By Jane Williams, Chris Degeling, Angus Dawson, Stacy Carter
Following the 2009 H1N1 pandemic there was a small explosion in the ethics literature on how to allocate scarce pandemic vaccine. There were many different suggestions about how we should distribute vaccine in an ethical way. One proposal was that a random allocation through a lottery, weighted or otherwise, was fair way of managing shortages. Such a lottery could either be used as the only allocation tool or used in ‘tie breaker’ situations, if other criteria are used. COVID-19 has prompted a renewed interest in how to prioritise scarce healthcare resources, from triaging patients for care to allocation of respirators, and now, to vaccines. The focus in existing commentary is, for the most part, to prioritise those who are at greater risk of harm from COVID. But lotteries continue to be put forward as a fair way to deliver scarce resources within priority groups or after those groups’ needs have been met.
The argument that vaccine lotteries are fair relies on the premise that everyone in the affected population has an equal moral claim to the resource and an equal chance of ‘winning’, and thus benefiting. In order to work, lotteries rely on ideal conditions such as the winners being able to access the thing that they have won. We see three issues with the promotion of vaccine lotteries, or at least justifying them on the grounds of fairness. First, the enthusiasm of ethicists for lotteries is not matched by the public, potentially undermining legitimacy. Second, the claim to fairness that is used to justify lotteries is difficult to defend. Third, the recent rollout of vaccine lotteries in parts of the US as a response to constrained resources highlights the profound unfairness of lotteries in practice.
Lotteries are widely rejected in studies of community attitudes to prioritising scarce healthcare. The public, it turns out, does not value randomness when the stakes are high and moral claims are not seen as being equal. One recent study asked lay people to rank different approaches to the ethical allocation of scarce resources and found that lotteries were least popular, replicating the findings of an earlier survey-based study. Both studies concluded that public views were at odds with some ethicists’ normative claims. Perhaps because resource allocation is so contested, there has also been extensive deliberative research about these questions. Unlike surveys, deliberative processes provide people with evidence, time and support to consider difficult questions together and make recommendations. A striking feature of reports of resource allocation juries, including those about pandemic vaccines, is the consistency with which these groups reject lotteries. Such findings raise significant concerns about the perceived legitimacy, and, thereby, the public acceptability of basing policy upon using random allocations.
In addition, the appeal to the idea of lotteries is more contentious that it may look at first sight. The appeal of random allocations is that it assumes that all are equal. This is an attractive egalitarian intuition. However individuals are not at equal risk of harm. This has been evidenced by disproportionately high COVID mortality in particular population groups and the large variation in prevalence of community spread in different countries. It is also unclear whether the equality that lotteries appeal to pertains to opportunity or outcome. The worry is that lotteries may amplify existing inequality. Lotteries can decrease the likelihood of equal outcomes because of different background chance of benefit. They are also likely to fail to deliver equality of opportunity, because people are unequally positioned to benefit from a one-size-fits-all vaccine lottery. These worries have been borne out in current attempts to employ lotteries in vaccine distribution.
Random allocation has a long history of use in healthcare research in situations of treatment equipoise, but, with a small number of exceptions, not to manage scarcity. This means that until very recently, arguments for allocating scarce healthcare resources via lottery were not likely to be seriously considered for practice. The COVID-19 vaccine rollout has been a very difficult logistical exercise in many places, particularly where a federalised system has meant little centralised guidance or control. In recent weeks, several US counties and municipalities have instituted lotteries to schedule and administer delivery of the vaccine, as a way of managing insufficient vaccine and over-burdened infrastructure. There are widespread reports of struggles to make online booking systems work, particularly for older cohorts who are currently at the front of the queue. It is these systems that are now being managed by lottery in some jurisdictions; winners are drawn at random from a website they have signed up to and the “prize” is an appointment. These lotteries cannot promise every eligible person an equal chance; in order to enter the lottery would-be competitors must be able to access and use the technology necessary for sign-up. Of those lucky registrants, not all will be able to capitalise on their win because they must be able to travel to a location at a time of someone else’s choosing in order to receive the vaccine.
These arrangements differ fundamentally from the proposals for an ethically fair system and reveal holes in pro-lottery arguments. In a socio-political environment where access to healthcare is profoundly inequitable, the ideal logic of ‘fairness’ underpinning lottery arguments simply cannot be realised in practice. Ethical solutions to real world problems that turn a blind eye to existing disadvantage are likely to further embed the sorts of practices that exacerbate injustice. Ethicists, in our view, have a responsibility only to advocate for solutions that are not only justifiable and legitimate, but also able to be realised in actual socio-political environments. To do otherwise is to neglect an ethical imperative to respond to real-world harms and injustice.
Authors: Jane Williams1, Chris Degeling2, Angus Dawson1, Stacy Carter2
- Sydney Health Ethics, The University of Sydney
- Australian Centre for Health Engagement, Evidence and Values, University of Wollongong
Competing interests: None
Social media accounts of post author(s):
Jane Williams @janewilliams141; Chris Degeling @cdegeling; Angus Dawson @PublicEthics; Stacy Carter @stacymcarter