioned by resource distribution, and some have argued that this approach should be undertaken when distributing lifesaving resources [48]. Cumulation is the approach of utilitarianism.

A cumulative approach to resource allocation does not respect the separateness of persons because it joins individual claims together into faction claims and manages individuals as if their interests were able to be embodied into collective interests. As Rawls noted, in utilitarianism, ‘many persons are fused into one ’…‘ [the] gains and losses of different persons [are balanced] as if they were one person’ [49]. The main goal of moral concern draws its attention to the maximization of the good; however, this lacks deliberation of the individual claims of persons.

Incorporating the ethic of shared accountability requires that we make ourselves accountable to each patient who requires our assistance. Particularly, it should be understood how each patient’s need compares to every other patient’s need [50]. Persons who are prioritized in receiving a healthcare resource should have the strongest individual claim, as opposed to the strongest collective claim. An ethic of shared accountability does not account for cumulative considerations in the decision-making process, as cumulation fails to respect persons as separate [51].

A utilitarian counter objection could nonetheless respond that a cumulation of individual claims is possible without violating the respect for persons principle. Instead, we can respect persons if we provide their claim with suitable consideration when choosing whose claims to meet. In other words, in the event there are two competing individual claims, insofar as each claim is provided with sufficient consideration, as opposed to instant dismissal, then each claim-need has been appropriately respected. Therefore, due consideration can be provided to individual claims while aggregating the individual claims.

Although cumulation indeed takes into consideration the claims of individual persons, it does so in a manner that is irreconcilable with a second-personal commitment to human dignity concerning moral claims. Cumulation joins individual claims into group claims, and treats individuals ‘as if their interests were subsumable into group interests’ [46].

In Italy, an aggregate (cumulative) approach was used based upon age—those older than a particular age, and those younger. Rather than assessing the individual claim-needs of each patient, patients were grouped by age. Therefore, this cumulative approach to allocation failed to respect the separateness of persons [46]. This approach does not take into consideration the second-personal element of human dignity, the ability to demand respect. Instead, the claim-needs of persons are treated as a ‘fact, norm, or value’ as opposed to a ‘private deliberation’ [52].

Under an aggregation or utilitarian framework, people’s claim-needs are engaged with as if they were ‘utils’ that could be aggregated rather than assessing each individual’s claim-needs. Notably, when the claim-needs of persons are assessed in context, it becomes evident that it is crucial to each patient ‘that he rather than someone else lives’ [53]. Thus, a problem arises when aggregating the interests of different patients for the purposes of allocating resources, as the utilitarian approach in Italy did.

Criterion of Need

The second manner in which the utilitarian concept fails to reconcile with a respect for persons approach is its inability to adopt a criterion of need—a concept that will be expounded upon later on in this paper. In other words, people make a claim on lifesaving care when they are in circumstances where their life is in danger and they need the distribution of medical treatment. Interventions in this situation are based upon their health needs. Given their bad state of health, their claim has moral force [46] (p. 397). However, this claim-need was ignored with the framework used in Italy, because they focused on the age of the patient, rather than their individual need. For this reason, the utilitarian approach used in Italy is incompatible with the respect for persons approach as espoused in this framework. Furthermore, another critique of the approach used in Italy is the factor used as the determining indicator of resource allocation—age. While frailty is often associated with older age, purely age-based criteria are frequently inaccurate, as younger people can also present with frailty, and many older people are healthy and robust [54]. The correlation between polymorbidity and age is far from perfect, due to the heterogeneity of aging [55].

In conclusion, utilitarianism is understood and implemented in numerous ways. However, it can be generally understood that the morally correct act is the act that creates the most good. The ‘good’ under examination in the utilitarian consequentialist framework used in Italy is the maximization of the number of human lives saved.

However, the issue with this framework is that it does not show adequate respect to each person, nor does it implement a criterion of need or assess each individual’s claim-needs. Instead, an ageist approach was used to allocate healthcare resources. If a person did not meet the age limit set, they were not provided with the appropriate resources; no other factors were taken into consideration. Furthermore, this utilitarian approach moved away from Italy’s traditional deontological attitude as endorsed by the Italian Medical Association.

5. The Ontological Personalist Framework

This article introduces an alternative framework for resource allocation in the context of a pandemic, grounded in an ontological personalist perspective. The discussion begins with a definition of personalism, followed by an exploration of ontological personalism and its relevance to the current situation. The article then details the proposed framework and its application.

5.1. What Is Personalism?

There are various different versions of personalism and for this reason, it is difficult to define as a theological and philosophical theory. Many schools of philosophy have one prominent thinker, or central work, at their core that constitutes a canonical standard. Personalism, however, is a more subtle and diverse school of thought and has no such familiar point of reference. It is thus better to speak of personalism in the plural, rather than the singular. Jacques Maritain commented by writing that there are ‘a dozen personalist doctrines, which at times have nothing more in common than the word ‘person’ [56].

Foundational to personalism is the emphasis upon the dignity and ultimate reality in personhood—human and, to most personalists, divine. This theory accentuates the importance, distinctiveness, and inviolability of the human person, in conjunction with the person’s relational or social dimension. Personalists hold that the human person should be the epistemological and ontological origin of philosophical deliberation [24]. This theory investigates the status, experience, and dignity of the human being as a person, and considers this as the inception for all philosophical exploration [24]. Furthermore, personalism is centered on our universally shared human nature and its primary ethical principle is the concept that all human beings are worthy of respect [57].

5.2. What Is Ontological Personalism?

Ontological personalism is an anthropological theory which protects the objective worth of the human person based upon their ontological status. The human person is endowed with reason, freedom, and awareness and is of special value, above that of other creatures. The human person is the foundation and guiding point of what is right and wrong. This philosophical view acknowledges the objective value of the human person and, therefore, the ethical principles derived from it will always be subject to, and cater for, every human life [58].

As noted by Giglio, ontological personalism should be differentiated from other varieties of personalism such as existential, hermeneutical etc., in that it focuses on human dignity according to what the person is, and not simply on activities that they develop during their lifetime. It is not within the scope of this paper to articulate the differences between the various types of personalism in comparison to the chosen personalist approach. Sgreccia explains that ontological personalism asserts ‘that there is an existence and an essence, a body-soul composite, at the foundation of subjectivity itself … In man personhood consists in an individuality constituted by a body animated and structured by a spirit’ [59].

5.3. Why Ontological Personalism?

The reason for choosing a personalist framework is because it takes a ground-up approach to ethical dilemmas as opposed to a top-down approach. That is, this framework focuses on the individual as the reference point, rather than focusing on other factors such as maximizing social benefits and population outcomes [60]. This is a nonutilitarian view that emphasizes the paramount value of each human life [17]. Ontological personalism also has strong applicable characteristics because it provides a suitable framework to bioethical issues to human beings such as euthanasia, abortion, organ transplantation, etc. [61]. In this case, it will be applied to the just allocation of resources in a pandemic.

6. Particulars of the Proposed Framework

This particular approach offers a set of principles to direct the ethical assessment of resource allocation in harmony with the protection of human dignity and life [25]. The ethical principles resulting from ontological personalism are applicable to every human life. From conception until death, in every circumstance of health or anguish, the human person is the ‘reference point and standard for distinguishing licit from illicit’ [59] (p. 58).

These principles can be applied in a pandemic environment as well as in contexts where they may not be present. For the purposes of this paper, the focus will be on applying these principles within the context of COVID-19, specifically addressing the challenges of resource allocation. It is important to acknowledge that due to the scarcity of resources, these principles may encounter limitations. In situations where critical resources are in short supply, difficult decisions must be made, which could mean prioritizing one individual’s access to lifesaving interventions over another’s.

This reality underscores the complex interplay between ethical principles and practical constraints in pandemic resource management. Nonetheless, the dignity of each person will be taken into consideration when deciding who to offer the lifesaving resource to even though this ‘dignity’ by way of saving their life could not be protected.

There are two characteristics of personalism. First, all the principles submit to a distinct anthropological theory, the protection of the person’s physical, mental, and spiritual well-being. The second is that all the other principles are regarded as results of this core feature [21] (p. 695). Furthermore, the four personalist principles, as articulated by Sgreccia, are the principle of (a) inviolability; (b) totality or therapeutic (c) liberty and responsibility; and (d) sociality and subsidiarity [59] (p. 58).

6.1. Four Principles of Personalism

1.

The Principle of Inviolability

This principle involves respect for each human life which is inviolable and inalienable from the moment of conception and until natural death. Physical life is the most imperative observable object—this concept leads all the other principles and values. Thus, any reduction on the value of human life is an offence to human dignity [61].

2.

The Therapeutic (or Totality) Principle

The totality principle classifies the circumstances of the ethical permissibility of medical intervention on human life. As Coupland summarizes, medical intervention follows the following principle: ‘acting on the part where the disease is located to save a healthy organ, where there is no less invasive nor less destructive therapeutic action, given there is a reasonable likelihood of success, and having obtained the patient’s informed consent’ [61].

3.

The Principle of Liberty and Responsibility

Within the personalist framework, the principle of liberty and responsibility, or autonomy, cannot be universally applied because it is limited by the principle of respect for physical life and improved by the liability resulting from freedom. In contrast to the patient’s principle of autonomy, the physician’s liberty is recognized, thus allowing for the right to conscientious objection [61].

4.

The Principle of Sociality and Subsidiarity

In terms of public health policies, and for the purposes of this paper, a framework used to allocate resources, this principle is the most relevant. It states that the common good is achieved through the good of individuals. ‘Common good’ entails collaboration to encourage circumstances that improve the prospect for the human flourishing of all people within society [62].

If there is a conflict between the common good and individual good, the principles above assist in making a decision. According to the principle of sociality, human life and health are personal but they are also social goods. On the other hand, the subsidiarity principle is concerned with the allocation of resources and the coordination of healthcare policies. This principle necessitates that all members of the community, wherever achievable, are provided with equal access to treatments and resources that are available and necessary. Therefore, the approach to healthcare policies is based on solidarity, the condition of urgency, proportionality of treatment, and causal selection [61].

6.2. Respect for Persons

A portion of this framework, concerning the respect for persons principle, was developed by Xavier Symons [46] and Stephen Darwal [52] to approach the just allocation of resources. Similarly to Symons, this paper does not intend to offer a complete account of the framework, nor does it intend to overemphasize its implication in offering guidance for resource allocation [46]. The paper uses this framework to approach the Problem as it provides a counter-narrative to the utilitarian approach to justly allocate resources in a pandemic. As argued by Symons, a utilitarian framework that centers on the maximization of life-years saved is irreconcilable with this framework [46]—as demonstrated in the previous section.

The concept of respect for persons is rooted in our common human nature [63] which provides us with ‘the authority to make claims and demands on one another as free and rational agents’ [52]. Persons do not gain respect because they are free and rational beings, but because they possess the ability to demand respect [46] (p. 394), which is a second-personal element of human dignity [52] (pp. 13–14). In other words, respect is based on inherent dignity and is not something earned. As Darwall explains, ‘dignity is not just a set of requirements with respect to persons; it is also the authority persons have to require compliance with these requirements by holding one another accountable for doing so’ [52] (p. 14).

However, while this is a sufficient condition, it is not a necessary one. This does not preclude showing respect for those who do not possess this ability; for instance, severely cognitively impaired children or the elderly with advanced dementia. Even if they cannot converse with us as moral counterparts, the norms for respect for persons are ‘in force’ in our moral community, and these norms ought to preside over actions irrespective of whether they are specifically stated by persons [46]. Darwall writes: ‘respect for others thus involves making oneself accountable to others as equal persons, rather than simply taking account of any fact, norm, or value about one another as persons in our own private deliberations’ [52] (p. 137). Thus to respect someone is to provide sufficient importance to the fact that they are persons [64].

Darwall states that we are obligated to show respect for persons whether or not they request this of us. The standards of respect for persons, he proposes, are prevalent in our moral community, and these standards should oversee behavior irrespective of whether they are explicitly stated by persons. He notes:

• [I]t takes neither an explicit actual demand nor a demand that is implicit in actual human beings prone to make it, either individually or collectively, in order for a claim or demand to be in force. The demand is made by the ‘moral community’ and by all of us insofar as we are members [52] (p. 65).

As summarized by Symons, we respect persons by recognizing their ability to converse with us as moral counterparts [46] (p. 395). In other words, irrespective of whether a person makes an explicit claim-need, in this instance, the need for a healthcare resource, the ‘moral community’ has an obligation to take each person’s claim-need seriously because each of us form part of this community. Therefore, establishing an age-based approach to resource allocation fails to take seriously, if at all, the claim-need of each person, because those who do not fit the age-criterion have their claim-needs quashed. However, in the proposed framework, each person’s claim-need is taken into consideration, irrespective of the person’s age.

6.3. Criterion of Need

In conjunction with the respect for persons approach, this framework will also integrate a criterion of need. It is important to recognize that the therapeutic (or totality) principle encompasses this concept, addressing the necessity of prioritizing resources based on the level of need. Numerous criteria have been proposed for healthcare resource allocation including factors such as desert [65], utility [66], and age [67] However, these criteria do not discuss the basic substance of the claims that people formulate on lifesaving healthcare resources, which surrounds a claim of need. Therefore, a criterion of need is an appropriate criterion to utilize when allocating healthcare resources.

At a minimum, we should desist from assigning lifesaving resources to persons who cannot profit from receiving this resource. In effect, a person who will not profit from the allocation of the scarce resource has no significant need for that resource. Arguably then, a patient must benefit in such a way that offsets balancing concerns such as the yoke of treatment. That is to say, the benefit received must outweigh the consequences suffered, be they physical or otherwise [68]. This requirement is the bare minimum for the allocation of resources in a pandemic and to be clinically suitable or medically designated.

Thus, in a sense, there is a synonymous relationship between the capacity to benefit/the concept of the futility of care and a dimension of need that is integrated into a ‘Darwallian approach’ to the allocation of resources [46]. This paper will therefore also explore the concepts of the principle of need and the concept of the futility of care.

In conclusion, a personalist framework was chosen because it focuses on the individual as the reference point, rather than focusing on other factors such as maximizing social benefits and population outcomes, places emphasis on the paramount value of each human life, and has strong applicable characteristics to bioethical issues. This framework uses the four principles of personalism, in conjunction with the underlying notion of respect for persons and a criterion of need to provide an alternative approach to resource allocation amid a pandemic.

7. Application of the Personalist Framework

This section will apply the proposed personalist framework to the below hypothetical scenario:

Two persons—P1 and P2—are admitted into the hospital for respiratory issues as a result of COVID-19. Both patients require a ventilator and without it, they will die. However, the hospital has only one ventilator that can be allocated.

P1 is seventeen years of age and is diagnosed with stage 3 small-cell carcinoma.

P2 is seventy years of age and has hypertension, type 2 diabetes, and a heart murmur.

Both patients have requested a ventilator (‘claim-need’).

7.1. Respect for Persons

Given that personalism bases its primary ethical principle upon the concept that all human beings are worthy of respect [57], P1 and P2 will be provided with the appropriate level of respect. This is demonstrated by providing equal weight to the claim-need of each patient. The respect given to P1 and P2 is not contingent upon a particular characteristic but simply because they are human beings. Unlike the framework used in Italy, care is not provided based solely on age. Therefore, the age of each recipient is not the sole characteristic taken into consideration when providing them with respect or in resource allocation.

This framework holds us accountable to both P1 and P2 to ensure that their demands for the appropriate resource are taken seriously, because their claim-need has moral force given their bad state of health [46] (p. 397). As such, all the circumstances (where timely and appropriate) will be taken into consideration when deciding who to provide with a resource. This includes age, underlying health, functional status, and co-existing comorbidities, assessing the short-term and long-term outcomes of the treatment offered and the futility of care.

7.2. Four Principles of Personalism

• The Principle of Inviolability

Unlike the framework used in some hospitals in Italy, neither patient’s age is the deciding factor for the allocation of resources: in this case, a ventilator. This is because this framework incorporates the belief that every patient, despite their age, has dignity which does not diminish with age. Any reduction in the value of human life is an offence to human dignity in this framework [61].

2.

The Therapeutic (or Totality) Principle

This principle invokes the criterion of need/futility of care concept. Given the above characteristics of the patient, a ventilator will not be automatically provided to P1 simply because he is younger. Instead, it is important to consider the health needs of each patient and base the decision on these grounds [46] (p. 398). From the above, although P2 has numerous health issues—hypertension, type 2 diabetes, and a heart murmur, when compared to P1’s diagnosis of stage three small-cell carcinoma, it changes how this issue is addressed.

Given that COVID-19 has been known to cause acute respiratory failure consistent with acute respiratory distress syndrome [69], P1’s underlying health condition triggers the concept of the capacity to benefit/concept of the futility of care. This is because even if P1 receives the ventilator and survives the issues relating to COVID-19, they still have an underlying terminal illness that has placed them at the end stages of life.

This framework suggests that we should desist from assigning lifesaving resources to persons who cannot profit from receiving this resource. That is, lifesaving resources should not be provided to patients with an illness that, even if this particular resource aids them in recovering from this particular medical difficulty—for instance, for a ventilator for respiratory problems—they still have a condition whereby they are at the end stages of their life cycle. It seems futile to provide P1 with a ventilator given his condition. Therefore, on the balance of competing needs, a ventilator should be allocated to P2 given they would benefit from the resource offered.

3.

The Principle of Liberty and Responsibility

Both patients have the right to autonomy as such; they have both expressed their claim-need of requiring a ventilator to survive. However, this principle also recognizes the physician’s liberty and thus allows for the right to conscientious objection [61]. In other words, even if the patient would like to undertake a particular treatment, thus expressing their autonomy, the physician has the right not to perform that treatment on conscientious grounds.

Given the circumstances, a physician may decline to provide P1 with a ventilator on conscientious grounds because providing P1 with a ventilator would cause the consequent death of P2. And since the treatment offered to P1 is futile, it seems redundant to provide P1 with a ventilator. Therefore, a doctor may decline to fulfill the claim-need of P1 on the grounds of the futility of care in conjunction with a conscientious objection to provide P1 with a resource knowing that P2 would die as a result. The doctor understands that there are two lives that require this lifesaving resource. Although the circumstances deem that only one may survive, at least temporarily, the doctor also takes into consideration the effectiveness of providing the treatment to either patient. The doctor believes that providing P1 with a ventilator would be deemed as futile treatment; however, if P2 is provided with the same resource, this treatment is not rendered futile.

It is on this basis that the doctor cannot conscientiously bring about the claim-need of P1 because he knows that providing P1 with the ventilator is futile and given that it would be at the expense of P2’s life, he cannot, in good conscious, prioritize P1 over P2, because P2 would die for unjustified reasons, in his view.

4.

The Principle of Sociality and Subsidiarity

This principle follows the ‘common good’ approach, which is reflected in individual human flourishing. Ideally, this framework would uphold the dignity of both patients by allowing both to flourish. However, given the circumstances, this is not possible. The issue of resource scarcity means that the life and dignity of all human beings cannot be protected. However, the dignity of both P1 and P2 is still upheld because both their circumstances are taken into consideration when deciding who to allocate the ventilator to.

P1 and P2 both have equal access to treatments and resources that are available and necessary; this invokes the subsidiarity principle, and given that the life of P1 and P2 are not just of personal importance, but social importance too (principle of sociality), it is thus crucial to ensure that one patient does not benefit at the expense of society. For instance, although P1 will benefit temporarily from attaining a ventilator by prolonging his/her life, this would be at the expense of P2 whose benefit far outreaches that of P1. Thus, if it was standard practice to prioritize patients in P1’s position over that of P2, then the ‘common good’ would be impeded upon because the benefit of receiving this resource is only temporary, while human flourishing is greatly increased if P2 were to be provided with the required resource.

8. The Concept of Futility in Care: A Case Study of Australian Law

Some commentators have noted that there is no consensus on the definition of ‘futile’ [70]. Nonetheless, various guidelines provide their own definition. Furthermore, it is important to also note that, like the word ‘futile’, the words ‘benefit’, ‘dignity’, ‘best interest’, and ‘unreasonable’ are largely undefined terms. The issue here, is, although these terms are commonly used, they are rarely defined and, therefore, they can be interpreted subjectively by the decision-maker.

Legally, if the terms are legislatively undefined, the rules of statutory interpretation require the reader to revert to the intention of Parliament at the time of creating the legislation [71]. Thus, the individuals who create policy for NSW require assistance to help them ‘interpret’ terms such as ‘futility’, ‘unreasonable’, ‘dignity’, ‘best interest’, and ‘benefit’ within the context of COVID-19 and resource allocation. According to a personalist approach, it is inappropriate to use an age cut-off approach. However, a personalist framework does view age as a relevant factor because there is nothing intrinsically immoral or unlawful in using age in a decision-making process.

The law provides very limited guidance on how to interpret these terms, and so any policy is assisted by a preamble or objects statement that makes it clear how these terms are to be interpreted for that document. It is outside the scope of this paper to argue for a specific definition of these terms. However, these terms should be defined using a personalist framework as its guiding principle.

• Australia’s National Health and Medical Research Council Guidelines states that ‘treatment is futile only if it produces no benefit to the patient (i.e., does not slow down the progress of disease, sustain the patient’s life, reduce disability and improve health, or relieve the patient’s distress or discomfort)’ [72].

The New South Wales Health Guidelines noted that futile treatment ‘offers no benefit or where the benefits are small and overwhelmed by the burden to the patient’ [73]. With respect to how to approach futile treatment, numerous guidelines propose that it should be avoided and falls outside the standard of care owed to patients.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) in its National Consensus Statement: Essential Elements for Safe and High-Quality End of-Life Care provides that non-beneficial treatment (also referred to as futile treatment) should be avoided for dying patients as it is deemed as an unnecessary burden:

Unnecessary burdens associated with medical treatment should be avoided for dying patients. For example, nonbeneficial and/or unwanted observations, surgical interventions, investigations, medications, and treatments should not be prescribed or administered [46].

The ACSQHC defined non-beneficial treatment as ‘interventions that will not be effective in treating a patient’s medical condition or improving their quality of life. … Non-beneficial treatment is sometimes referred to as futile treatment, but this is not a preferred term’ [74].

In a similar vein, the National Health and Medical Research Council in its guidelines titled Ethical Guidelines for the Care of People in Post-Coma Unresponsiveness (Vegetative State) or a Minimally Responsive State states that futile care may be categorized as being ‘overly burdensome’ and thus it falls outside the level of care for health and life that carers may be obliged to provide. These guidelines advise that futile treatment ‘ought neither be continued nor initiated’ [75].

Correspondingly, the New South Wales Government Department of Health (‘DOH’) takes a similar approach. In its guidelines on end-of-life care and decision-making, the DOH states that ‘health practitioners are under no obligation to provide treatments that are futile. That is, treatment that is unreasonable and offers a negligible prospect of benefit to the patient’s medical condition’ [72]. Queensland’s own DOH stated ‘that doctors are under no legal or ethical obligation to offer or attempt treatments that are considered futile; that is, medical treatment that potentially affords no benefit and would cause the patient harm’ [76]. This idea was echoed by the Australian Medical Association [68].

There are numerous cases dealing with the issue of the futility of care. Legal decisions have generally supported the idea that a physician is under no obligation to provide treatment that is ‘futile’. Grubb and Kennedy, commenting on Re J (A Minor) (1992) 4 All ER 614, noted that a patient cannot require a form of care which the doctor ‘in the exercise of reasonable medical judgment determines is futile, in that it will be of no benefit of any kind to the patient. As in all cases where a doctor has formed a reasonable and responsible clinical judgment that treatment is not called for, the law will not second-guess him by ordering him to provide the treatment’ [77].

In Brightwater Care Group (Inc) v Rossiter (2009) WASC 229, Rossiter, a quadriplegic, was dependent on others for all his needs. He could only take nutrition and hydration orally, but only through a percutaneous endoscopic gastronomy tube (‘PEG’). Rossiter wanted to end his life and asked the staff at Brightwater Care Group to cease providing him with the required sustenance, save for hydration to the extent necessary to allow the dissolution of the painkilling medication that he took. The court allowed for Rossiter’s request to be fulfilled.

A similar case was decided by the court in H Ltd. v J & Anor (2010) SASC 176, where J, a woman who was 74 years old, was diagnosed with type 1 diabetes and post-polio syndrome. J lived in a residential aged care facilities high-care unit of a residential home run by H Ltd. J required assistance for all her basic hygiene and toileting needs and was confined to a wheelchair. J wanted to end her life because her quality of life was no longer acceptable. She asked H Ltd. if they could withdraw from providing her with insulin, water, or food so that she may pass. H Ltd. asked the court whether it could comply with her demands. The Court, following a review of the decision in Brightwater Care Group (Inc) v Rossiter (2009) WASC 229, 153 held that H Ltd. has no legal obligation to provide J with the required sustenance.

Australian courts have also deemed futile treatment to not be in the best interest of the patient. In Messiha v South East Health (2004) NSWSC 1061, the patient, a 75-year-old man who had a cardiac arrest that caused his brain to be oxygen deprived for ca. 25 min, was unconscious and in a deep coma when he was admitted to the hospital’s intensive care unit. While he was receiving artificial ventilation, nutrition, and hydration, the health care team thought that withdrawing this life-sustaining treatment would be in his best interests. The family opposed this position and requested an injunction to oblige the health care team to maintain treatment. However, their request was unsuccessful because the court was convinced by the unanimous medical evidence from three physicians that continuing this treatment was not justifiable on medical grounds. Howie J held that it was not in the best interest of the patient to maintain the treatment [70] and that the withdrawal of treatment was allowed on the basis of futility [78]:

Apart from extending the patient’s life for some relatively brief period, the current treatment is futile … burdensome and … intrusive. The withdrawal of treatment may put his life in jeopardy but only to the extent of bringing forward what I believe to be the inevitable in the short term. I am not satisfied that the withdrawal of his present treatment is not in the patient’s best interests and welfare (see Messiha v South East Health (2004) NSWSC 1061, [27]).

This section has illustrated that physicians and other health care workers do not have a legal obligation to provide futile treatment, to the extent that some guidelines suggest not providing treatment if it is deemed to be futile because it is not in the patient’s best interest. Thus, the concept of the futility of care and its treatment under the law and healthcare policy supports the theory of ‘need’ that this framework adopts.

Given that the concept of futility is a well-used concept in both law and health guidelines, this justifies its use in the proposed framework in which resource allocation can be justly unallocated on these grounds. Unlike the framework used in Italy, this personalist framework does not exclude those from receiving a healthcare resource based upon age, but based on need and the futility of care—which is bespoke given the circumstances.

9. Conclusions

The examination of Italy’s age-based ventilator allocation during the COVID-19 pandemic highlights critical ethical and legal challenges in the face of resource scarcity. This utilitarian approach, focusing predominantly on age to maximize survival rates, raises profound concerns regarding equity and the respect for individual dignity. The emphasis on age as a sole determinant not only risks ageism but also fails to acknowledge the intrinsic value of each individual, regardless of their age or specific health circumstances.

This critique underscores the need for a more nuanced approach to resource allocation. The ontological personalist framework offers a compelling alternative by prioritizing human dignity and the intrinsic value of each person. This framework integrates the concept of the futility of care with principles of personalism, advocating for a balanced evaluation of medical need, potential benefits, and individual dignity. It ensures that each patient’s unique circumstances are considered, rather than relying solely on reductive criteria such as age.

The personalist framework’s application to the hypothetical scenario of P1 and P2 demonstrates its commitment to treating each individual as an end in themselves. By incorporating principles such as inviolability, therapeutic totality, liberty and responsibility, and sociality and subsidiarity, this approach fosters a more equitable and respectful allocation of resources. The principle of futility plays a crucial role in guiding decisions, acknowledging that while both lives are equally valuable, the likelihood of benefit from treatment must be assessed. Rejecting the purely utilitarian approach, the personalist framework affirms that resource allocation should reflect a deep respect for individual dignity and the capacity to benefit from treatment. This ensures that decisions are not merely driven by statistical optimization but are rooted in a profound commitment to the moral worth of every person.

In conclusion, the ontological personalist framework provides a robust and humane alternative to traditional models of resource allocation. It aligns ethical decision-making with the fundamental respect for human dignity and individual needs, offering a more compassionate and equitable response to critical healthcare decisions. As the world continues to navigate the complexities of pandemic responses, this approach serves as a vital counter-narrative, advocating for a just and respectful treatment of every individual, irrespective of broader utilitarian calculations.