A legal epidemiological study of patients' rights and healthcare rationing in England during the COVID-19 pandemic

国民健康保险制度的治疗供不应求。长期的资金限制和包括工作人员、床位和设备在内的资源严重短缺的时期，引发了关于患者获得治疗的权利以及配给NHS资源对临床医生的影响的问题。这些担忧在新冠肺炎大流行的初始阶段加剧，当时人们认为医院和临床医生的资源优先排序指导具有很大的局限性。i例如，有人认为，关于出于资源优先目的而停止生命支持治疗的政策可能是非法的，并且基于功利主义道德原则(挽救最多的‘生命年’)的政策可能构成对老年人和合并疾病患者的歧视。在没有政策的情况下，配给落在个别临床医生身上，存在患者不一致和偏见的固有风险，以及对临床医生造成道德伤害的风险。虽然定量配给来管理激增的需求是合理的，但这需要一个足够的法律框架来保护患者和临床医生。IV Newdick、Sheehan和Dunn认为，患者在资源分配决定方面拥有程序性权利，这可以通过分析早期与NHS治疗相关的法律决定来阐明。他们建议将此作为国家总体框架的基础，以指导地方资源分配决策，以保护患者的权利。V我建议的研究应用这一理论框架，并使用混合方法，包括法律流行病学的新应用，以澄清患者获得国民保健系统治疗的合法权利，并确定在新冠肺炎大流行期间关于配给的政策/指导在多大程度上保护或克减了这些权利。NHS资源的持续压力表明，资源优先排序仍然是大流行后的一个重要问题，预计这项研究的结果将有助于政策制定者和临床医生在未来做出合法的资源分配决定。

Demand for NHS treatment outstrips supply. Long-term funding constraints and periods of acute scarcity of resources including staff, beds, and equipment, raise questions about patients' rights to treatment and the impact on clinicians of rationing NHS resources. These concerns intensified in the initial stages of the COVID-19 pandemic, when it was considered that resource prioritisation guidance for hospitals and clinicians had significant limitations.i For example, it has been argued that policies regarding withdrawal of life supporting treatment for resource prioritisation purposes may be unlawful and that a policy based on the ethical principle of utilitarianism (saving the most 'life-years') may amount to discrimination in respect of the elderly and patients with comorbidities. iii Where no policies exist, rationing falls to individual clinicians, with inherent risks of inconsistency and bias for patients, together with a risk of moral injury to the clinicians. While rationing to manage a surge in demand can be justified, this requires an adequate legal framework to protect patients and clinicians.iv Newdick, Sheehan and Dunn argue that patients have procedural rights in respect of resource allocation decisions, which can be elucidated through analysis of earlier legal decisions related to the provision of NHS treatment. They propose that this should be used as the basis for an overarching national framework to guide local resource allocation decision-making to protect patient rights. v My proposed research applies this theoretical framework and uses mixed methods, including a novel application of legal epidemiology, to clarify patients' legal rights to NHS treatment and to ascertain the extent to which policies/guidance on rationing during the COVID-19 pandemic protected or 3 derogated from those rights. The on-going pressure on NHS resources indicates that resource prioritisation remains an important issue post-pandemic and it is anticipated that the findings of this research will assist policy-makers and clinicians in making legally informed resource allocation decisions in future.