The Mixed Approach
Michael A. Gillette, Ph.D.

In this, the final installment of our treatment of ethical issues in the allocation of scarce resources, it is time to discuss the concept of a mixed approach to rationing. In past months we have seen that each of the possible approaches to rationing -- the market system, the lottery, and the committee procedure -- have displayed both strengths and weaknesses. Up until now, we have been faced with the unhappy necessity of choosing between the two desirable values of fairness and efficiency. The question left for us to pose, therefore, is whether or not an approach to allocation that mixes elements of each of these rationing systems can balance and satisfy these competing claims.

To begin to answer this question, I quote an excerpt from a "Practical Ethics” that I wrote in January of 1996. In that newsletter, I outlined a theory of fairness that was developed by John Rawls in his book A Theory of Justice. The excerpt reads as follows:

Let us begin the Rawlsian point of view by asking a simple question. How should a person who is taking care of two children proceed when a cake is to be divided between them? If the caretaker cuts the cake then at least one of the children will accuse him/her of preferring the other child. If one child cuts the cake and then distributes the pieces, then the other child will undoubtedly accuse the cutter of cutting unfairly. What should be done? The answer, as most parents know, is to ask one child to cut the cake and allow the other child to make the selection. By proceeding in this way, the first child is motivated to cut the two pieces equally, as any other cut will lead to him receiving a smaller than possible share...

...In other words, without knowing whether you would end up being the winner or the loser in an unequal division of the cake, it would make sense for you to worry first about what would happen if you ended up being the loser.

Imagine that I were to offer you two possible solutions to this problem. We could give all the cake to one child and none to the other, or we could split the cake evenly. If you know that you are one of the children but you don't know which one, it is only logical that you would prefer the equal split. You would rather reduce possible winnings than create a situation in which you would lose entirely. Since you don't know which child you are, you are unbiased in this choice. It is, therefore, fair.

While the above example is a great over-simplification of Rawls' view, it does display one important aspect of his position. According to Rawls, the fairest possible distribution of social goods is the one that a self-interested but unbiased person would rationally select. In some cases, that choice is one of equality. Where the outcome of equality is undesirable, however, the rational choice is the one that would benefit the least advantaged. This is true, because if you did not know whether you would be the winner or loser once your ignorance to your own situation is lifted and you become biased, you would naturally seek to avoid a very bad outcome.

Applied to the allocation of scarce resources, Rawls' view is very helpful. If I know that I live in a world in which some will receive care and some will not, how should the recipients of care be selected? According to Rawls, you must first forget what your own qualities are, since knowledge of that sort would make you biased. Once you are ignorant of your own position in society, as well as your own talents, abilities, and specific characteristics, you can rationally determine which characteristics are fair bases for judging who wins and who loses in the allocation of resources.

Would we want to live in a world where strict equality is guaranteed by giving resources to no one unless all can be served? This seems irrational since it sentences you to a loss regardless of who you turn out to be.

Would we choose to live in a world where the wealthy can buy all the health care they want (or need), and the rest are left to do without? That is not likely to be acceptable since we would be worried that we might end up being among the less wealthy.

Would we want to live in a world where people were selected based on their ability to speak convincingly to a committee, or to look cute on TV? These qualities would seem to be unacceptable.

Finally, would we want to live in a world where resources are doled out randomly, regardless of the likelihood that any particular recipient will actually be able to benefit from the service they receive? That also seems irrational since it is likely to generate such significant inefficiency that many who might have otherwise been saved, will die.

According to the Rawlsian model, it seems that a mixture of approaches is actually the fairest method of allocation. We would each, if unbiased, desire that scarce resources be used as efficiently as possible, so that our own individual chances of benefiting would improve. We would not, however, want to see 'efficiency' defined in idiosyncratic ways that benefit certain socio-economic classes, races, or religious.

It is likely, if we could be unbiased for a moment, that the scheme most likely to gain our favor would be one that balances medical efficiency -- the ability to save as many potential recipients as possible -- with a random selection that does not favor anyone on the basis of social criteria. This mixed approach would rely on a restricted concept of efficiency to establish a pool of recipients from which the final choice is made by random lottery. The introduction of random choice recognizes the equal value of the lives of those people who can actually benefit by receiving care.

This mixture does more than just increase comfort levels for all parties involved. It is a mixed approach to allocation that makes real strides toward reconciling fairness with efficiency.