Using a lottery to resolve indeterminacy when allocating resources for drugs for rare diseases

Healthcare resource allocation decisions for high-cost drugs for rare diseases (DRDs) raise several challenges for decision makers, and, given the complexity of the decisions and the limited funding available for DRDs, it is reasonable to anticipate indeterminacy arising about which DRDs to fund. We argue that when indeterminacy does arise, one might consider resolving it by using a lottery. We examine the extent to which a lottery and the commonly used process of first come, first served satisfy the requirements of formal equality and several substantive and procedural values. We then examine two practical issues that arise when implementing a lottery, identifying the lottery participants and determining what happens to the 'losers' of a lottery, to examine the extent to which various ethical issues are raised by these practical decisions. We conclude that, while lotteries may not be used frequently to allocate healthcare resources, at least under the conditions outlined here, a random selection process has a morally justified role in allocating funding for DRDs and may sometimes be preferable to first come, first served.