A majority of the doctors in the current study reported familiarity with the general criteria for priority setting and, to some extent, the priority setting legislation ("Prioriteringsforskriften"), while, at the same time, being unfamiliar with the specific guidelines for priority setting under the pandemic. A large majority (between 60.9% and 75.2%, depending on the guideline) had not used any guideline at all under the pandemic. Further, most reported having seen changes in priorities between patient groups and that some of their patients were deprioritized. Finally, 47.5% considered these priorities medically indefensible to some (40.6%) or a large (6.9%) degree, and GPs most often did so.
Insufficient knowledge of priority setting guidelines
These findings tell us, first, that the clinicians' knowledge and use of specific guidelines for priority setting in the clinic is rather scant. This is remarkable because the health authorities presumably issue guidelines with the expectation that they be used generally and in extraordinary situations. For the health authorities in a country that has debated, adopted and implemented priority setting principles and guidelines for decades, this is a finding that should attract attention. Clearly, adopting principles and enacting legislation is insufficient for priority setting principles to be consciously utilized by clinicians in their daily work.
Although Norway has well-established general priority setting criteria (viz. utility, resource use and severity), the health authorities clearly considered them too general to be sufficiently action-guiding during the pandemic. Hence, the need arose for more specific, tailored priority setting advice. In the Norwegian Directorate of Health’s priority setting guideline for the pandemic , the degree of explicitness and concreteness varied between fields. For example, in the case of ICU, the priority guidelines were explicitly built on the priority criteria and provided concrete priorities, while the priority guidelines for the primary health and care services did not explicitly refer to the criteria.
The general criteria are not only too general in a pandemic situation, but need to be operationalized for specific contexts also in normal times. This has been acknowledged by health authorities, and priority setting guides were established for 33 medical specialties between 2008 and 2012 . The guides aid Norwegian hospital clinicians in evaluating referrals to their departments. They explicitly build on the three priority setting criteria. Developing similar guides for other areas of Norwegian healthcare would be an interesting prospect which would be one way of bringing the priority setting criteria out to clinicians.
Our findings of insufficient knowledge and usage of priority setting principles and legislation corroborate the findings in a 2018 Directorate of Health report . The authors of the report urged that clinicians be taught priority setting theory and how such theory can be applied in practical work; and that venues for multidisciplinary reflection and discussion on priority setting issues be established.
Clinicians are used to and sympathetic to clinical guidelines. A Norwegian study found that clinical guidelines belonged to the least controversial of the instruments aimed at governing clinical care . A study of physicians and nurses in Western Norway in 2020, found that most of the 1606 participants agreed with national and local prioritization guidelines. Here, 83% and 80% agreed or strongly agreed, while 5% disagreed and 7% disagreed strongly .
However, the actual use of clinical guidelines seems to vary considerably , which has been confirmed in our study. If priority setting in clinical practice is to proceed in accordance with the priority setting principles and guidelines, these must be translated into a clinically relevant context, and doctors’ familiarity with them must improve.
Reluctance to rationing care
Priority setting guidelines are different from clinical guidelines. Whereas the aim of a clinical guideline is to provide the doctor with the best evidence for making decisions, that is, to contribute to the best diagnostics or treatment for improving the patient's health, priority guidelines are explicitly limit setting. This potentially makes the latter harder to adhere to. Although it can be argued that clinical guidelines indirectly set limits as well, the priority guidelines aim solely at rank ordering treatments, hence also ranking patients. This is a much harder and ethically more controversial undertaking.
The scarcer the resources, the harder the priority setting. Under normal circumstances, clinicians find it hard to prioritize; in a crisis, the no's become even more evident, frequent, and potentially controversial. For example, the Italian guidelines  were criticized for ageism , because it was explicitly stated that an age limit "may ultimately need to be set". In our study, many doctors expressed concerns about the priorities that were made, and an impression of systematic deprioritization of certain patient groups (e.g. older patients) might have contributed to this judgment.
Many doctors, as well as leaders and politicians, find it hard to say no. The doctor's traditional duty is to give the patient good care, not to deny care. This might be an even stronger predicament for doctors if they perceive that such a rationing has not been officially and explicitly mandated. Arguably, the social contract of which healthcare is part involves the expectation that every patient will receive care of sufficient quality. This is especially true in a situation in which the need for significant rationing has not been officially acknowledged, and in which having to ration in such a way is likely to lead to moral distress for doctors.
Furthermore, there is an inherent tension between the roles for the clinician, as the patient's advocate on the one hand, and the responsibility to allocate resources in line with the general priority criteria on the other hand . This can lead to unjustified inequalities between patient groups if the power to influence resource allocation varies between specialties.
Medically indefensible priorities
Not only did we find that the clinicians' knowledge and use of priority guidelines was limited, but our findings also indicate that even though the priority guidelines were not applied, the pandemic still involved a change in priorities, many of which were considered medically indefensible. It is not clear how the concept "medically indefensible" was interpreted by the doctors in the study, or if it was interpreted similarly by all the respondents. Whether they considered the rationing to be indefensible in strict legal terms—involving liability—is not clear. Our interpretation is that a concern was expressed; that the rationing was considered problematic from a medical viewpoint. However, the study was not designed to shed light on the severity of the actual consequences for the patients in question.
Why did the decisions about priorities change? Our data cannot tell us this, but we know that it was not (mainly) a result of the individual doctor's use of the priority setting guidelines, at least according to their own reports. If the clinicians did not implement the priority guidelines, the decisions on changing priorities must have been made by others. In a hospital setting, the hierarchical system could indicate that priority decisions are made by the department and/or hospital leaders. This could relieve individual doctors from the responsibility of deprioritizing their own patients, but increase the experience of imposed prioritizations and make it psychologically more probable to be critical of the decisions. We saw no difference between hospital doctors and GPs regarding the experience of deprioritization, while more GPs considered the priorities to be medically indefensible. A possible reason for this may be that the GPs were closer to the nursing homes, where the mortality rates were the highest .
It is, however, unreasonable to believe that considering priorities as medically indefensible can be explained solely by a lack of co-decisioning. It was reported that the patient groups that suffered the most were the same patient groups who notoriously come out behind the others in more normal times, namely the chronically ill, psychiatric patients, people with addictions, and patients with co-morbidities (often high age). Observing that the normally lowest prioritized patients became even less prioritized in the pandemic, could be a reasonable cause for concern, perhaps even moving some to consider the priorities as a potential breach of law.
Another aspect of this pattern is that the authorities' demand to free up capacity through postponing elective surgery likely exacerbated existing social inequalities. A study of the NHS , concluded that "As ever, those individuals, and countries with least resources, were affected most by the shock." Studies of previous pandemics supports the conclusion , and there is no reason to assume that Norway differs from other countries in this respect. Because the distribution of health and illness follows a social gradient , the disruption of elective treatment will hit the various patient groups in a socially skewed pattern.
Guidelines can be a valuable aid when allocating scarce resources. They suggest that the hard decisions on limits to care are moved away from the doctor-patient relation, which can relieve tensions between the two. Guidelines can also reduce some tensions between the doctors' different roles, ideally also helping reduce the unjustified inequalities between patient groups. This requires however, that the guidelines be based on good evidence and common values, that clinical decision makers accept and use them, and that there are effective and transparent systems for changes in, and evaluations of, the guidelines. As we have seen in the present study, the guidelines were not used by the individual clinician, and the priority decisions that were made were to a large extent considered indefensible. This should be important knowledge for health authorities.
Strengths and weaknesses
A strength of the current study is the closeness in time between the start of the COVID-19 pandemic and the measurements asking for the doctors´ experiences and views. This reduces the potential for false memories. It should be acknowledged, however, that the pandemic is not over. The patterns we have seen here might change over time. Clearly, we cannot know whether the findings pertain only to the initial phase.
The relatively high response rate (70%) is another strength. This is higher than for other surveys of the medical profession . The sample is also representative of the population of practicing doctors in Norway, in key aspects like gender, age and workplace . This provides a good basis for generalization, but does not entirely rule out the possibility of nonresponse bias.
Because the pandemic laid a large amount of stress on health personnel, it is possible that the most stressed doctors opted out of answering the questionnaire. On the other hand, doctors who were confronted with harsh priorities might have a stronger interest in reporting back on their experiences.
Another limitation is that we only have self-reported data. When investigating attitudes, this is a plausible methodology. However, there is much more uncertainty when it comes to self-reports on actual behavior. The responses to the question of which patients groups suffered the most is, however, substantiated by other studies of systematic deprioritizations in health care.
We have not used validated questions because we could not find any good examples that explore what we wanted to study.