The Lottery & Political Approach
Michael A. Gillette, Ph.D.

In order to continue our discussion of the ethical issues involved in the allocation of scarce resources, it is necessary this month to touch on two prominent approaches - choice by lottery (the Lottery Approach) and choice by committee (the Political Approach).

To review briefly, last month's discussion dealt with the possibility of applying a market approach to the allocation of scarce resources. Although this approach does have advantages, it also has at least one major drawback. The market seems to discriminate unfairly against those with moderate or low financial assets.

The lottery approach is often developed in response to the concern that people have a right to receive healthcare even when they cannot afford it. According to the lottery, recipients of care are chosen by random selection. The random element is provided either in an artificial way, such as drawing a name from a hat, or naturally, by serving people on a first-come first-served basis.

The advantage of the lottery is clear. By providing every individual with an equal opportunity at receiving the resource in question, fairness seems to be maintained. Losers in a lottery are more likely to accept their misfortune as 'bad luck'. Furthermore, we are all used to waiting for the things like the bus. If one bus gets full, we know that we will have to wait for the next. There is nothing personal involved in missing a bus. It just seems fair that those waiting on line the longest should get the first available seats.

Although the lottery seems much more fair than does the market, this appearance can be deceiving. On second glance it becomes apparent that the fairest looking procedure -- the first-come first-served approach that does not even allow for corruption by human tampering -- has a serious built in bias.

If we ask ourselves who is most likely to be at the head of the waiting list, assuming that there is no intentional tampering, the answer is obvious that the person who first developed a need for services will have been waiting longest. Since that person has been waiting the longest, we reason, it is only fair that he should receive care first. This impression, however, is likely to be incorrect. The person who is most likely to be at the head of the line is the person who was first diagnosed with a need, and who was educated and aware enough to seek out services where they are offered. The wealthy are most likely to benefit from a lottery.

Consider two individuals with symptoms of a kidney problem. The wealthy one is employed in a salaried position, and can afford to take time off from work to see the doctor. Furthermore, she has a primary care physician who knows her and sees her annually for routine care. This woman has read a bit about kidney ailments and becomes concerned when she doesnÌt feel well. After all, given her good diet and regular exercise she is sure to notice when her health is not quite right. She goes directly to her physician and is diagnosed quickly. Her physician orders the necessary tests quickly, and the costs are covered by her private insurance.

Consider a second person. He is a day laborer who cannot afford to take time from work. He does not have a relationship with any single doctor and his medical history is not neatly documented in one place. It is unlikely that this person will see a doctor until he is far too sick to go to work, and even then the project of making a diagnosis might be much more difficult given his unknown history. This person, who does not have extensive education, may not know what a nephrologist is, and may not be able to fully advocate on his own behalf. It is likely that this gentleman, who might have become ill prior to his competitor for resources, will find himself further back on the waiting list.

In addition to the blatant unfairness of a lottery system that caters to the wealthy, we must also be concerned that the people who need the most immediate attention may not be first on line. In this case, not only is the lottery unfair, it is inefficient. It might be the case that the person at the front of the waiting list is not a good match for the next available transplantable organ, for instance. Or he may be so sick that he will die whether or not care is provided. In either event, an organ that could have saved someone else will be 'wasted' on an inappropriate recipient.

To deal with these problems, we shift to the application of a committee selection procedure which is often referred to as the political approach. According to this mechanism, a recipient of care is selected by committee on the basis of specific criteria.

The first question about the political approach that must be answered is 'What are the criteria upon which a person is selected?' Should social criteria matter? Should people with dependents take priority over single individuals? Should gainfully employed tax payers be selected prior to someone who is unemployed? Should we restrict the bases of choice to clinical factors only, such as likelihood of success or tissue match? Can we even draw a line between the social criteria and the medical criteria? Where would life-expectancy fit in for people who live in violent neighborhoods? When does age become a reasonable clinical factor?

The problem with the political approach is that as it seeks to deal with the inefficiency of the lottery, it reintroduces an overt element of selection that smacks of unfairness. It seems that while efficiency must be maintained in order to do the best we can with the little resources that we have, efficiency conflicts with fairness. Ultimately, do we have to choose from among only bad options, or is a balanced answer available?

Next month, we will finish our analysis of this topic with a discussion of the mixed approach.