Manufactured scarcity and the allocation of scarce resources – Authors' reply
Authors: Ezekiel J Emanuel, Govind Persad
Journal: The Lancet (2024)

In response to our Health Policy,1Emanuel 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 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. In December, 2020, when COVID-19 vaccines were authorised by the US Food and Drug Administration and the European Medicines Agency, there were only a few hundred million vaccines at first—much less than the 8 billion needed to vaccinate the entire world. Moreover, the number of health-care workers was insufficient to administer the vaccines. There was scarcity among and within all countries, requiring decisions about who would be vaccinated first. Nowhere do we assume that scarcity is immovable. Had Smith interrogated our five fundamental values, he might have noticed instrumental value—"allocating resources to indirectly realise other values in the future."1Emanuel 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 An example of this value would be prioritising vaccinations of front-line health-care workers to reduce future personnel scarcity. Although scarcity is reducible through coordinated efforts, initial scarcity is inevitable for novel interventions. Smith does not explain how the world could have produced and administered billions of COVID-19 vaccines without a scale-up process and ensuing temporary scarcity. Administering these vaccines inevitably drew personnel and capacity away from other needed efforts.2Peacocke EF Heupink LF Frønsdal K Dahl EH Chola L Global access to COVID-19 vaccines: a scoping review of factors that may influence equitable access for low and middle-income countries.BMJ Open. 2021; 11e049505 Crossref PubMed Scopus (39) Google Scholar Opportunity costs and near-term scarcities cannot be wished away—they must be addressed through fair allocation. We agree with Mitchell Berger that ethical values are necessary but not sufficient to ensure fair allocation.3McCoy MS Emanuel EJ Public engagement in health policy: mapping aims and approaches.in: Lever A Poama A The Routledge handbook of ethics and public policy. Routledge, London, UK2018: 368-380Crossref Google Scholar First come, first served gave preference to people with internet connections, computer skills, ability to travel, and time to wait—that is, well-off individuals.3McCoy MS Emanuel EJ Public engagement in health policy: mapping aims and approaches.in: Lever A Poama A The Routledge handbook of ethics and public policy. Routledge, London, UK2018: 368-380Crossref Google Scholar We also advocated building infrastructure to contact vulnerable groups, such as older individuals with low income who are at higher risk of being hospitalised or dying from COVID-19, to facilitate their receipt of scarce medical resources.3McCoy MS Emanuel EJ Public engagement in health policy: mapping aims and approaches.in: Lever A Poama A The Routledge handbook of ethics and public policy. Routledge, London, UK2018: 368-380Crossref Google Scholar As we point out, one of the problems in the USA was the passive allocation of vaccine—requiring people to sign up and travel to mass vaccination sites. We note that the USA's inability to contact patients at high risk proactively and systematically through telephone call, text, or email and schedule them for vaccine appointments caused inequity and failed to realise the ethical principles of allocation. We also agree with the importance of public engagement and responsiveness. Public engagement must be genuinely representative of the considered judgements of a wide cross-section of the public.3McCoy MS Emanuel EJ Public engagement in health policy: mapping aims and approaches.in: Lever A Poama A The Routledge handbook of ethics and public policy. Routledge, London, UK2018: 368-380Crossref Google Scholar Public engagement should not devolve into interest-group policy making, where scarce resources are directed to those who have the best lobbyists, the most intense preferences, or the most time to attend public meetings. We agree with Berger that resource scarcity can be mitigated. We propose a principle of sustainability, which promotes "the future development of and access to affordable and socially valuable vaccines and therapies".4Emanuel EJ Buchanan A Chan SY et al.What are the obligations of pharmaceutical companies in a global health emergency?.Lancet. 2021; 398: 1015-1020Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar Stephen P Miranda and Justin T Clapp are correct to identify ethical failures in COVID-19 allocation policies. However, their example of unfair hospital policies that disadvantaged essential health workers is a distinct issue from the allocation of scarce resources. Paying these workers fairly or thanking them for their work would not have diverted lifesaving resources from patients at the highest risk, but prioritising them more highly for vaccines might have.5Ubel PA Vaccinating health-care employees—do they all deserve early access?.N Engl J Med. 2021; 384: e39Crossref PubMed Scopus (4) Google Scholar Rawls observed that "Justice is the first virtue of social institutions, [such that] institutions no matter how efficient and well-arranged must be reformed or abolished if they are unjust."6Rawls J A theory of justice. Harvard University Press, Cambridge, MA, USA1971Crossref Google Scholar The values we identify present a compelling starting point for assessing the justice of allocation policies, even while the details of institutional reforms should be sensitive to the details of specific health systems and interventions. We declare no competing interests. Manufactured scarcity and the allocation of scarce resourcesAn ethical framework to allocate scarce resources by influential US-based ethicists Ezekiel J Emanuel and Govind Persad is riddled with shortcomings that have the potential to detract from global health ethics, rather than advance the moral utility of the field.1 Full-Text PDF Manufactured scarcity and the allocation of scarce resourcesEzekiel J Emanuel and Govind Persad have pinned the failures of the COVID-19 pandemic response on inadequate operationalisation of ethical principles in public health.1 The authors outline three procedural approaches they claim would have facilitated rapid development of priority groups and avoided mistakes in resource allocation.2 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? Full-Text PDF Manufactured scarcity and the allocation of scarce resourcesI appreciated the discussion by Ezekiel J Emanuel and Govind Persad,1 but would like to raise three considerations. First, although the authors claim, "A consensus exists on what ethical values are relevant to addressing the challenges of allocating scarce medical resources within and among countries",1 such arguably broad consensus did not always translate into clear and fair prioritisation criteria during the COVID-19 pandemic. For instance, at times during the COVID-19 pandemic, governments and various advisory commissions and panels developed criteria that neglected some individuals most at risk of developing the infection, including people with intellectual or developmental disabilities and mental illness. Full-Text PDF 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