“We could use that as a tiebreaker” – Yes, but why should we?

By Borgar Jølstad and Erik Gustavsson.

Health care priority setting should be based on morally relevant factors such as need, severity, and maximizing health outcomes. But sometimes we must choose between health care allocations where these primary considerations are tied. It is sometimes suggested, and implemented in practice, that in these situations other, perhaps more controversial, factors can play the role of tiebreakers. For example, age, healthcare worker status, and first come, first serve, have been suggested as tiebreakers for ventilator guidelines in many U.S. states. This may seem an elegant solution, but tiebreakers are deeply problematic.

First, there is the issue of the value of the tiebreaker. If it is important enough to make a difference in ties, why is it not important enough to make a difference in other cases? That is, why are these factors only valuable in ties? Since any difference among the primary considerations in the priority setting system will offset the tiebreaker, any value ascribed to the tiebreaker will be miniscule. This is particularly strange in priority setting systems where ties are frequent, and the tiebreaker plays a major role in the end. The result is a minimal value making a big difference.

For example, in the Australian pandemic priority setting guidelines people are allocated to “high” and “low” priority groups based on likelihood of recovery and benefiting from treatment. Ties are to be broken by previous disadvantage and health care worker status. Presumably, the reason why these factors are ascribed the role of tiebreakers is that they are not important enough to decide whether someone is “high” or “low” priority. But strangely, they tip the scale in many cases. If a factor is important enough to make such a big difference, relegating it to the status of tiebreaker or secondary consideration seems strange.

Secondly, it is doubtful whether our reasons for implementing a tiebreaker can overcome our reasons for preferring a lottery. In Against Tiebreaking Arguments in Priority Setting we argue that lotteries are the reasonable way to break ties. Lotteries can be justified by referring to impartiality, respect for the separateness of persons, fairness, and the moral value of chances. Our reasons for preferring a lottery are particularly strong in ties, where people’s claims are, presumably, equally strong. If tiebreakers are only valuable enough to make a difference in ties, how can they overcome these reasons for preferring a lottery? Both fairness and impartiality are preserved by lotteries, whereas deciding using a tiebreaker involves allowing a professedly minimally important factor to be decisive for the outcome.

Tiebreakers are puzzling and seem notoriously difficult to justify for priority setting. If a factor is truly important, it should simply be part of our primary considerations, while ties should be decided by lottery.


Paper title: Against Tiebreaking Arguments in Priority Setting

Authors: Borgar Jølstad and Erik Gustavsson


  1. Borgar Jølstad

(A) The Health Services Research Unit—HØKH, Akershus University Hospital (Ahus), Lørenskog, Norway.

(B)  Institute of Health and Society, Faculty of Medicine, University of Oslo, Norway.

  1. Erik Gustavsson

(A) Centre for Applied Ethics, Department of Culture and Society, Linköping University, Sweden.

(B) National Centre for Priorities in Health, Department of Health, Medicine and Caring sciences, Linköping University, Sweden.

Competing interests: None

Social media accounts of post authors: @Borgar_Jolstad

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