Lottery or Triage? Controlled Experimental Evidence from the COVID-19 Pandemic on Public Preferences for Allocation of Scarce Medical Resources

BackgroundBioethicists have advocated lotteries to distribute scarce health care resources, highlighting the benefits that make them attractive amid growing health care challenges. During the COVID-19 pandemic, lotteries were used to distribute vaccines within priority groups in some settings, notably in the United States. Nonetheless, limited evidence exists on public attitudes toward lotteries.MethodsTo assess public support for vaccine allocation by lottery versus expert committee, we conducted a survey-based experiment during the pandemic. Between November 2020 and May 2021, data were collected from 15,380 respondents across 14 diverse countries. Respondents were randomly allocated (1:1) to 1 of 2 hypothetical scenarios involving COVID-19 vaccine allocation among nurses: 1) by lottery and 2) prioritization by a committee of expert physicians. The outcome was agreement on the appropriateness of the allocation mechanism on a scale ranging from 0 (<i>strongly disagree</i>) to 100 (<i>strongly agree</i>), with differences stratified by a range of covariates. Two-sided <i>t</i> tests were used to test for overall differences in mean agreement between lottery and expert committee.FindingsMean agreement with lottery allocation was 37.25 (95% confidence interval [CI] 34.86-39.65), ranging from 21.1 (95% CI 15.07-27.13) in Chile to 62.33 (95% CI 54.45-70.21) in India. In every country, expert committee allocation received higher support, with mean agreement of 61.19 (95% CI: 60.04-62.35), varying from 51.25 in Chile to 69.77 in India. Greater agreement with lotteries was observed among males, higher-income individuals, those with lower education, and those identifying as politically right leaning.ConclusionsDespite arguments for lottery-based allocation of medical resources, we found low overall public support, albeit with substantial variation across countries. Successful implementation of lottery allocation will require targeted public engagement and clear communication of potential benefits.HighlightsThis study surveyed 15,380 respondents from 14 diverse countries during the COVID-19 pandemic, analyzing international agreement with the appropriateness of using lottery allocation for scarce health care resources.There was universal preference for allocating vaccines by expert committee rather than by lotteries, but there was significant variation in agreement between countries, indicating the need for region-specific policy approaches.Successful implementation of lottery allocation requires targeted public engagement and communication of their benefits, especially with groups less supportive of lotteries.