The pain lottery

Ann Palliat Med. 2023 Sep;12(5):919-924. doi: 10.21037/apm-22-1278. Epub 2023 May 4.


Moral challenges with addiction and overdosing have resulted from the abundance of opioids, but the coronavirus disease of 2019 has prompted reflection on ethical issues that could arise from a shortage. Driven by a duty to plan, some jurisdictions have formed committees to see if standard allocation considerations extend to cover a shortage of opioid pain medication. The problem, we argue, is that the standard allocation protocols do not apply to a shortage of opioids because prognosis only has limited relevance and the moral disvalue of pain is not dependent upon a patient's status as a frontline worker, age, or residence in a disadvantaged community. While the use of lotteries in allocation schemes has been deemphasized in standard allocation schema, we argue for and outline the details of a tiered lottery that first prioritizes opioids needed for emergent procedures and then moves on to allocate opioids based on the severity of a patient's pain. Additionally, we argue that some deception, in the form of withholding information from patients about the implementation and details of a pain lottery, is ethically permissible to address the unique moral tension between transparency and beneficence that arises for the treatment of pain in conditions of opioid scarcity.

Keywords: Justice; Opioids; pain; scarcity.

MeSH terms

  • Analgesics, Opioid* / therapeutic use
  • Humans
  • Morals
  • Pain* / drug therapy


  • Analgesics, Opioid