**Abstract**

This chapter proposes a theoretical reflection on the ethical deliberation process in the allocation of beds and respirators, in the light of the Theory of Health Justice, the Accountability for Reasonableness approach and the principle of health equity of the Brazilian Unified Health System (SUS, as per its Portuguese acronym), before the COVID-19 pandemic in Brazil. The pandemic has become a serious threat to health systems, as installed capacity has been exceeded whether in terms of material resources, equipment, technology and human resources. Thus, according to the theory of Accountability for Reasonableness, a fair and deliberative process aims to ensure resource allocation through limits and constraints (reasonableness), but government responsibility derived from human rights must be considered, allowing for health programming (accountability). Faced with this scenario, where the situation will often require us to make choices, this chapter intends to discuss the assumptions for ethical deliberation, taking into account the context of the act and its foreseeable consequences.

**Keywords:** Equity in Access to Health Services, Resource Allocation, Social Justice, Coronavirus Infections, Pandemic

#### **1. Introduction**

Throughout December 2019, in Wuhan city, Hubei province, Chinese health authorities identified pneumonia cases of unknown aetiology, which were subsequently attributed to the emergence of a new coronavirus (SARS-Cov-2) [1]. The World Health Organisation (WHO) has declared a state of public health emergency of international concern. Originally called 2019 - n - CoV, the infection caused by the new coronavirus was officially named COVID-19 on 11th March 2020, when it was declared a pandemic [2].

According to the Ministry of Health, in Brazil, until 28th April 2021, 14,521,289 confirmed cases of infection by COVID-19 had been notified, with 79,726 deaths [3]. This advance has led government agencies to adopt strategies to control the

spread of the virus, such as closing schools and shops, banning meetings, instituting teleworking, isolating people in their homes, and also banning international and even national travels [2].

The Brazilian Unified Health System (SUS, as per its Portuguese acronym) has always been at the front line of public health emergencies in Brazil and it has not been different in the context of facing the COVID-19 pandemic. It is one of the largest health systems in the world and the fight against the pandemic has integrated all levels of healthcare, based on its guidelines and principles described in the organic laws of health n° 8080 and n° 8142, dated 1990 [4, 5]. SUS must respond in a planned, systematised and equitable way to this new challenge imposed.

In an analysis of SUS, in its 30 years of existence, the system's lack of priority and underfunding, associated with the country's economic crisis and especially, the Constitutional Amendment 95 (EC-95/2016), which freezes the public budget for twenty years, were highlighted as factors detrimental to the system [6]. Thus, the system is overloaded and, faced with the new pandemic context, needs investment in material resources and equipment, as well as physical and human resources [7].

In the context of the pandemic in China, substantial regional disparities in the availability and accessibility of health resources were observed that could partially explain the low mortality rates (despite the large number of cases) in the more developed provinces, such as Zhejiang (zero deaths among 1,171 confirmed cases) and Guangdong (four deaths among 1,322 cases). Following analysis of this data, the Chinese government moved to rapidly build new local medical facilities in the less developed provinces, a key measure that helped control the epidemic, protect front-line health professionals and mitigate the severity of the disease in patients [8].

A reflection was introduced by health professionals from the United States on the need for resources to care for a large number of patients with COVID-19 after the declaration of the pandemic in the country, questioning how prepared the US hospitals were in relation to material and human resources in the face of uncontrolled transmission of the virus and consequent challenges in clinical decision making. In moments of crisis, health resources must be allocated in an ethical, rational and structured way, so as to benefit a greater number of patients. It is pointed out that the main conflict in decision making is the definition of ethical criteria for the allocation of mechanical ventilation equipment and beds in Intensive Care Units (ICU) [1].

We need to think about what ethical duties should be observed in this scenario, when the health system is being demanded beyond its capacity. How to allocate resources equitably, ensuring resources to all levels of care and regions? [2].

In pandemic contexts, there is a direct concern with equity in the use of resources as a moral and legal imperative to respect, protect and fulfil human rights in relation to health service delivery, based on international norms and standards. Nevertheless, in relation to the human rights-based approach, "even if attention is paid to the philosophical foundations linked to relevant rights recognised in international law, this does not provide guidance on how these relevant rights help determine priorities among claimants" [9].

General theories of justice alone do not provide adequate guidance for the problem of priority setting. This is because these theories are too broad to provide precise answers to the key distributional questions necessary for priority setting. However, the Accountability for Reasonableness approach, suggested by Daniels, guides prioritisation and is consistent with human rights due to its concern with justice and the social determinants in its process, which enables it to be applied to health systems [9].

*Ethical Deliberation in the Allocation of Respirators and Beds during the Covid-19 Pandemic… DOI: http://dx.doi.org/10.5772/intechopen.98589*

Accordingly, this chapter proposes a theoretical reflection on the process of ethical deliberation in the allocation of ICU beds and respirators, in the light of the Theory of Health Justice [10] and Accountability for Reasonableness approach [9], both proposed by the American philosopher and politician Norman Daniels; and the principle of SUS equity, before the COVID-19 pandemic in Brazil.
