1.1 Macro allocation and prioritization of healthcare services: The Oregon experience

Let us briefly consider the most innovative and pioneering case of macro-allocation of healthcare resources in the era of healthcare technology. We refer to the 'Oregon Basic Health Services Act', an initiative of the North American State of Oregon, approved in 1989 and implemented in 1994, which established a mandatory health insurance for all employees, guaranteed by their employers, and created a package of universal state coverage of basic healthcare for the most deprived in the population (^{Golenski and Thompson, 1991}; ^{Morone and Ehlke, 2013}).

The context of this initiative goes back to the severe economic depression that this State had gone through, during which time a significant segment of its population lost health insurance, and the State excluded some therapeutic interventions from public coverage due to their financial cost. However, the process was triggered, in 1987, by the highly mediatized case of a 7-year-old boy who suffered from leukemia and needed a bone marrow transplant, one of the procedures excluded from state health coverage. The child died while a public fundraising initiative was underway (^{Spicer, 2010}), which generated a strong social outcry.

Prompted by the widespread criticism by public opinion, the political power within the State launched an initiative to expand the coverage of healthcare and to prioritize the services to be considered, using two methodologies. A first one, technical and quite common, of economic cost-utility analysis, in which the ratio between the cost of the therapeutic procedure in question and the benefits produced is evaluated in terms of health obtained and years of life gained (^{Robinson, 2009}). And a second one, an unprecedented methodology of community decision-making, in which citizens are consulted about the medical care that should be covered by the State. This process encouraged the enthusiastic involvement of the population who, in public hearings and through their representatives, expressed their personal opinions. In 1984, a parliament for health care, composed only of citizens, gathered to analyze the reports produced by the various communities, and prepared a final report that included a list of 15 public health policy principles to be used as criteria for the prioritization of healthcare services. At the end of this process, about 700 different clinical conditions and respective treatments were analyzed and prioritized, taking into account the citizens' own ideas of justice.

The Oregon case shows that the macro-allocation of health resources, in a context of severe financial constraints, could not only depend on an economic (technical) assessment, but also had to integrate the ethical opinions of citizens.

1.2 Micro allocation and the beneficiaries' selection: The God's Committee experience

Let us now consider, also briefly, the most outstanding paradigmatic case of micro-allocation of healthcare resources, in order to, once again, highlight the decisive character of the ethical component. We are referring to the famous God's Committee, the name by which the Admissions and Policy Committee became known. It was established by the American nephrologist Belding Scribner, in 1962, when he was confronted with a far greater number of kidney patients than the hemodialysis capabilities available could contend with. He had improved the dialysis machine, previously created for a single use in a poisoning situation, making it then suitable for regular use. This treatment was extraordinarily expensive and each admitted patient would need to maintain the treatment throughout their lifetime. Patients began to flock to the Seattle Artificial Kidney Center in an ever-increasing number, making it impossible to assist everyone. Scribner then created a commission of nephrologists - the Medical Advisory Committee - to analyze the clinical processes of the candidates, selecting only those whose survival depended on access to hemodialysis. The number of patients selected by this commission, however, was still greater than the technical capacities of the Center, so it was necessary to submit the patients, who had already been evaluated (technically, medically) as being in a life-threatening situation, to a new selection process, this time focusing on social rather than strictly medical criteria.

This commission, made up of seven ordinary people - lawyer, minister, bank employee, housewife, state government official, labor leader, and surgeon (^{Levine, 2009}) - as a micro representation of society, sought to establish selection criteria that favored an objective and impartial assessment of the cases. Among these non-medical criteria, different aspects were considered, such as age, sex, marital status, number of dependents, income, net worth, emotional stability, educational background, profession, past performance and future potential, and even took into consideration personal references obtained from other individuals. The commission's members tried to evaluate what we could call the 'social value' of each patient, taking into account the person's merits (past), as well as the consequences of their potential death (future), especially with regard to the well-being of their dependents (^{Jonsen, 1998}). The selection methods of this commission provoked much criticism, but they had the merit of highlighting the need to formulate non-technical criteria, in addition to medical assessments and financial interests, for prioritizing beneficiaries of available resources. In a serious situation of scarcity of resources, the selection of patients by the commission sought to be ethical, in an attempt to determine what would be fairer to the various candidates.

Briefly, all resource allocation, macro or micro, in the past as in the present, has an ethical dimension that cannot be concealed and that inexorably demands the consideration, well-founded and sustainable, of the criteria to be enunciated and implemented.

1.3 Basic ethical principles in healthcare resources allocation: Justice and Transparency

The proposal of ethical criteria for the allocation of health resources becomes all the more pressing as it is certain that they will remain inexorably necessary. Indeed, despite the budgetary strengthening of most national health systems, which should lead to a relief in the urgency and strong impact of decisions to be taken, the pressure on health budgets continues to increase (WHO, 2019) due to a plurality of factors such as: the aforementioned continually evolving new cutting-edge technologies and the latest generation drugs, with very high acquisition costs, to which are added a growing prevalence of chronic diseases and an increase in life expectancy, which are, in turn, reflected in a higher number of users of health services and in a greater need of care.

Throughout the long ethical reflection on macro and micro allocation of health resources, the principle of justice is invariably invoked as elementary and imperative. This, however, only refers the obligation to 'treat equals as equals and different as different' (Aristotle), without advocating any form of action. It is from this formal and abstract definition of justice that several theories develop specifying this general principle in concrete rules of action, structuring different criteria for the allocation of resources.

Among the theories of justice with the greatest impact on healthcare is that of the utilitarian. Justice, in the utilitarian theory, consists of the realization of the greatest good for the greatest number of people; that is, in the maximization of good, in what corresponds to the specification of the principle of utility (and not exactly of justice), formulated by Jeremy Bentham and Stuart Mill. In this perspective, however, individual rights or the plurality of social values may be neglected. There is also no commitment to an equitable distribution that, for utilitarians, will only be justified if it contributes to increase social utility. This being the hegemonic criterion, the utilitarian macro-allocation will privilege healthcare services that assist the greatest number of people and whose provision brings a greater good; that is, those which produce a more beneficial and lasting situation.

In the context of the SARS-CoV-2 pandemic, utilitarianism will justify, for example, the priority given to COVID-19 patients over those affected by other pathologies, due to the high infectious level of the coronavirus and the exponential number of people affected by this disease. At the micro level, utilitarianism will grant priority access to healthcare according to the benefit that each person can convey to the community, naturally excluding the elderly due to their reduced life expectancy. The God's Committee patient selection criterion, according to its social value, was utilitarian. At both levels, macro and micro, utilitarianism will establish priorities based on an economically oriented cost-benefit analysis that guarantees an allocation of available resources in order to maximize the benefit, the well-being of the population concerned, the best for the greatest number; that is, the production of maximum efficiency.

On the other hand, the egalitarian theory of justice is structured precisely on the principle of equal distribution of elementary or basic goods by all people, such as primary healthcare. This is the maximin rule that aims to maximize the minimum that everyone should enjoy. Egalitarianism, especially in the philosophy of John Rawls (who was not a strict egalitarian), refers to an 'equality of opportunity' (principle of fair equality of opportunity) which, in certain situations, will require the establishment of some inequalities to benefit the most disadvantaged (principle of difference), thus contributing to equality, namely by eliminating the negative effects that the 'lottery' of life - gender, race, ethnicity, disability, among others - can originate. The principle of fair equality of opportunity and the difference principle, together, allow to compensate arbitrary and undeserved disadvantages, thus building a distributive justice of benefits and burdens, of rights and duties; that is, justice as equity. Maximizing benefits and equity are often considered to be the structuring principles of resource allocation (^{Brock and Wikler, 2006}). In any case, for Rawls, denoting the influence of liberalism, once the fundamental freedoms of all are guaranteed, some inequalities that seek to promote overall equality, or that work as a stimulus for the social performance of each, are acceptable.

Egalitarianism will require, at the level of macro-allocation, the universal availability of basic, primary care, similar to that which occurred in the State of Oregon. At the micro-allocation level, it will also recommend a (maximum) minimum of healthcare for all patients, namely with COVID-19. However, strict egalitarianism will accept the order of arrival ('first come, first served') criterion for access to differentiated care; in a liberal egalitarianism, Rawlsian-type, like the one developed by Norman Daniels, it would be expected that each person would take due steps in relation to their own health throughout their lifetime, the exclusion of patients on account of their advanced age also being justifiable in a pandemic, thus contributing to a more equitable enjoyment of life span (^{Daniels, 1988}).

As another example, it is justified to mention the communitarian theory which, in general, in common features that we find in Michel Sandel, Alasdair MacIntyre or Charles Taylor, rejects the whole pre-established model of justice, considering that the hypothesis of a unique and universal model of justice, objective and valid for all societies, is utopian and uprooted from reality. It then states the importance of addressing different communities, in their cultural traditions, in their moral experiences, in the individual and social rights they recognize, in order to formulate a specific theory or principle of justice that responds to the needs of that community, while remaining in line with their common morals and contributing to the strengthening and consolidation of social cohesion. The process of citizen consultation in Oregon's macro-allocation illustrates well the communitarian model of justice that, in the micro-allocation plan, will require a contextualized debate, a deliberative process for the formulation of prioritization criteria consensual with the values of the community to which it relates.

This specific reference to some theories of justice intends to highlight the difficulty, or impossibility, of adopting a single model of justice to the exclusion of all others. Even if it were possible to identify a widely consensual notion of justice - as tends today to happen with justice as equity - and also of norms or criteria for its application to specific cases - more doubtful because of the controversy which arises in the construction of equity, in the forms of compensation for natural disadvantages - it would still be necessary to attend to the socioeconomic context of the community in which it intervenes: more or less egalitarian societies will require different strategies to achieve justice. In summary, social justice must be seen as a deliberative, plural and inclusive process, and permanently open.

In fact, this is the fundamental reason for requiring a second irreducible and transversal ethical principle in the allocation of resources: that of transparency. The obligation of transparency - formulated in the financial domain, developed in the political domain and in both associated with the notion of duty to be accountable or answer to others - originally refers to what 'lets the light through', thus also letting the eye see or become visible; that is, making a given reality publicly accessible. In the case of the distribution of limited goods by the population, criteria are required to be visible or accessible to all, and must also be widely explained, rationally argued and consensually accepted. Any criterion of prioritization that it is considered convenient to hide from public opinion is being hidden because it is, after all, not ethical. Transparency is proof of commitment to justice and an essential requirement for its legitimacy.

We therefore consider that there are two ethical principles that are strictly imposed as being imperative, at the macro and micro level of allocation: that of justice, in the enunciation of the criteria for the allocation of resources, especially in a situation of scarcity, and that of transparency, in their application.

2.1 Definition of concepts and their operability

The distinction between 'rationing' and 'rationalization' should start with the recovery of their etymology as an objective basis for their definition.

From an etymological point of view, 'rationing' and 'rationalization' have a common Latin etymus, ratio (onis). This noun, however, has two meanings: it can refer to the 'account', 'calculation', a numerical calculation; that is, the product or result of a mental activity; it can also refer to the 'ability to calculate', reason, intelligence or judgment; that is, the mental exercise itself, the human faculty that is reason. Hence, the Latin ratio is at the origin of both the verb ratiocinor (aris, ari, atus, sum), which means 'to count', 'to make calculations', and that of the adjective rationale (is), which means 'endowed with reason', 'in which reasoning is employed'.

The current words 'rationing' and 'rationalization' recover the original two meanings of ratio, respectively: 'rationing' focuses on the product, the ratio or coefficient between two values, such as the goods to be assigned and the people in need of them, what is allowed to establish the relationship between both; 'rationalization' focuses on the exercise of reason, the act of rationalizing or applying reason to any decision, including the allocation of resources, in order to obtain the maximum benefit, making it more effective.

So also, from a conceptual point of view, built upon the etymology of the terms, but above all from their use over time in various contexts, particularly the economic and financial contexts in which they have developed, 'rationing' refers to the administrative process, to the regulatory and mainly to the control distributing limited goods. 'Rationalization' refers to the process of reorganizing the systems or processes in question, which may include reducing or eliminating lines of action or reinforcing investment in others, making the action more logical and justified, as well as more consistent and efficient.

From an operational point of view, that is, from the application of these concepts to the concrete reality, considering their modalities and impacts, and very specifically to the allocation of health resources, 'rationing' classifies official restrictions on the consumption of certain goods made accessible to a limited number of people. For example, at the beginning of the pandemic, disinfectants ran out of public sale. As small quantities of these products arrived on the market, their sale was being rationed, allowing each person to purchase only a limited quantity, on a 'first come, first served' basis, until the product ran out again. The objective was to make these goods accessible to a maximum number of people, by reducing the quantity available to each one. Another relevant example is related to face masks, which ran out not only in the public consumer market, but also in the supply chain to healthcare professionals. When the production of masks intensified, priority was given to healthcare professionals and others in the first line of defense against the coronavirus. This is another form of rationing through prioritizing people.

In this same context, 'rationalization' refers to the reorganization of spaces, equipment and the performance of healthcare professionals in order to, with the existing means and their eventual reinforcement, meet the care needs at a given moment. In the pandemic situation of SARS-CoV-2, there was an exceptional influx of patients with very high infection levels that needed to be isolated from all physical contact, so it was also imperative to restructure procedures. The reorganization of spaces for the circulation of patients and professionals, and the protocols for personal hygiene and disinfection of hospital spaces, for example, corresponded to actions to rationalize resources. In this process, hospital services were also closed and it became necessary to reschedule, for example, medical appointments and surgeries for non-COVID-19 patients, which should have been done by endeavoring to enhance the profitability of the available means. This is another way of rationalizing health care, by prioritizing services and not individuals.

Prioritization in health is not synonymous with rationing, as the general bibliography assumes, but it can also be done through the rationalization of resources, which implies different procedures, with different grounds and ethical implications.

2.2 Ethical foundation of healthcare prioritization

The scarcity of resources to respond to the healthcare needs of the population imposes an increased ethical requirement in the proposal of fair and transparent prioritization criteria, which is aggravated in the exceptional situation of the pandemic given the potentially dramatic consequences of the decisions being taken.

The refusal to formulate prioritization criteria, such as maintaining the 'first come, first served' rule, in its intrinsic randomness, could be endorsed by strict egalitarians given the recognition of the inability to formulate an objective justice principle. However, the entities involved would be subject to criticism for failing or abnegating their responsibilities.

The adoption of the criterion 'greater severity, greater priority', maintaining the classic model of emergency screening and extending it to the field of public health, is challenged, in particular, by utilitarians who criticize the investment directed at patients with no reasonable prospect of survival, diverting the scarce resources to less needy patients, but those who are more likely to recover.

There is, therefore, an urgent need to consider the models of 'rationing' and 'rationalization' in establishing priorities in access to scarce healthcare.