Q&A: Ethics and COVID-19: resource allocation and priority setting
What is the basis for deciding who should have priority access to scarce resources?
The ethical basis for deciding which individuals or groups might be
prioritized, including the principles to be applied, are presented in the
below table:
Ethical considerations when deciding who to prioritize
Principle|  Description|  Practice implication
---|---|---
Equality|
Each person’s interest should count equally unless there are good reasons that
justify the differential prioritization of resources.
Irrelevant characteristics of individuals, such as race, ethnicity, creed,
ability or gender, should not serve arbitrarily as the basis for the
differential allocation of resources.
This principle can be used to justify the allocation of resources by a lottery
– that is, randomly by chance – or by a system of first come, first served.
|
May be most appropriate to guide the allocation of scarce resources among
individuals or populations who can be expected to derive the same benefit from
the resource, for example, vaccines among high-risk populations, or
ventilators among those with similar clinical indicators for benefit.  
Best outcomes (utility)|
This principle can be used to justify the allocation of resources according to
their capacity to do the most good or minimize the most harm, for example,
using available resources to save the most lives possible.
|
May be most appropriate to guide the allocation of scarce resources that
confer substantially different benefits to different individuals, for example,
ventilators to those expected to derive the most benefit.  
Prioritize the worst off|
This principle can be used to justify the allocation of resources to those in
greatest medical need or those most at risk.
|
May be most appropriate to guide the allocation of resources that are designed
or intended to protect those at risk, for example, PPE for health care
workers, vaccines for those most at risk of infection and severe illness, or
those most in need, as in the case of provision of drugs in short supply to
those needing them most urgently.  
Prioritize those tasked with helping others
|
This principle can be used to justify the allocation of resources to those who
have certain skills or talents that can save many other people, or because
something is owed to them on account of their participation in helping others.
|
May be most appropriate to guide the allocation of resources to health care
workers, first responders, etc.  
Allocation principles may be relevant or justified at different stages of
resource scarcity (from less scarcity to more scarcity). For example, where
little scarcity exists, the allocation of resources such as ventilators may be
most justified by the principle of first come, first served (which promotes
the value of equality). When those resources become increasingly scarce, their
allocation may be justified according to a principle that prioritizes those
most in need. With even greater scarcity, a principle that aims to maximize
benefit from the resource may be most justified. At each stage, allocation
should aim to promote equality – that is, first come, first served, or random
allocation, when no relevant factors distinguish individuals within a
particular scheme of allocation (for example, among those with similar needs,
or among those who can be expected to benefit similarly from the resources, or
among those that are at similar levels of risk).
In addition, multiple principles may be combined within an allocation scheme.
For example, an allocation scheme for PPE might find its justification in a
principle prioritizing those most at risk as well as a principle prioritizing
those tasked with helping others, which would support priority allocation of
PPE to health care workers.