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Duke Medical Ethics Journal

Ethics of Medical Resource Allocation

By: Shubhika Munot

Should scarce medical resources be provided to those who have waited

for them the longest or require it the most? Should a 20-year-old be

prioritized over an 80-year-old for a life-saving cure? Let’s say we have

one hospital bed for every 1000 citizens or only 57,000 ventilators in a

country of over 1.3 billion people [1]. Who gets precedence?

Unfortunately, this is the very challenge that plagues many developing

countries every day. 


How do we fairly allocate medical resources, especially when there is a

critical shortage of them? This brings us to the conversation on the

ethics of healthcare rationing, which has never been more imperative

than today as we strive to recover from a global pandemic. The COVID-19 pandemic has exposed poor healthcare systems around the world, especially in my home country of India, where systemic inequities are highly prevalent – whether this be the lack of primary care providers, low medical supplies, inadequate hospital infrastructure, or shortages of medical devices. Those who can least afford these limited resources are disadvantaged the most, while the private healthcare sector continues to grow, providing for the urban rich. However, rationing simply based on socioeconomic status is evidently unfair, so here are some alternative approaches of distribution:


  • Aged-based approach: Most experts believe that a country should distribute its strained resources such that it simultaneously saves the most lives and maximizes the benefits received, either by prioritizing patients more likely to recover or have a longer post-treatment life. This is supported by the fair innings approach developed by Alan Williams, which contends that the lives of the young are of higher value as compared to patients who have lived a long life (i.e., already had a “fair inning”). [2]


  • Providers of the family: The policies of the World Bank contest that persons of working age should be given preference, as they often work to financially sustain themselves and their families. [3]


  • Economic approach: This approach claims that those less well-off, particularly in developing countries, deserve a higher priority as they are often more susceptible to poor health and possibly live in more vulnerable environments, wherein the spreading of infections is more likely. Thus, the treatment of these patients could contain the transmission of potential diseases. [4]


Despite all these considerations, no perfect solutions to rationing healthcare exist, and medical professionals, policymakers, and the public are stuck with tough choices. However, greater regulation, public and private partnerships, and standardization of healthcare across a country are essential and urgent to move forward. Along with this, an increase in awareness about bioethics, especially in developing countries, is imperative to gain a collective understanding of how to adequately respond to considerations of rationing and allocation.


If you would like to know more about the ethics of healthcare rationing, feel free to check out this episode of my podcast, where I spoke with Dr. Saumil Kapadia about allocating medical resources in a developing country like India, especially in a pandemic: 

"How do we fairly allocate medical resources, especially when there is a critical shortage of them?"
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Design Editor: Shanzeh Sheikh

[1] Singh P, Ravi S, Chakraborty S. COVID-19: Is India’s health infrastructure equipped to handle an epidemic? 2020 Mar 24[cited 2020 Apr 8]. Available from: front/2020/03/24/is-indias-health-infrastructure-equipped-to-handle- an-epidemic/

[2] Williams A. Intergenerational equity: An exploration of the ‘fair innings’ argument. Health Economics. 1997 Mar-Apr;.6(2), 117–32

[3] Wagstaff A. QALYs and the equity-efficiency trade-off. J Health Econ. 1991 May; 10(1), 21–41. doi: 10.1016/0167-6296(91)90015-f.

[4] Mahurkar, A. (2020). Ethics in the COVID-19 emergency: Examining rationing decisions. Indian Journal of Medical Ethics, 05(02), 168–169.

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