Last spring amid the pandemic, I found myself waiting on a long line outside a national chain grocery store.  Like elsewhere, these businesses were restricting the number of customers allowed in the store to reduce exposure. Handwritten signs taped to an adjacent brick wall instructed customers queuing up to maintain 6 feet of distance apart from one another and have adequate face covering to reduce the spread of COVID-19.  Another sign below it instructed pregnant customers and those over age 60 to proceed to a separate spot for expedited entrance to the store.

A week later arriving at a big box store, I found that as an essential health care worker I was permitted to advance to the front of the line. I was struck by the difference in rules that afforded advantages to certain shoppers and began to wonder how the stores arrived at them.  How the shopping sector decided on priority shoppers was an interesting study in how access to products and services are ordered in a time of crisis and reflects a central ethics tension when addressing scarcity. How do we decide who goes first?

Guiding Principles

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Indeed, healthcare professionals have been at the center of decisions about access to healthcare services during the COVID-19 pandemic. From the most extreme decisions about intensive care unit (ICU) beds if their available supply is outstripped by demand, to deciding who receives the COVID vaccine or remdesevir first, to how best to extend the reasonable life of personal protective equipment (PPE), these decisions all revolve around how to make fair and justifiable decisions in the face of scarcity. Each of these decisions is complex and requires the expertise of professionals in healthcare, logistics, operations, ethics (and in some cases, the public), but they are all guided by the principles of fairness, transparency, and consistency. To maintain accountability and the public’s trust, the healthcare system should incorporate these key principles when arriving at decisions about prioritizing access to a scarce resource.

What would happen if the healthcare system did not appeal to these basic ethics principles when addressing scarcity in health care? For example, consider why the Advisory Committee on Immunization Practices (ACIP) decided not to recommend prioritizing access to the new COVID vaccines simply on a first-come, first-served basis. This approach would be unfair on its face, as it would exacerbate existing health disparities in care; would not necessarily benefit those who are at highest risk of morbidity and mortality from the disease based on the available evidence; and would lead to greater total harm for the US population. The framework the ACIP developed reflects strong ethics practices in allocation and prioritization by resting on an ethical framework that seeks to maximize benefits and minimize harms, promote justice, mitigate health inequities, and promote transparency.1

Bedside Decisions

As another example, why have states developed clinical frameworks for addressing scarcity if the demand for resources exceeds the available supply in their healthcare systems? With no transparent system to guide healthcare professionals in the face of extreme resource scarcity, difficult decisions about who among a group of patients should be given priority for treatment would fall to a bedside clinician. Such bedside decisions in the context of scarcity would be more likely to be inconsistent, based on incomplete information, subject to unconscious bias, and lack transparency.2 Together, such a process would lead to unfair prioritization of scarce resources.

Better than grappling with the ethical challenges of prioritizing scarce resources is working to avoid a situation when it would be required.3 Augmenting health system capacity through a variety of means helps avoid having to implement a scarce resource allocation protocol. This is what happens when overwhelmed hospitals turn post-anesthesia care units into fully functioning medical ICUs and thus increase the number of beds to care for patients; when states reduce legal barriers for retired nurses and doctors to return to work and thus provide support to hospitals with dwindling staff; or when US companies increase production of ventilators to avoid scarcity, or production of gowns, N95 masks, and gloves to safeguard the essential staff that are needed to fight the pandemic. 

To ensure that healthcare professionals can promote equity and public trust, they should familiarize themselves with the currently authorized frameworks for prioritizing scarce resources and when they are applicable. These frameworks are intended to be transparent to the public, consistently applied, promote equity, and maximize benefit and minimize harms to those mostly likely to be affected.  We can overlook a grocery store for not getting fair prioritization right. The healthcare system and the public it serves has much more to lose.


  1. McClung N, Chamberland M, Kinlaw K, et al. The Advisory Committee on Immunization Practices’ Ethical Principles for Allocating Initial Supplies of COVID-19 Vaccine — United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1782-1786. doi:10.15585/mmwr.mm6947e3
  2. Rosoff PM, Patel KR, Scates A, Rhea G, Bush PW, Govert JA. Coping with critical drug shortages: An ethical approach for allocating scarce resources in hospitals. JAMA Intern Med. 2012;172(19):1494-1499. doi:10.1001/archinternmed.2012.4367
  3. Hick JL, Hanfling D, Wynia MK, Pavia AT. Duty to plan: health care, crisis standards of care, and novel coronavirus SARS-CoV-2. NAM Perspectives. Discussion paper. National Academy of Medicine. Washington, DC. doi:10.31478/202003b