HLTH 3100 Week 10 Peer Rebuttal Post Example

Week 10 Discussion: Rebuttal to Marcus

One Step in Marcus's Argument Does Not Hold: A Neutral Process Does Not Guarantee a Fair Allocation

Marcus, your post argued that the 20 diabetes program places should go to the first 20 applicants. I agree with much of it: that the criterion should be simple, that it should be announced in advance and that staff should not be choosing patients they like. Those points stand, and they reflect a real concern for treating people as equals, which is one part of what justice asks (Beauchamp & Childress, 2019). My rebuttal is aimed at one step only, the step where your argument moves from the process to the result.

The step. You wrote: "First come, first served is fair because it treats everyone the same. Nobody is judged on their condition or background; the clock decides." The inference here is that a rule which does not look at who people are must produce a fair allocation.

Why it does not hold. A rule can treat everyone the same at the moment of applying and still favor some people systematically, because people do not reach that moment equally. In our case, applicants learned about the program from their clinicians and from a text message sent to the clinic's patient list. Patients without reliable phones, with shift work that keeps them from answering during the day, or who needed an interpreter to understand the message, would apply later, if at all. Those are disproportionately the patients with the worst-controlled diabetes and the fewest resources. The clock does not judge them, but the circumstances that set their place in line do. The allocation literature makes this point about first come, first served generally: it can appear impartial while favoring the well-off and well-connected, who are better positioned to be first (Persad et al., 2009).

What stands after the rebuttal. The rest of your argument survives. Simplicity, advance notice and protection against favoritism are real virtues, and they are why I proposed a lottery among equally needy applicants rather than staff discretion. If the center sent the message by phone call and text in every language its patients use, gave everyone a full week to apply and treated all applications received in that week as arriving at the same time, then first come, first served would collapse into something close to a lottery, and much of my objection would fall away.

The step that fails: a process that ignores who people are is not neutral if who people are decides when they arrive. Marcus, would you accept a one-week window, with every application in that window treated as arriving first?

Reply From Marcus and My Response

Marcus, thanks for engaging. You agreed to the one-week window but pointed out that within it, someone still has to choose 20 out of 60, and you would rather use a lottery than A1c, since a lottery is the purest form of equal treatment. That is a fair position, and the disagreement is now about something different: whether need should count at all once access has been equalized. I still think it should, because the program's purpose is to reduce harm, and harm is concentrated among patients with the highest A1c (Emanuel et al., 2020). But I accept that a pure lottery after a fair window is a defensible choice, and it is much closer to my view than where we started.

References

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., Zhang, C., Boyle, C., Smith, M., & Phillips, J. P. (2020). Fair allocation of scarce medical resources in the time of Covid-19. New England Journal of Medicine, 382(21), 2049-2055. https://doi.org/10.1056/NEJMsb2005114

Persad, G., Wertheimer, A., & Emanuel, E. J. (2009). Principles for allocation of scarce medical interventions. The Lancet, 373(9661), 423-431. https://doi.org/10.1016/S0140-6736(09)60137-9