HLTH 6405 Week 10 Program Places Allocation Case Example

Allocation Case: Twelve Places in an Intensive Diabetes Prevention Program and Thirty Eligible Adults, a Two-Step Rule of Risk Tiers Then Lottery, Applied to Named Candidates and Accounting for the Eighteen It Leaves Out

Student Name

Walden University

HLTH 6405: Ethics and Social Justice

Instructor Name

Month Day, Year

Allocation Case: Twelve Places in an Intensive Diabetes Prevention Program and Thirty Eligible Adults, a Two-Step Rule of Risk Tiers Then Lottery, Applied to Named Candidates and Accounting for the Eighteen It Leaves Out

The Case

Lakeside Community Clinic, a composite health center, has funding for 12 places in a year-long intensive lifestyle program for adults with prediabetes, modeled on the program tested in the Diabetes Prevention Program trial, where the lifestyle group saw its diabetes incidence fall 58% below the placebo group's (Diabetes Prevention Program Research Group, 2002). Thirty adults meet the clinic's eligibility criteria: an A1c in the prediabetes band of 5.7% to 6.4%, a body mass index of 25 or more and willingness to attend weekly sessions for the first six months. The clinic must choose a rule, apply it and account for everyone the rule leaves out. There is no option that serves all 30 this year.

Candidate Rules

Persad et al. (2009) sort allocation principles into four families, equal treatment, priority to those worse off, getting the most total benefit and rewarding social usefulness, and they argue that no single principle captures everything morally relevant, so principles must be combined. Five rules are considered here.

First come, first served treats people equally in form, but in practice it favors those with flexible schedules, phones and transportation, who are often not those at greatest risk. Rejected.

A pure lottery treats all eligible people equally and is easy to explain, but it ignores large differences in risk among them. Considered, and kept as a tie-breaker.

Sickest first, giving places to those closest to a diabetes diagnosis, favors the worst off. Applied alone, it ignores whether a person can attend, but attendance is already an eligibility condition.

Maximizing benefit gives places to those expected to gain most. In a program with a similar relative effect for all participants, absolute benefit is largest for people at higher baseline risk, so this principle points in the same direction as sickest first.

Social usefulness, giving priority to people with roles valued by others, such as caregivers or community leaders, is rejected because it ranks people's worth and is hard to apply fairly.

The Chosen Rule

Step 1, risk tiers. Tier 1 includes candidates with an A1c of 6.0% to 6.4% or a documented history of gestational diabetes, markers the clinic treats as signaling higher risk of progressing to diabetes. Tier 2 includes all other eligible candidates.

Step 2, lottery within tiers. Places go first to Tier 1. If Tier 1 has more candidates than places, a lottery among them fills the places. If places remain, a lottery among Tier 2 candidates fills them.

The rule combines favoring the worst off and maximizing benefit, which point the same way here, with equal treatment through the lottery among people whose risk is similar. It avoids judging anyone's worth and does not reward those best able to claim a place first.

Applying the Rule

Of the 30 eligible candidates, 14 meet Tier 1 criteria and 16 fall in Tier 2. Ten are listed to show how the rule works.

Because Tier 1 alone exceeds the 12 places, no Tier 2 candidate receives a place this year. Two Tier 1 candidates, Darnell W. and Hector P., were not drawn.

Table 1

Ten of Thirty Eligible Candidates and Their Placement Under the Rule

Candidates and values are composite; Tier 1 had 14 candidates for 12 places, so 2 Tier 1 candidates and all 16 Tier 2 candidates are not placed.

Accounting for the Eighteen Left Out

An allocation rule is not finished until it says what happens to those it excludes.

The two Tier 1 candidates not drawn are first in line if any participant withdraws in the first month and are guaranteed places in the next cohort.

The 16 Tier 2 candidates are offered the clinic's lower-intensity options now: a monthly group nutrition class and referral to any recognized diabetes prevention program available nearby or online. Their A1c will be rechecked at six months, and anyone whose value rises into Tier 1 range moves into Tier 1 for the next cohort.

All 18 receive a written explanation of the rule, the lottery results and their place on the waitlist, so the process can be checked. Public justification of an allocation rule is part of what makes it fair, a point public health ethics treats as a condition for any decision that imposes burdens on some people (Childress et al., 2002).

Why the Rule Is Public Before It Is Used

The clinic should publish the rule, including the tier criteria and the lottery method, before the application period closes. Announcing the rule in advance prevents it from being shaped to favor particular candidates and lets applicants understand where they stand. The lottery should be drawn with a witness from outside the program staff, and the results recorded. These steps cost little and turn a decision that might look arbitrary into one any applicant can check.

Pressure on the Rule

Someone in Tier 2 may say the rule punishes her for being healthier. The answer is that the rule gives priority to greater need and greater expected benefit, and it offers her a real alternative and a path into the next cohort. A clinician may argue that motivation matters more than A1c. Another may argue that the clinic should simply choose the candidates it believes will succeed. Motivation is hard to measure fairly and easy to confuse with having time and resources, so the rule relies on attendance commitment as an eligibility condition rather than as a ranking.

References

Childress, J. F., Faden, R. R., Gaare, R. D., Gostin, L. O., Kahn, J., Bonnie, R. J., Kass, N. E., Mastroianni, A. C., Moreno, J. D., & Nieburg, P. (2002). Public health ethics: Mapping the terrain. Journal of Law, Medicine and Ethics, 30(2), 170-178. https://doi.org/10.1111/j.1748-720X.2002.tb00384.x

Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346(6), 393-403. https://doi.org/10.1056/NEJMoa012512

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