Could Frailty be a Fair Fit for Healthcare Resource Allocation?

Abstract

Recently in New Zealand frailty has been proposed as a possible determining factor for use in healthcare resource allocation. Frailty is known to relate to vulnerability, an individual’s risk of ‘adverse outcomes’ when subjected to stressor events. The rationale is that by considering frailty decision-makers will be able to protect vulnerable individuals from poor health outcomes, enabling better care. This thesis uses ethical and philosophical analysis to address whether frailty can play a role in fair healthcare resource allocation, and the conditions that need to be met in order to do so. This thesis has several sub-questions. First, what principles should guide the use of frailty within healthcare resource allocation, in order to mitigate any possible risks or objections? Second, can frailty be defined in a way that supports fair allocation? Third, can frailty be identified in practice in a way that supports fair allocation? Regarding the first condition, we require a process by which to employ frailty as a determining factor, promoting fair allocation. Drawing on political philosophy, this thesis takes up Norman Daniels’ (2008) interpretation of the Rawlsian theory ‘Justice as Fairness’ and the Accountability for Reasonableness framework. It is argued a fair process lies in the principles based upon procedural justice. Through this, irrespective of the decision, a fair-minded individual would see the decision-making process as sound. In terms of the second condition, there is no consensus in terms of a conceptual or operational definition for frailty. I highlight that each definition in use is informed by the views and singular purpose of its author(s). This thesis then provides a definition of frailty designed to support fair healthcare resource allocation. The third condition requires a fair identification method to support the role of frailty within healthcare resource allocation. Again, the literature demonstrates that there is a lack of clarity and precision in terms of what constitutes a frail individual. This thesis proposes five criteria for establishing whether a frailty identification tool is fair, based upon the conditions of Accountability for Reasonableness.