Unweighted lotteries and compounding injustice: reply to Schmidtet al

Abstract

I argue that Schmidt et al, while correctly diagnosing the serious racial inequity in current ventilator rationing procedures, misidentify a corresponding racial inequity issue in alternative ‘unweighted lottery’ procedures. Unweighted lottery procedures do not ‘compound’ (in the relevant sense) prior structural injustices. However, Schmidt et al do gesture towards a real problem with unweighted lotteries that previous advocates of lottery-based allocation procedures, myself included, have previously overlooked. On the basis that there are independent reasons to prefer lottery-based allocation of scarce lifesaving healthcare resources, I develop this idea, arguing that unweighted lottery procedures fail to satisfy healthcare providers’ duty to prevent unjust population-level health outcomes, and thus that lotteries weighted in favour of Black individuals (and others who experience serious health injustice) are to be preferred.

Centring race, deprivation, and disease severity in healthcare priority setting

“…Two papers respond to Schmidt et al's work. Alex James Miller Tate accepts their argument, 8 but, drawing on Hellman's criteria for the compounding of structural injustice, 9 suggests that their dismissal of unweighted ventilator lotteries is too quick. Tate argues that ventilator lotteries do not amplify inequalities.…”

“…However, Tate concedes that ventilator lotteries violate healthcare providers' duties to prevent further injustice, on the grounds that they ought to be actively 'leveraging the populationlevel effects of allocation frameworks to correct for past injustices, rather than merely trying to avoid making their effects worse'. 8 In their response, Douglas White and Bernard Lo, architects of the New Jersey ventilator allocation guidelines, take issue with Schmidt et al's contention that the guidelines pay no attention to inequity, drawing attention to the guidelines' prioritisation of younger patients and essential workers. 10 They argue that since people of colour are over-represented in frontline essential work, and are, due to health inequalities, more likely to suffer severe disease even when young, these criteria for ventilator allocation tend to offset race-based health inequality.…”

“…(Indeed, many people support lotteries because they destabilise the idea that those who are in better health—who are disproportionately white, wealthy, young, and non-disabled—are more deserving of lifesaving interventions.) However, Tate concedes that ventilator lotteries violate healthcare providers’ duties to prevent further injustice, on the grounds that they ought to be actively ‘leveraging the population-level effects of allocation frameworks to correct for past injustices, rather than merely trying to avoid making their effects worse’ 8…”