Lottery or triage? Controlled experimental evidence from the COVID-19 pandemic on public preferences for allocation of scarce medical resources

Journal article

Background: Bioethicists have advocated lotteries to distribute scarce healthcare resources, highlighting benefits which make them attractive amid growing healthcare 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 towards lotteries.

Methods: To 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 one of two hypothetical scenarios involving COVID-19 vaccine allocation among nurses: (i) by lottery; (ii) prioritization by a committee of expert physicians. The outcome was agreement on the appropriateness of the allocation mechanism on a scale from 0 (“strongly disagree”) to 100 (“strongly agree”), with differences stratified by a range of covariates. Two-sided t-tests were used to test for overall differences in mean agreement between lottery and expert committee.

Findings: Mean agreement with lottery allocation was 37.25 (95%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.

Conclusions: Despite arguments for lottery-based callotcation 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. 

Authors: Thomas, RL; Roope, LSJ; Duch, R; Robinson, T; Zakharov, A

• Publication status: Published
• Peer review status: Peer reviewed
• Publisher: SAGE Publications
• Journal: Medical Decision Making
• Volume: 46
• Issue: 1
• Pages: 102-115
• Publication date: 2025-09-27
• Acceptance date: 2025-07-05
• DOI: 10.1177/0272989X251367777
• EISSN: 1552-681X
• ISSN: 0272-989X
• Language: English
• Keywords: vaccine allocation; COVID-19; lottery allocation; public preferences; cross-country comparision; survey experiment