Who should get the last NICU bed, according to the public?
When forced to choose which critically ill newborn gets the only intensive-care bed, ordinary people overwhelmingly chose to save the baby with the better prognosis, except when the difference between babies was tiny.
Source
The Intensive Care Lifeboat: a survey of lay attitudes to rationing dilemmas in neonatal intensive care
Study at a glance
- Design
- Cross-sectional — Online survey of lay adults answering repeated hypothetical rationing dilemmas that varied one prognostic factor at a time, plus veil-of-ignorance and lifeboat versions.
- N
- N=109 · Adult Mechanical Turk respondents who completed the questionnaire; the lifeboat item was answered by a subset (88 of 90 chose to save five).
- Population
- Lay members of the public, mostly from the US, recruited online
- Outcome
- Choice between admitting the infant with the better outcome (utilitarian) or tossing a coin (egalitarian) when only one intensive-care bed is available
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What they did
Adults recruited online answered 20 hypothetical rationing scenarios in which two newborns differed in chance of survival, severity of future disability, life expectancy or treatment cost. For each they could admit the infant with the better outcome (scored utilitarian), the worse outcome, or toss a coin (scored egalitarian). Two scenarios were repeated behind a 'veil of ignorance' (one of the infants might be their own future child), respondents answered the classic lifeboat case of saving five versus one, and they completed empathy, need-for-cognition and political-conservatism scales.
What they found
Respondents were strongly utilitarian: in all but one scenario most chose the infant with the better prognosis or cheaper treatment, and utilitarian choices rose as the gap between infants grew. The exception was a one-year difference in life expectancy, where most preferred a coin toss. Answers behind the veil of ignorance did not differ from the ordinary versions, and 98% of those answering the lifeboat case chose to save five rather than toss a coin. Empathy, need for cognition and political views were unrelated to choices, while being a parent or female was linked to some egalitarian answers.
The limits
What it doesn't show
Public intuitions cannot settle what is actually just; the authors say the data feed reflective equilibrium rather than yield normative conclusions. The sample was a small online Mechanical Turk group that may not represent the wider public, and the survey did not ask why people chose as they did, so answers may be quick first reactions sensitive to wording. Scenarios gave both infants equal need, so prioritarian intuitions (favouring the worst off) were not tested, and single-variable comparisons are less realistic than real triage.
Key terms
- Utilitarianism (in allocation)
- Directing scarce treatment where it will produce the most total benefit, e.g. to the patient with the best prognosis.
- Egalitarianism (in allocation)
- Giving equal claims equal chances, for example by lottery or first-come first-served.
- Prioritarianism
- Giving extra weight to benefits for those who are worst off.
- Veil of ignorance
- Rawls's device of choosing rules without knowing which position you will occupy, meant to remove bias.
- Reflective equilibrium
- A method of adjusting principles and case judgements against each other until they fit together coherently.
Flashcards
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Quiz yourself
In the survey, choosing to toss a coin between two infants was classified as:
Common questions
If most people are utilitarian, does that mean utilitarian rationing is right?
No. The authors stress that what people believe cannot by itself tell us what is just, but it can inform debate and democratic legitimacy.
What did the veil-of-ignorance test show?
People imagining their own future child in the scenario still chose the better-prognosis infant, which supports the prediction that choosers behind the veil would maximise survival chances rather than use a lottery.
Why did people toss a coin in one scenario?
When the babies differed by only one year of expected life, most chose a lottery, perhaps judging the gain too small to override equal chances or doubting such precise predictions.
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