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William A Silverman and Iain Chalmers suggest that it is ethical to
use a randomised controlled trial as a way of deciding who should get a
treatment that is as yet unevaluated and that is in short supply.(1) We
argue elsewhere for important ethical qualifications to this proposal.(2)
Here, we dispute the claim that an historical practice of allocating
scarce resources by lot is ethical justification for it. Distributive
justice often requires that we allocate such resources according to
individual need, expected utility, or desert. It would thus be
permissible, or even obligatory, to allocate such resources by lot if and
only if the individuals in question were equally in need of the resources,
expected the same amount of utility from them, or were equally
deserving.(3)
Now we can relate the just distribution of scarce resources to the
need to evaluate them in randomised controlled trials. When proposing such
a trial, it would be ethically important to establish that the decision to
do research is really independent of the decision to randomise, otherwise
there would be a potential conflict of interests between serving the best
interests of the current population and those of a future society. The
interests of the current population are best served by distributing scarce
resources fairly while the best interests of a future population are best
served by doing good science, however the resources are distributed.
Science could compromise just distribution of resources by recruiting a
study population from society who are least in need of the resources,
least likely to benefit from them, or smaller in size than what resources
are available, for example. In addition, there may be money available to
do research but not for routine health care delivery which would give an
incentive to provide some access albeit not in a just way. There would
thus be a trade-off between the sheer numbers of people getting the
resources and the distributing of those resources fairly among the
population.
Sarah JL Edwards
Lecturer in Ethics in Medicine
Simon Kirchin
Lecturer in Philosophy
University of Bristol, UK.
1. Silverman William A, Chalmers I. Casting and drawing lots: a time
honoured way of dealing with uncertainty and ensuring fairness. BMJ 2001;
323: 1467-1468.
2. Edwards SJL., Kirchin S. Rationing, randomising, and researching health
care provision. Journal of Medical Ethics 2002; 28 (1). Forthcoming.
3. Harris J. The Value of Life: an Introduction to Medical Ethics.
Routledge. London. 1985.
Rationing, randomising, and researching
Rationing, Randomising, and Researching
Dear Editor,
William A Silverman and Iain Chalmers suggest that it is ethical to
use a randomised controlled trial as a way of deciding who should get a
treatment that is as yet unevaluated and that is in short supply.(1) We
argue elsewhere for important ethical qualifications to this proposal.(2)
Here, we dispute the claim that an historical practice of allocating
scarce resources by lot is ethical justification for it. Distributive
justice often requires that we allocate such resources according to
individual need, expected utility, or desert. It would thus be
permissible, or even obligatory, to allocate such resources by lot if and
only if the individuals in question were equally in need of the resources,
expected the same amount of utility from them, or were equally
deserving.(3)
Now we can relate the just distribution of scarce resources to the
need to evaluate them in randomised controlled trials. When proposing such
a trial, it would be ethically important to establish that the decision to
do research is really independent of the decision to randomise, otherwise
there would be a potential conflict of interests between serving the best
interests of the current population and those of a future society. The
interests of the current population are best served by distributing scarce
resources fairly while the best interests of a future population are best
served by doing good science, however the resources are distributed.
Science could compromise just distribution of resources by recruiting a
study population from society who are least in need of the resources,
least likely to benefit from them, or smaller in size than what resources
are available, for example. In addition, there may be money available to
do research but not for routine health care delivery which would give an
incentive to provide some access albeit not in a just way. There would
thus be a trade-off between the sheer numbers of people getting the
resources and the distributing of those resources fairly among the
population.
Sarah JL Edwards
Lecturer in Ethics in Medicine
Simon Kirchin
Lecturer in Philosophy
University of Bristol, UK.
1. Silverman William A, Chalmers I. Casting and drawing lots: a time
honoured way of dealing with uncertainty and ensuring fairness. BMJ 2001;
323: 1467-1468.
2. Edwards SJL., Kirchin S. Rationing, randomising, and researching health
care provision. Journal of Medical Ethics 2002; 28 (1). Forthcoming.
3. Harris J. The Value of Life: an Introduction to Medical Ethics.
Routledge. London. 1985.
Competing interests: No competing interests