Manufactured scarcity and the allocation of scarce resources
Authors: James Smith
Journal: The Lancet (2024)

An 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.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 Among several issues, the authors do not elaborate on the methodology used to collate reports on allocating scarce resources. 11 (85%) of 13 reports relate to resource allocation in five high-income countries. The authors boldly claim that there is "consensus"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 on guiding ethical principles and "that in the future there is no need to develop all-new underlying values",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 and yet have synthesised a partial body of literature that neglects knowledge and experience emanating from the majority world. This approach is a prime example of knowledge-solicited epistemic injustice.2Pratt B de Vries J Where is knowledge from the Global South? An account of epistemic justice for a global bioethics.J Med Ethics. 2023; 49: 325-334Crossref PubMed Scopus (21) Google Scholar Furthermore, Emanuel and Persad's allocation framework effectively assumes that scarcity is an immovable reality. This view is problematic and irresponsible within normative ethical discourse, and reflects a tunnel vision that is pervasive in global health.3Schrecker T Interrogating scarcity: how to think about resource-scarce settings.Health Policy Plan. 2013; 28: 400-409Crossref PubMed Scopus (16) Google Scholar Without interrogating the five "fundamental values"3Schrecker T Interrogating scarcity: how to think about resource-scarce settings.Health Policy Plan. 2013; 28: 400-409Crossref PubMed Scopus (16) Google Scholar the authors suggest, I propose another value tentatively titled the undoing scarcity value. This value requires that we identify and act to undo the root causes of scarcity. Emanuel and Persad use the example of the RST,S/AS01E malaria vaccine to advance their allocation of scarce resources framework, arguing the vaccine must be rationed until production meets demand: in approximately 4–6 years. The authors do not mention production and procurement barriers imposed by high costs and delayed knowledge transfer agreements.4GAVI, the Vaccine AllianceMalaria vaccine market shaping roadmap.https://www.gavi.org/news-resources/knowledge-products/malaria-vaccine-market-shaping-roadmapDate: 2023Date accessed: January 17, 2024Google Scholar In the Framework for the Allocation of Limited Malaria Vaccine Supply, WHO clearly states, "It is an ethical imperative to address the underlying causes of the current scarcity and to pursue ways to accelerate increased supply to meet demand as soon as possible."5WHOFramework for the allocation of limited malaria vaccine supply.https://www.who.int/publications/m/item/framework-for-allocation-of-limited-malaria-vaccine-supplyDate: 2022Date accessed: January 17, 2024Google Scholar Without disruptive action to unsettle manufactured scarcity we accept deep-seated structural injustices: what can be ethical about that? JS is a trustee of Medact. 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