Equality by lot

“For patients with similar prognosis, who cannot be separated in other ways, a random allocation, such as a lottery, may be used”, says the protocol.

So says a Report in the Daily Telegraph (UK) of 5th January by Paul Nuki titled “Covid ‘lottery’: Doctors draw up triage protocol in the event treatment has to be rationed” (Telegraph usually paywalled, but this seems open-access)

It refers to a paper in J Medical Ethics “Development of a structured process for fair allocation of critical care resources in the setting of insufficient capacity: a discussion paper” also accessible f.o.c.

This is circulating in NHS hospitals as a proposed protocol.

The protocol – drafted by medical, legal and palliative care specialists at the Royal United Hospital Bath NHS Trust – is the most sophisticated attempt yet to devise an ethical system for rationing care in the event that there are insufficient resources to treat everyone.

Now this is exciting! But it is not new. Right from the start of organ transplantation (1960s) such moralistic contentions were weighed up.

In Seattle the so-called ‘God committee’ was set up to make these difficult choices (reported in Calabresi & Bobbit (1978) Tragic Choices). The committee eventually found that it was too agonising to make these choices, and passed the task back to the medical practitioners. In the end it was felt that only medical  factors should be taken into account. Even if no overt rules on social merit were in place, we should not be surprised if the doctor, genuinely uncertain on medical grounds,  was to pick the ‘nicer’ of the two patients.

A secret lottery?

Elster (1989) in his masterly ‘Solomonic Choices’ gives the example of child custody cases, where the judge is frequently unable (in his own mind) to give a clear-cut decision. Yet decide he must, so he goes ahead, dressing up the verdict with trappings of rationality.

This, claims Elster, satisfies both parties, the winner praising the wisdom of the judge, the loser cursing his bias. No doubt a similar process might go on when a medical doctor decides, even if partly randomly and in secret, between her two patients: So long as both patients believe that their case is decided clinically by an expert, then both winner and loser may find it acceptable.

The doctor herself may even be a bit cognitively dissonant—convincing herself that she is doing the right thing for the right reason, exercising judgement based on intuition  rather than validated knowledge. This form of fudging may be acceptable all round, but it is fraught with dangers.

If fakery is suspected, patients rapidly lose their trust in their professionals. Unwitting discrimination seems inevitable. True expertise will fail to develop unless its limits are acknowledged.

Against a lottery is Greely (1977) who suggests that if recipients can argue about any allocation, they feel more satisfied. Anand was also interested in what is called ‘voice’—that one of the reasons a coin-toss was thought to be unfair is that it deprived customers of a say in the decision.

In favour of a visible act of coin-tossing Calabresi & Bobbit explain that it draws attention to the fact that resources are limited. Edgeworth (1888) suggested another benefit would be that the public, seeing a random drawing take place, would be alerted to the ‘aleatory nature’ of the decision. Bureaucrats might not like having such attention focussed on this shortage of resources and their uncertain knowledge.

[This was part of my 2006 thesis Who Gets The Prize. It can be viewed in full on my website www.conallboyle.com]

Filed under: Academia, Distribution by lot, Press, Proposals | Tagged: NHS |