Abstract

One of the most important motifs within (medical) ethics is scarcity: where essential (health) resources are scarce, urgent ethical questions arise. Over the last decade, at least 250 papers addressing the allocation of scarce health resources have been published in the Journal of Medical Ethics alone.1 In the typical set-up, the authors introduce a situation of scarcity and then review and adjudicate the available or recommended courses of action, sometimes through the lens of a pet normative ethical theory. It is much less common for (medical) ethicists to focus their enquiries on the origins of scarcity. Why aren’t there sufficient health resources to go around? Who caused the scarcity, and how should they be held responsible? These questions are also firmly within the remit of the discipline. Discussions of scarcity tend to circumvent these difficult questions by focussing on exceptional cases in Global North settings, where scarcity is relatively rare, and is sometimes defensible or insoluble. For example: it would be wasteful for a hospital to overstock expensive, bulky, energetically intensive, specialist equipment whose supply would only be challenged under the most extreme and unforeseen circumstances (eg, a pandemic), and there may never be sufficient usable donor organs to meet the demand for transplants. Much less attention is given to under-resourced settings, generally in the Global South, where scarcity is common, and is often both indefensible and soluble. The literature appears to favour what is ‘unusual’ and ‘interesting’ in some contexts, rather than what is commonplace, and by that fact more worrying, in others. This division of attention entrenches the idea that scarcity is a fixed feature of certain places and lives. Why do medical ethicists so often fight shy of these meta-questions? They are, of course, harder and messier. More work and greater care are needed to contextualise …