As we plan for future public health challenges like the fair distribution of a new malaria vaccine in sub-Saharan Africa, MEHP Online Faculty Director Ezekiel J. Emanuel—in a collaboration with University of Denver Sturm College of Law professor Govind Persad—delineates a framework for the allocation of scarce medical resources informed by lessons learned from COVID-19. In a June 2023 Lancet article titled “The Shared Ethical Framework to Allocate Scarce Medical Resources: A Lesson from COVID-19,” the pair offer 3 main points:

1. COVID-19 guidance documents from groups like the US Advisory Committee on Immunization Practices, the Nuffield Council in the UK, and the World Health Organization’s Strategic Advisory Group of Experts on Immunization all point us toward 5 ethical values that inform the allocation of resources:

• Maximizing benefits and preventing harm
  Directing resources first to those who can gain the most benefit and protection.

• Mitigating disadvantage
  Directing resources first to those who are disadvantaged because of income, race, or other characteristics.

• Equal moral concern
  Treating similar people similarly while acknowledging differences among populations, like disease burden, that may inform resource allocation.

• Reciprocity
  Directing medical resources first to those who have worked directly with people afflicted by the current health problem.

• Instrumental value
  Directing allocation first to those in a position to mitigate future harms—for example, health care providers working directly with patients.

2. Tiers for prioritizing the allocation of resources must “primarily emphasize instrumental value, minimizing harm, and mitigating disadvantage” in order to maximize their impact for populations that are immediately at risk, as well as those who may be affected in the future.

3. The implementation of a resource allocation plan requires careful attention to promote effectiveness, and to “ensure disadvantaged groups are not further disadvantaged.”

Drs. Emanuel and Persad argue that priority tiers, as they were deployed during the COVID-19 pandemic response, were both insufficiently nuanced and too inflexible. For example, any employee of a health system in the United States was eligible for priority vaccination—not just those in close proximity to patients. And at the same time, surpluses of COVID-19 vaccine were frequently thrown away rather than being reallocated to lower-priority individuals. Similarly, COVAX initially proposed distributing vaccines internationally based on each country’s population. This would have both ignored differences among countries in burden of disease and exacerbated shortages in areas with more demand.

They conclude that future challenges could better be approached by defining priority tiers more systematically, then allocating resources to meet widely recognized ethical values. They suggest that the implementation of resource distribution should be active, not passive—that texting eligible individuals or even going door-to-door would increase the uptake of needed treatments and reduce the risk of compounding health disparities. And finally, they recommend priority tiers that are less strictly bounded, so that medical resources can still be used even if they cannot be distributed to the highest-priority individuals.

This framework, they say, will contribute to a more ethical starting point for planning the allocation of scarce medical resources ahead of the next global pandemic. And it should inform discussions of resource allocation in other contexts, like the distribution of mpox, malaria, and cholera vaccines—which are all in short supply.

Read more about resource allocation lessons from COVID-19 in The Lancet:

Emanuel, Ezekiel J., and Govind Persad. “The Shared Ethical Framework to Allocate Scarce Medical Resources: A Lesson from COVID-19.” The Lancet 401, no. 10391 (June 3, 2023): 1892–1902.

And learn more about Dr. Emanuel’s approach to rationing and allocation of scarce medical resources—and receive continuing education credit—by taking this short, self-paced course, Rationing Care.