One of the ethical conflicts facing public health is that which pits utilitarian ethics against egalitarian ethics, that is, the principle of maximizing aggregate health against the principle of moral equality. Public health codes and guidelines usually incorporate both of these principles because the ethical objectives of public health pursue the greatest health for the population and respect for the equality of all people and greater equity in health. The conflict between the two is particularly evident in contexts of health care rationing. In such contexts, the utilitarian ethic is the winner, contrasting with equality and equity in public health. The thesis I defend here is that this conflict stems from a deficient interpretation of both ethics, which should be corrected as follows: on the one hand, utilitarianism should be interpreted on the basis of the principle of equality and not against it, and, on the other, egalitarianism should include utilitarian decisions when these are the best way to interpret the principle of equality. By way of conclusion, public health codes and guidelines should incorporate this reconciliation between utility and equality in order to better guide ethical decisions in public health, including tragic choices in contexts of rationing and disasters.

Healthcare rationing is unavoidable in systems constrained by limited resources. While decisions about who should be treated are ethically complex, they must reflect not only efficiency concerns but also socially accepted values. This study aims to develop a multi-criteria decision-support system - Vital Priority System, that prioritise patients using a Random Forest algorithm trained on multiple rationing criteria endorsed by Portuguese civil society. Based on a Portuguese online survey data, the model incorporates nine dimensions: clinical need, life expectancy gain, quality of life improvement, age, waiting time, parental status, lifestyle responsibility, and social role. Our results show that clinical need, expected treatment effectiveness, waiting time and age were the most influential, followed by parental status. Lifestyle and social role factors were least weighted. The proposed system enables the classification of patients as ‘priority’ or ‘non-priority’, providing healthcare professionals with a transparent, consistent, and ethically grounded tool to support decision-making. This study advances the literature by operationalising, for the first time in the Portuguese context, public preferences in a replicable AI-based framework for fairer patient prioritisation.Supplementary InformationThe online version contains supplementary material available at 10.1038/s41598-025-14363-8.

Public opinion on public healthcare rationing regarding gender identity is crucial for democratic policymaking because of public concern regarding sexual orientation, gender identity, and gender expression (SOGIE). Based on rationality theory, rationally equitable rationing depends on equity orientations and prioritizing public interest over self-interest. Specifically, equity orientations include those toward equality, need, personal contribution, and social contribution. To project public preference for public healthcare rationing, this study involved 744 Chinese people in a web survey. These participants indicated their preferences for public healthcare rationing and self-interest, public interest, and equity orientations, including those based on contribution, equality, and need. Regression analysis based on the rationality framework showed that public healthcare rationing that was equal across SOGIE identities was predominantly preferable, based on rational equity. In contrast, public healthcare rationing without considering SOGIE was less preferable, and rationing unequally across gender identities was not preferred. These results imply that affirmative and egalitarian rationing is the most rationally equitable approach.

Abstract Introduction: Chronic noncancer pain affects approximately one-fourth in population-based studies calling for more nuanced insights by applying the Graded Chronic Pain Scale-Revised (GCPS-R) framework for classifying graded chronic noncancer pain distribution in national disease surveillance. Objectives: The GCPS-R framework was included in the comprehensive questionnaire repeatedly used in the Danish National Health and Morbidity Surveillance program to provide more distinct measures for chronic non-malignant pain disease manifestation in Denmark. Methods: A cross-sectional study inviting randomly 25,000 adults 16 years and older to self-report questionnaires comprising the GCPS-R framework as part of the nationwide Danish National Health Survey 2023. Prevalences (%) and multivariate-adjusted odds ratios (ORs) with 95% confidence intervals (95% CI) by ordinal logistic regression were calculated for GCPS-R by sex, area of living, age, country of origin, socioeconomic factors, body mass index, and Charlson Comorbidity Index. Results: The prevalence of chronic noncancer pain was overall 28.1% (95% CI 27.2%–29.0%) in 8,643 included individuals without cancer diagnosis counting 7.4% (6.9%–8.0%) with mild-impact, 7.1% (6.6%–7.6%) with bothersome-impact, and 13.6% (12.9%–14.4%) with high-impact chronic noncancer pain. Women had 66% (odds ratio (OR) 1.66; 95% CI 1.50–1.84) elevated odds of more severely graded chronic noncancer pain referenced to men. Socioeconomic factors influenced odds inversely. Body mass index was related to GCPS-R by dose-response effects of more than doubled elevated odds in World Health Organization obese class II (2.42; 1.92–3.06) and obese class III (4.43; 3.30–5.93) referenced to normal body mass index individuals. Comorbidity elevated odds of more severely graded chronic noncancer pain by 86% (1.86; 1.57–2.19) referenced to individuals without comorbidity. Conclusions: More than one-quarter individuals reported chronic noncancer pain characterized particularly by high-impact graded chronic noncancer pain when applying the GCPS-R framework for classifying graded chronic noncancer pain distribution in national disease surveillance for rational health care administration.

BackgroundFormal rationalization is the process whereby an organization achieves the greatest efficiency through the control of work and is occurring in the United States as an effort to control healthcare costs. This study aimed to explore the McDonaldization thesis’s impact, a contemporary form of formal rationalization, on the academic physicians teaching in a clinical setting where patient care is also being delivered.MethodsFocus groups of physicians from a single academic medical in the Southeast United States were conducted. Eighteen physicians participated in four groups, representing seven specialties. Session transcripts and field notes served as the data set analyzed.ResultsFour major categories of impact on physicians who teaching in the clinical setting were identified: (1) they hold the view that rationalizing processes will diminish positive features of practicing medicine for learners (2) the compensation plan emphasizes clinical productivity and efficiency at the expense of time to teach (3) the appropriate use of patient cares algorithms embedded in the electronic health care system is an emerging learning need that they are struggling to meet (4) this group of academic physicians is adapting in a number of ways to accommodate to these changes.ConclusionPhysicians teaching in clinical settings has changed in response to the continued formal rationalization of healthcare. Physicians in this study expressed concern about the immediate and long-term consequences of these changes but also described their strategies for adapting. Despite their distress, they are adapting to try to preserve and enhance their teaching efforts despite the increasing demands of patient care. Our results support the previous recommendation of teaching job crafting and suggest the potential value of team job crafting. However, these group-level approaches must be accompanied by systems changes that address perception of inequity of recognition between clinical work and teaching held by these physicians.Clinical trial numberNot applicable.

It has been over three decades since it was predicted that the processes of formal rationalization would lead to dire consequences for all physicians. Prompted by a social concern about elevated burnout rates in U.S. physicians, there have been some investigations about organizational influences on their work lives. However, these studies have not used formal rationalization as a conceptual framework. This exploratory study was undertaken to examine the work lives of a group of academic physicians in the United States using McDonaldization thesis features as the organizing framework. Eighteen academic physicians were recruited from a single academic medical center in the United States. Focus groups were conducted by a physician and a medical sociologist, and the transcripts analyzed. Academic physicians could identify programs consistent with the McDonaldization of health care and reacted variably to them. The features were found to interact in differing ways with control over work being superordinate to the other three features. There was evidence for the consequence of irrationality in that inefficiency was increased and the quality of the patient interaction reduced. Physicians’ reactions to overall changes to their work are variable ranging from distress to varying degrees of acceptance.

To examine the association between insulin rationing and health care utilization. Cross-sectional study of all 2021 National Health Interview Survey respondents with diabetes using insulin. Logistic regression and zero-inflated negative binomial regression models examined associations between insulin rationing (skipping, delaying, or reducing insulin to save money) and 1) emergency department (ED) visit or hospitalization and 2) number of urgent care visits. All analyses were age-stratified and used survey weights. Among 982 respondents representing 7,593,944 U.S. adults (median age 61 years, 47% women), 17% reported rationing. Among adults 18-64 years old, rationing was not significantly associated with health care utilization. Among adults ≥65 years old, rationing was associated with more urgent care visits (relative risk 2.1, 95% CI 1.2-3.6) but not with odds of ED visit or hospitalization (odds ratio 0.7, 95% CI 0.3-1.4). Insulin rationing was not associated with higher health care utilization, but concurrent rationing of health care may mask a relationship.

Over the last decade managed care has become the dominant form of health care delivery, because it has reduced the cost of health care; however, it has also created serious conflicts of interest for physicians and has threatened the integrity of the traditional physician-patient relationship. In this Article, Dr. Grochowski argues that the efficiencies created by managed care are one time savings and will not in the long run reduce the rate of rise of health care expenditures without a concomitant plan to ration health care. He explores the traditional physician-patient relationship and concludes: a) that while rationing of health care is inevitable, physicians must not ration care at the bedside; b) that physicians must be advocates for their patients; c) that physicians must avoid conflicts of interest whenever possible; d) that physicians must put the needs of the patient before their own self-interests; and e) that physicians must act in ways to promote trust in their relationship with patients.

Introduction: While implantable cardiac defibrillators (ICD) decrease sudden cardiac death, disparities in ICD use remain. The COVID-19 pandemic created strains on the US healthcare system that may have exacerbated these disparities. Methods: Using the US NCDR registry of primary and secondary prevention ICD implants, we compared sex, racial and ethnic disparities for 239,014 patients, aged 19-90 years, grouped into three time intervals from 2016 to 2022: Pre-COVID, COVID and Post-COVID. Centers without consistent reporting were excluded, as were patients with incomplete sex, race or ethnicity data. ICD implantation rates were compared using a Poisson regression model with interaction tests for sex, race and ethnicity by time window to see if disparities changed within this period. Implant rates by indication were also assessed. Results: Overall ICD implants decreased over the study period (Figure 1) with an average monthly rate of 3271 in the first three months of 2016 declining to 2334 in the last three months of 2022 (p=0.017). Disparities in ICD implantation for women, racial and ethnic minorities were observed pre-COVID and persisted (Table 1). Average ICD implant rates during these time periods varied by race with predominance in White patients. While gaps in ICD implant persisted, the disparities did not worsen during COVID-19 by sex, race or ethnicity (p-value for interactions were 0.79; 0.47; and 0.095, respectively). There was a more significant decrease in primary prevention ICD compared to secondary prevention ICD (p<0.0001), but similarly, there was no significant interaction based on sex, race and ethnicity. Conclusion: Since COVID-19, a period of extreme healthcare rationing, overall ICD use decreased. Historical gaps in ICD implantation for women, racial and ethnic minorities persisted but did not increase. While it is encouraging that disparities did not worsen during a time of limited resources, there is an ongoing need for greater equity in ICD implantation.

The rationing of healthcare resources has emerged as an important issue, which has been discussed by medical experts, policy-makers, and the general public. We consider a rationing problem where medical units are to be allocated to patients. Each unit is reserved for one of several categories, and each category has a priority ranking over the patients. We present a class of allocation rules that respect the priorities, comply with the eligibility requirements, allocate the largest feasible number of units, and do not penalize agents for rising in the priority ranking of a category. The rules characterize all possible allocations that satisfy the first three properties and are polynomial-time computable.

Clinical prediction models (CPMs) are tools that compute the risk of an outcome given a set of patient characteristics and are routinely used to inform patients, guide treatment decision-making, and resource allocation. Although much hope has been placed on CPMs to mitigate human biases, CPMs may potentially contribute to racial disparities in decision-making and resource allocation. While some policymakers, professional organizations, and scholars have called for eliminating race as a variable from CPMs, others raise concerns that excluding race may exacerbate healthcare disparities and this controversy remains unresolved. The Guidance for Unbiased predictive Information for healthcare Decision-making and Equity (GUIDE) provides expert guidelines for model developers and health system administrators on the transparent use of race in CPMs and mitigation of algorithmic bias across contexts developed through a 5-round, modified Delphi process from a diverse 14-person technical expert panel (TEP). Deliberations affirmed that race is a social construct and that the goals of prediction are distinct from those of causal inference, and emphasized: the importance of decisional context (e.g., shared decision-making versus healthcare rationing); the conflicting nature of different anti-discrimination principles (e.g., anticlassification versus antisubordination principles); and the importance of identifying and balancing trade-offs in achieving equity-related goals with race-aware versus race-unaware CPMs for conditions where racial identity is prognostically informative. The GUIDE, comprising 31 key items in the development and use of CPMs in healthcare, outlines foundational principles, distinguishes between bias and fairness, and offers guidance for examining subgroup invalidity and using race as a variable in CPMs. This GUIDE presents a living document that supports appraisal and reporting of bias in CPMs to support best practice in CPM development and use.

This study aims to investigate the impact of organizational culture (i.e., rational, hierarchical, and group) on healthcare supply chain resilience (SCR) in Jordan. This paper further examines the moderating role of technology integration on the relationship between organizational culture and healthcare SCR. Cross-sectional research was conducted, and participants were recruited from different hospitals in Jordan. An electronic survey was employed to collect the responses from 304 participants, including senior professionals designated as doctors, nurses, ray technicians, physical therapists, procurement officers, pharmacists, and lab technicians with more than three years of work experience. There was no statistically significant influence of rational culture on healthcare SCR (p-value = 0.156) and an adverse impact of hierarchical culture on healthcare SCR (p-value = 0.030). Group culture had a statistically significant impact on healthcare SCR (p-value = 0.007). Technology integration had an influential moderating influence on the association between rational culture and healthcare SCR (p-value = 0.042) and the association between hierarchical culture and healthcare SCR (p-value = 0.0129). However, technology integration had no moderating influence on the association between group culture and healthcare SCR (p-value = 0.331). The analysis revealed that group culture has an influential impact on healthcare SCR, while hierarchical culture has a negative impact on healthcare SCR. Moreover, technological integration was observed to improve the beneficial influence of rational culture and the negative effects of hierarchical culture on healthcare SCR. However, the technology integration was not observed to moderate the relationship between group culture and healthcare SCR. Acknowledgment The author acknowledges all the associated personnel who, in any reference, contributed to the completion of this study.

Background. Rationing of health care—restricting patients’ access to potentially beneficial health care interventions through non-market instruments—is a natural feature of all health care systems as they operate under resource constraints. The purpose of this study is to characterize rationing practices and the attitude of doctors themselves to it, with an emphasis on comparing Russia and the United States and on changes in the perception of rationing during the COVID-19 pandemic. Methods. We conducted a bibliometric analysis of publications in the medical scientific literature since 1989 on the issue of rationing of medical care. To characterize rationing practices in Russia and the United States and the attitudes of doctors towards them, we used data from published studies and data from semi-structured in-depth interviews with 28 Russian doctors. Results. Despite the increasing frequency of publications related to the topic of resource allocation over the past 20 years, studies using the term “rationing” are rare. Both Russia and the USA have practices of explicit and implicit rationing. In Russia they are more diverse and widespread. In both countries, doctors prefer implicit rationing and do not want open discussion of these issues. The practice of rationing is institutionalized. In Russian medical organizations its most common form is a chain of permissions for the use of resources. But most doctors believe they are not rationing care. The pandemic briefly brought the topic of rationing into the public sphere, but then its discussion was limited. The probable reason is that medical practice during the pandemic was carried out within the previous legal framework. Professional organizations have developed several recommendations for rationing, but their usefulness and level of acceptance by professionals and the public is unclear. Conclusions The transition from implicit to explicit rationing is extremely difficult, but is necessary to ensure equitable patient access to scarce medical resources and the effective functioning of health care systems. A major barrier to the explicit and informed use of rationing instrument is the limited public acceptance of it and the reluctance of professional communities to make public decisions that maximize public benefit by prioritizing access to effective interventions.

Healthcare resources are necessary for individuals to maintain their health. The Chinese government has implemented policies to optimize the allocation of healthcare resources and achieve the goal of equality in healthcare for the Chinese people since the implementation of the new medical reform in 2009. Given that no study has investigated regional differences from the perspective of healthcare resource agglomeration, this study aimed to investigate China's healthcare agglomeration from 2009 to 2017 in China and identify its determinants to provide theoretical evidence for the government to develop and implement scientific and rational healthcare policies. The study was conducted using 2009-2017 data to analyze health-resource agglomeration on institutions, beds, and workforce in China. An agglomeration index was applied to evaluate the degree of regional differences in healthcare resource allocation, and spatial econometric models were constructed to identify determinants of the spatial agglomeration of healthcare resources. From 2009 to 2017, all the agglomeration indexes of healthcare exhibited a downward trend except for the number of institutions in China. Population density (PD), government health expenditures (GHE), urban resident's disposable income (URDI), geographical location (GL), and urbanization level (UL) all had positive significant effects on the agglomeration of beds, whereas both per capita health expenditures (PCHE), number of college students (NCS), and maternal mortality rate (MMR) had significant negative effects on the agglomeration of institutions, beds, and the workforce. In addition, population density (PD) and per capita gross domestic product (PCGDP) in one province had negative spatial spillover effects on the agglomeration of beds and the workforce in neighboring provinces. However, MMR had a positive spatial spillover effect on the agglomeration of beds and the workforce in those regions. The agglomeration of healthcare resources was observed to remain at an ideal level in China from 2009 to 2017. According to the significant determinants, some corresponding targeted measures for the Chinese government and other developing countries should be fully developed to balance regional disparities in the agglomeration of healthcare resources across administrative regions.

Purpose: Here we describe the challenges and procedures adopted to ensure safe paediatric surgery services during the COVID-19 pandemic at the paediatric surgery department in non-Covid-19 wing of Dhaka Medical College Hospital-1. Materials and Methods: Design: Retrospective study. Setting: Department of paediatric surgery in non-Covid- 19 wing of Dhaka Medical CollegeHospital-1, a tertiary care academic medical center in Dhaka, Bangladesh. Participants and duration: All patients who were admitted in the department of paediatric surgery in Dhaka Medical College Hospital-1 from March 1 through June 30, 2020. Methods: We identified patients with or without a rRTSARS- CoV-2 PCR receiving care at the department of paediatric surgery. The healthcare professionals were trained to clean, disinfect, use of PPEs, and other wastes were disposed of as per waste management protocols. Data collection & analysis: Patient data were manually abstracted from the medical record for evaluation. Responses were analysed using Microsoft Excels & SPSS, and presented as categorical data and percentages. Main outcome measures: We describe patient characteristics including demographics, presenting symptoms, type of treatment (Surgery vs Non Surgery), outcomes (morbidity & mortality), hospital stay, and distance travelled for treatment. Results: A total of 320 paediatric surgical patients were included in this study, among all patients about 66.87% patients were male child and 79.06% patients required surgeries. There were 5 patients with confirmed COVID- 19, who were transferred to the Covid-Surgical unit. During this period, there were 4 (1.25%) children who died due to non-COVID related causes. In surgical group only 24(7.5%) patients developed postoperative complications. Length of hospital stay of 44 (13.75%) of non-surgical patients were less than 72 hours, whereas 141 (40.06%) of surgical patients were more than 72 hours. Majority of patients of both groups travelled more than 100 km distance for treatment. Conclusions: This corona crisis has provided an opening for rational health care and formulating global policies. So that in future such pandemics can be tackled more carefully and consistently with advancing knowledge and better preparation. Journal of Paediatric Surgeons of Bangladesh (2019) Vol. 10 (1 & 2): 15-21

Patient satisfaction is a crucial metric to gauge the quality of medical services, but the psychological factors influencing patient satisfaction remain insufficiently explored. This study examines these psychological factors by applying the theory of bounded rationality to 1,442 inpatients in Hangzhou, China, whose data were collected using a questionnaire. One-way ANOVA, correlation analysis, and hierarchical regression were used to analyze patient satisfaction and its associated factors. Additionally, the path analysis of the structural equation model revealed the mechanisms behind the key psychological factors that influenced patient satisfaction. Medical risk perception, the social cognition of the medical environment, and social desirability bias had significant positive impacts on patient satisfaction. By contrast, negative emotions had a significant negative impact on patient satisfaction. Notably, patients' negative emotions had both a suppressive effect and a positive moderating effect on the relationship between medical risk perception and patient satisfaction. Similarly, social desirability bias had a suppressive effect on the correlation between the social cognition of the medical environment and patient satisfaction, albeit with a negative moderating effect. These results suggest that when evaluating and improving patient satisfaction, accounting only for the factors that directly influence medical service quality is insufficient, as the indirect and moderating effects of patients' negative emotions and the social cognition of the medical environment must also be considered. Medical service providers should thus address patients' negative emotions, establish good doctor-patient relationships, optimize service environments, provide managers with medical risk education and training on negative emotions, and prioritize patient-centered care. Additionally, the government and relevant health departments should optimize medical policies, enhance fairness and accessibility, and create a positive social cognitive environment through public education and awareness campaigns.

Compared to the previous year, the share of healthcare expenditure in the state budget of Ukraine has decreased, which is associated with increased funding for the security and defense sector. In terms of gross domestic product, healthcare spending has reduced to 2.8 %, which corresponds to the figures for 2019. These circumstances indicate the importance of proper budget utilization, including effectively regulating medicine prices. One of the key elements of rational healthcare budget usage is the development and implementation of external reference pricing (ERP). A well-formulated and implemented ERP policy for pharmaceuticals contributes to improving patient access to essential medicines (EMs). The aim of this study is to analyze the current status of ERP implementation in Ukraine and provide recommendations for improving this policy. Materials and methods. During the research process, an analysis of the ERP’s current regulatory framework was conducted, and ERP implementation in Ukraine was assessed according to adherence to the 14 best practice principles of ERP proposed by Sullivan, Kanavos & Kalo in 2015. Results. In Ukraine, ERP has been introduced for medicines from the National Essential Medicine Lists (NEML) and the “Affordable Medicines” program. The Ministry of Health (MoH) of Ukraine has approved a Register of marginal wholesale prices for medicines purchased with state budget funds and subject to price regulation. Currently, the register includes 1239 medicinal products, of which 1233 are from NEML and 6 have undergone Health Technology Assessment (HTA). Approximately 58 % of medicines have a set price through ERP, 24 % are regulated by internal reference pricing (IRP), and nearly 18 % have declared prices. This indicates a lack of uniformity in approaches to price regulation for medicines and requires further improvements. According to the latest update of the Register of medicines for reimbursement under the state medical guarantees program, there are 486 medicines, including 72 insulins and 21 immunosuppressive medicines (184 medicines are provided with co-payment). Different approaches, including different reference countries and price calculation algorithms, are applied for the price regulation of medicines in NEML and the “Affordable Medicines” program. An assessment of the implementation of the ERP system in Ukraine based on the 14 best practice principles of ERP proposed by Sullivan, Kanavos & Kalo in 2015 showed that the current policy does not adhere to all principles. Conclusions. The analysis revealed different approaches to pricing for medicines NEML and the “Affordable Medicines” program, indicating the need for harmonizing pricing policies for different lists. The adoption of a unified positive list can contribute to improving pricing policies and efficient resource utilization. Collecting, disseminating, and exchanging data on drug prices is crucial to support transparency in pricing and its control. Regular monitoring of prices in the market will help ensure compliance with pricing policies and take appropriate measures in case of violations. The implementation of a unified pricing regulation policy for medicines in Ukraine is an important step towards European integration and compliance with international standards.

Abstract In England, coverage for treatment of post-traumatic stress disorder (PTSD), a health condition that disproportionately affects forced migrants, is universal, in principle provided free of charge to all. Yet, multiple informal access barriers typically arise and informal systems of social triage may emerge. Using intersectional analysis, this study asks what political and moral rationalities inform social triage in the NHS. It is particularly attentive to how and why a supposedly universal service reproduces differential racialisation, in which multiple and co-existing populations are stratified and ranked as more or less belonging to a nation. Fieldwork was conducted in two waves, in 2015-2016 and in 2019-2021. It included six months of participant observation in an NGO; 21 semi-structured interviews with health professionals across 16 different NHS and NGO service providers, purposively sampled until saturation was reached; six interviews with mental health commissioners and national policymakers; and analysis of grey literature. Transcripts and fieldnotes were analysed inductively to identify themes using NvivoR1. Results were validated by interviewees. Despite being covered, undocumented migrants and asylum seekers were systematically excluded from NHS PTSD services, through social triage. People with refugee status were prioritised. Mental health care providers consciously and subconsciously reproduced differential racialisation, which generated health inequality. This was facilitated by: austerity; omitting immigration status in measurement of health inequality; securitisation of mental health services and minoritised Muslim populations; and bifurcated activism in which the forced migrant sector was disconnected from established struggles to combat racism in mental health care. Policies extending coverage to undocumented migrants and asylum seekers must be accompanied by extra monitoring, as well as financial, political and social support to service providers. Key messages • Health professionals informally, but systematically, reproduce differential racialisation in the rationing of health care through practices such as obfuscation and silencing critique. • Informal systems of social triage erode universal health coverage. This is exacerbated in contexts of austerity, where health professionals use their discretion to ration limited resources.

A priority system has traditionally been the protocol of choice for the allocation of scarce life-saving resources during public health emergencies. COVID-19 revealed the limitations of this allocation rule. Many argue that priority systems abandon ethical values, such as equity, by discriminating against disadvantaged communities. We show that a restrictive feature of the traditional priority system largely drives these limitations. Following minimalist market design, an institution design paradigm that integrates research and policy efforts, we formulate pandemic allocation of scarce life-saving resources as a new application of market design. Interfering only with the restrictive feature of the priority system to address its shortcomings, we formulate a reserve system as an alternative allocation rule. Our theoretical analysis develops a general theory of reserve design. We relate our analysis to debates during COVID-19 and describe the impact of our paper on policy and practice. This paper was accepted by Axel Ockenfels, behavioral economics and decision analysis.

Policymakers must ration healthcare. This necessity became salient during the COVID-19 pandemic. Some policymakers took that opportunity to reduce inequality of health outcomes at the expense of overall health gains. There is a literature that seeks to quantify the optimal trade-off between efficiency and equality in health outcomes: economists employ surveys to quantify the public’s preferred level of equity/efficiency trade-off. An odd result from these studies is that a non-trivial subsample of respondents choose to “level down” i.e., they choose as though an additional year of life delivers negative utility to society if it accrues to the most privileged. In an experiment of US and UK respondents ( n = 495), we compare equity/efficiency trade-offs across an abstract scenario along the lines of that presented in previous surveys versus a COVID-19 scenario, where it is made explicit that healthcare rationing is a real and current necessity occasioned by the pandemic. We find that preference for “levelling down” is reduced in the COVID-19 scenario relative to the abstract scenario. This result implies that, at least in the context of the COVID-19 pandemic, previous results have overestimated the public’s willingness to sacrifice overall gains in population health in order to reduce inequality of health outcomes.