Using disadvantage indices to promote health equity in scarce resource allocation: Legality, degree, and culpability

Disadvantage indices (DIs)—which combine metrics such as socioeconomic status, household composition, disability, and minority status—have been used when allocating scarce health resources, particularly during the COVID-19 pandemic. While it is impossible to deny the racial and socioeconomic disparities in health-related outcomes, there is debate about the appropriate implementation of these indices. For instance, even though the NASEM vaccine allocation framework prioritizes vulnerable groups as measured by the Social Vulnerability Index, some have argued that this index does not meet the Supreme Court’s “strict scrutiny” standard for race-based policies. Others have countered that by not addressing known racial and ethnic disparities in access to health care, states and hospitals are violating anti-discrimination laws. Incorporation of a DI also prompts the question of degree, with some policies incorporating it into initial triage decisions and others only as a tie-breaker for patients with equivalent prognoses. Finally, even if one accepts the use of DIs in population-level decisions—such as vaccine distribution—there may be reluctance to apply them to individual triage decisions, in recognition of their inherent imprecisions. Others have countered that this is an example of “perfect being the enemy of the good,” even likening it to the famous “Trolley Problem” where concern for personal culpability may lead to greater loss of life.
A panel of ethicists, clinicians, and a legal scholar will define several frequently used DIs, examine legal debates regarding the use of race in resource allocation, and explore the appropriate use of DIs in resource allocation.