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The Ethical Basis of Resource Allocation in Cancer Care

Prof Clare Delany, Clinical Ethicist and a member of the VCCN Taskforce, supports the group’s consideration of complex issues using ethics principles to enable discussion and to progress resolutions. Here Prof Delany outlines how the Principle of Justice can be applied to two recent VCCN Taskforce resolutions that call for changes to currently imposed restrictions on the delivery of health care and availability of resources.

Managing and minimising the overall health impacts of the COVID-19 pandemic has required ongoing waves of practical, medical and ethical choices and decisions to guide the best possible way through.

Cancer care clinicians have detailed knowledge and expertise about the effect of any restriction or use of a resource which impacts patient care. They are concerned about the harmful impacts of such restrictions on patient care. Governments on the other hand have the broader population safety and conservation of resources, as their focus. How can these two seemingly conflicting positions be resolved? 

A feature of ethically complex decisions is that there is no one clear right answer. Multiple values are at stake, people may disagree about which values matter the most and yet a decision must still be made. In these circumstances, it is imperative that there is a strong ethical basis for such decisions and that the ethical basis is transparent so that even if there is disagreement about a restriction, there is an opportunity to see the ethical reasoning behind it.

In healthcare, ethical reasoning relies on four foundational health ethics principles:

  1. Treatment should produce an overall benefit to individual patients
  2. Treatment should not be harmful or add more burdens than benefits
  3. Each patient’s autonomy and individual preferences are acknowledged and respected
  4. Available health resources are used with justice

The fourth principle, justice, is particularly relevant to disagreements about the right balance between protection of people within a community through restriction of resources on the one hand, and use of resources for individuals who need access to or who will be harmed without them.  The principles of benefit, harm and respect for patient autonomy are also important to specify in the reasoning process. 

Using the Principle of Justice to guide Resource Allocation for Cancer Care

One common interpretation of a just process of allocation of health resources is to apply the same restrictions across the whole health sector. Examples of this type of approach are blanket restrictions to visitors in health settings or a ban on different categories of surgery. This approach is not concerned with how the restriction affects individual people in particular circumstances. It is concerned with achieving the best possible outcome for the most people overall.

A second interpretation of a just process of resource allocation is to allocate or restrict the use of resources according to specific criteria. Two criteria commonly used in health care are to allocate resources according to: 

  1. Those in most need – sickest, most at risk (NEED)
  2. Those who can benefit the most – (CAPACITY TO BENEFIT)

Allocating according to criteria of NEED requires thorough consideration and explanation of a person’s need and why it should take priority over other needs or be exempt from restrictions. This involves specifying the impact (harms and benefits) of any healthcare restriction or lack of access to resources on individual patients or groups of patients.  It also requires identifying whether there are any alternative ways to address the patient(s)' need other than accessing the restricted resources.  

Using these principles as a guide, the ethical justifications that sit behind two recent resolutions made to the Victorian Government by the Victorian COVID-19 Cancer Network Taskforce are summarised below.

Resolution 1:

It is essential that curative urgent category 2 cancer surgery be maintained and urgent consideration be given to recommence elective cancer procedures by utilising resources across the cancer sector, including private hospitals.

Resolution 2:

The Victorian COVID-19 Cancer Network Taskforce strongly recommends cancer patients on active treatment have continued access to two (2) Rapid Antigen Tests during treatment – one for the day of treatment and one to be kept in reserve in case symptoms develop.

Resolution Ethical Justification
  • curative urgent category 2 cancer surgery be maintained


  • recommence elective cancer procedures
  • The benefits of enabling patients to access curative cancer surgery are to optimise chance of cure; minimise risk of complications of local tumour progression; minimise anxiety to patients having to wait for cancer treatments.
  • The harms for patients of delaying curative category 2 cancer surgery are:
    • potential that the primary tumour may metastasize while waiting for surgery; potential    conversion from curative to non-curative surgery; increase the need to have adjuvant therapies; anxiety.
  • The harms for the health system of delaying curative cancer surgery include potential need for more extensive surgery, higher risks of complications and possible longer length of hospital stay
  • There are no other ways to address patients’ needs
  • There are facilities available and the surgery will not take resources away from other people with different needs
  • Cancer care clinicians are in the best possible position to assess patient need and capacity of the health system to address this
  • cancer patients on active treatment have continued access to two (2) Rapid Antigen Tests during treatment
  • Prioritising rapid antigen tests for cancer patients is based on the increased vulnerability of this patient population compared to others.
  • Cancer patients on active treatment have greater need than other patients to monitor for COVID infections because:
    • Cancer treatments may suppress the immune system and mean higher risk of more severe COVID-19 infection and complications despite vaccination
    • Prompt detection of COVID infection will enable cancer treatment to be adjusted to enhance a person’s immune response
    • Risk of transmission within chemotherapy day units to other patients who are not wearing tier 3 PPE unlike health care workers.
    • Increased vulnerability of cancer patients requires accurate and regular monitoring of infections to ensure cancer treatment facilities remain COVID free (for staff and patients)
  • Having timely access to RATs is an efficient and just use of resources because it protects the safety of both staff and vulnerable patients and enables cancer care to continue, avoiding delays to life saving treatment and future bottle necks in the health system.


Ethically balancing the needs of individual cancer patients on the one hand, with the need to protect and conserve resources for the broader community on the other, requires transparent reasoning anchored to health ethics principles. The reasoning process involves identifying and then weighing up different types of needs that people have and then considering and providing a clear justification for how to fairly allocate available resources to adequately meet those needs. Cancer care clinicians are well placed to lead the ethical deliberation required to ensure available health resources are fairly and transparently allocated to meet the specific needs of cancer patients.  

Professor Clare Delany

Professor Delany is a Clinical Ethicist at the Children’s Bioethics Centre at the Royal Children’s Hospital and at Peter MacCallum Cancer Centre in Melbourne. She is also a is Professor in Health Professions Education in the Department of Medical Education, Melbourne Medical School, at the University of Melbourne.

In clinical ethics, Clare conducts both individual and committee-based clinical consultations, supporting clinicians in ethical reasoning and deliberation. Clare is the lead editor of ‘Learning and Teaching in Clinical contexts (2018), and co-editor of ‘When Doctors and Parents Disagree: Ethics, Paediatrics and the Zone of Parental Discretion’ (2017).

In Research Ethics, Clare is the chair of the Central Human Research Ethics Committee at the University of Melbourne.

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