Manufactured scarcity and the allocation of scarce resources
Authors: Stephen P Miranda, Justin T Clapp
Journal: The Lancet (2024)

Ezekiel J Emanuel and Govind Persad have pinned the failures of the COVID-19 pandemic response on inadequate operationalisation of ethical principles in public health.1Emanuel EJ Upshur REG Smith MJ What COVID has taught the world about ethics.N Engl J Med. 2022; 387: 1542-1545Crossref PubMed Scopus (13) Google Scholar The authors outline three procedural approaches they claim would have facilitated rapid development of priority groups and avoided mistakes in resource allocation.2Emanuel EJ Persad G The shared ethical framework to allocate scarce medical resources: a lesson from COVID-19.Lancet. 2023; 401: 1892-1902Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar In doing so, the authors sidestep an important question: how useful or relevant are high-level guiding principles if we continually fail to implement them faithfully in different contexts? An alternative explanation of the poor COVID-19 response is that normative bioethical frameworks were unhelpful because they were too detached from the complexities of the pandemic to offer guidance. For instance, despite commitments to prioritise individuals with skills of particlar value in the face of the COVID-19 pandemic,3Emanuel EJ Persad G Upshur R et al.Fair allocation of scarce medical resources in the time of COVID-19.N Engl J Med. 2020; 382: 2049-2055Crossref PubMed Scopus (2088) Google Scholar we repeatedly observed unfair hospital policies that disadvantaged essential health workers.4Kinder M Essential but undervalued: millions of health-care workers aren't getting the pay or respect they deserve in the COVID-19 pandemic.https://www.brookings.edu/research/essential-but-undervalued-millions-of-health-care-workers-arent-getting-the-pay-or-respect-they-deserve-in-the-covid-19-pandemicDate: May 28, 2020Date accessed: June 2, 2023Google Scholar This issue possibly does not arise from an inability to properly weigh ethical principles. Rather, essential workers were already working in a system that undervalued them—financially, infrastructurally, and culturally—and this situation was unlikely to rapidly change during a pandemic. What if we confronted the reality that our health-care systems might reflect different values than those we proclaim? What if we developed an ethical framework based on the empirical intricacies of health and health care?5Clapp JT Keeping bioethics concrete: how social scientific research generates values.AJOB Empir Bioeth. 2020; 11: 8-10Crossref PubMed Scopus (1) Google Scholar One that anticipated problems because it was already immersed in describing their precursors and generating ideas about how they could be feasibly addressed? The authors' own follow-up paper suggests that we should be focusing not on what COVID-19 taught the world about ethics1Emanuel EJ Upshur REG Smith MJ What COVID has taught the world about ethics.N Engl J Med. 2022; 387: 1542-1545Crossref PubMed Scopus (13) Google Scholar but rather on the lesson2Emanuel EJ Persad G The shared ethical framework to allocate scarce medical resources: a lesson from COVID-19.Lancet. 2023; 401: 1892-1902Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar that COVID-19 taught ethics about the world. We declare no competing interests. The shared ethical framework to allocate scarce medical resources: a lesson from COVID-19The COVID-19 pandemic has helped to clarify the fair and equitable allocation of scarce medical resources, both within and among countries. The ethical allocation of such resources entails a three-step process: (1) elucidating the fundamental ethical values for allocation, (2) using these values to delineate priority tiers for scarce resources, and (3) implementing the prioritisation to faithfully realise the fundamental values. Myriad reports and assessments have elucidated five core substantive values for ethical allocation: maximising benefits and minimising harms, mitigating unfair disadvantage, equal moral concern, reciprocity, and instrumental value. Full-Text PDF Manufactured scarcity and the allocation of scarce resources – Authors' replyIn response to our Health Policy,1 James Smith asserts that viewing scarcity as a reality in global health is "problematic and irresponsible". Although scarcity can be mitigated, it is inherent to human life on this planet. Without scarcity there would be no need for principles of distributive justice. What is irresponsible is changing the subject away from how to address scarcity instead of fairly responding to the issue of scarcity. Without effective guidance, well-off people will take the preponderance of scarce resources while others discuss the end of scarcity. Full-Text PDF