Waiting lists are a standard approach to managing excess demand in elective health care. While waiting times are an important policy issue, the ethical validity of the first come, first served (FCFS) principle as such is rarely questioned. Presenting a psychiatric day hospital where all eligible patients have roughly equal claims as a case study, we criticize the reflex use of FCFS for allocation of elective psychiatric care, consider conditions under which this may not be the optimal strategy, and discuss (...) alternatives. We conclude that in our example prioritizing more recent referrals (last come, first served [LCFS]) makes more sense, clinically and ethically. Where several referrals arrive (near-)simultaneously under LCFS, we propose that a higher level of scrutiny be applied to detect possible good reasons for prioritizing one of them. We believe that our observations can be applied to other health care settings that share relevant characteristics with our case. (shrink)

After providing a novel taxonomy of lottery procedures for fairly distributing scarce goods, I defend a new weighted lottery theory. This taxonomy is necessary because the debate between unweighted and weighted lottery theorists overlooks a range of cases, overlap cases, in which conducting an unweighted lottery is impossible or implausible. Therefore, to account for all such cases, lottery theorists must adopt a weighted lottery. However, while no extant weighted lottery is adequate in overlap cases, my new weighted lottery theory is. (...) I conclude by discussing my theory’s practical implications. (shrink)

Fair priority setting is based on morally sound criteria. Still, there will be cases when these criteria, our primary considerations, are tied and therefore do not help us in choosing one allocation over another. It is sometimes suggested that such cases can be handled by tiebreakers. In this paper, we discuss two versions of tiebreakers suggested in the literature. One version is to preserve fairness or impartiality by holding a lottery. The other version is to allow secondary considerations, considerations that (...) are not part of our primary priority setting criteria, to be decisive. We argue that the argument for preserving impartiality by holding a lottery is sound, while the argument for using tiebreakers as secondary considerations is not. Finally, we argue that the instances where a tiebreaker seems necessary are precisely the situations where we have strong reasons for preferring a lottery. We conclude that factors that we consider valuable should all be included among the primary considerations, while ties should be settled by lotteries. (shrink)

In the event of a pandemic, demand for vaccines may exceed supply. One proposal for allocating vaccines is to use a lottery, to give all citizens an equal chance, either of getting the vaccine or of surviving. However, insistence on strict equality can result in seriously suboptimal outcomes. I argue that the requirement to treat all citizens impartially need not be interpreted to require equal chances, particularly where citizens are differently situated. Assuming that we want to save lives, we should (...) also seek to use vaccine efficiently, so far as this is compatible with equality. Thus, in allocating vaccine, we may want to be sensitive to different levels of need and/or effects on vaccine production. While such policies may result in unequal chances, they may even improve everyone’s chances. In such cases, the resultant inequality is not a violation of impartiality, but a consequence of considering each person’s claim seriously. (shrink)

Background The world is threatened by future pandemics. Vaccines can play a key role in preventing harm, but there will inevitably be shortages because there is no possibility of advance stockpiling. We therefore need some method of prioritising access. Main text This paper reports a critical interpretative review of the published literature that discusses ethical arguments used to justify how we could prioritise vaccine during an influenza pandemic. We found that the focus of the literature was often on proposing different (...) groups as priorities. Different reasons were often suggested as a means of justifying such priority groupings. We suggest that much of the literature, wrongly, assumes that we are able to plan priority groups prior to the time of a particular pandemic and development of a particular vaccine. We also point out the surprising absence of various issues from the literature. Conclusions The literature proposes a wide range of ways to prioritise vaccines, focusing on different groups and ‘principles’. Any plan to use pandemic vaccine must provide justifications for its prioritisation. The focus of this review was influenza pandemic vaccines, but lessons can be learnt for future allocations of coronavirus vaccine, if one becomes available. (shrink)

The current UK policy for the distribution of scarce vaccination in an influenza pandemic is ethically dubious. It is based on the planned outcome of the maximum health benefit in terms of the saving of lives and the reduction of illness. To that end, the population is classified in terms of particular priority groups. An alternative policy with a non-consequentialist rationale is proposed in the present work. The state should give the vaccination, in the first instance, to those who are (...) at risk of catching the pandemic flu in the line of their duties of public employment. Thereafter, if there is not sufficient vaccine to give all citizens equally an effective dose, the state should give all citizens an equal chance of receiving an effective dose. This would be the just thing to do because the state has a duty to treat each and all of its citizens impartially and they have a corresponding right to such impartial treatment. Although this article specifically refers to the UK, it is considered that the suggested alternative policy would be applicable generally. The duty to act justly is not merely a local one. (shrink)