Liability for unequal allocation of treatments

Introduction

Liability for unequal allocation of treatments concerns the legal responsibility that may arise when medical treatments, medicines, vaccines, hospital beds, clinical resources, or other healthcare services are distributed unequally among patients without a legally or ethically defensible justification. The issue becomes particularly important where healthcare resources are scarce and healthcare providers must decide which patients receive treatment first, which treatments are available to particular groups, or whether certain patients are excluded from access.

Unequal allocation is not automatically unlawful. Healthcare systems frequently use legitimate criteria such as medical urgency, likelihood of benefit, clinical compatibility, availability of resources, and emergency prioritisation. Liability arises when unequal treatment is based on prohibited discrimination, arbitrary decision-making, conflict of interest, negligence, or criteria that violate constitutional, statutory, contractual, or professional duties.

In India, the issue is closely connected with Articles 14 and 21 of the Constitution. Article 14 prohibits arbitrary and discriminatory state action, while Article 21 protects life and personal liberty. Where healthcare is provided by public authorities, arbitrary denial or discriminatory allocation can therefore attract constitutional scrutiny.

Nature of unequal treatment allocation

Unequal allocation can occur in several forms. A hospital may give a scarce medicine to one category of patients while excluding another without a rational basis. A public healthcare programme may distribute treatment disproportionately between regions or social groups. A private hospital may give preferential access because of wealth, status, personal relationships, or commercial considerations.

The central legal question is not simply whether two patients received different treatment. The question is whether the distinction has a reasonable and legally permissible justification.

A lawful allocation system generally requires:

• clearly defined eligibility criteria;
• medically relevant prioritisation;
• consistency in applying the criteria;
• transparency in decision-making;
• protection against arbitrary discrimination;
• appropriate documentation and review mechanisms.

Where these safeguards are absent, the affected patient may potentially seek compensation, judicial review, regulatory action, or other remedies depending upon the circumstances.

Constitutional protection in India

The Supreme Court has repeatedly recognised that the right to health and medical assistance forms an important component of Article 21.

In Paschim Banga Khet Mazdoor Samity v. State of West Bengal (1996), the Supreme Court held that failure of a government hospital to provide timely medical treatment can violate Article 21. The Court emphasised that the State has an obligation to provide adequate medical facilities.

This principle is important for unequal allocation because a public healthcare institution cannot arbitrarily deny treatment merely because of administrative convenience or discriminatory considerations.

Similarly, in Parmanand Katara v. Union of India (1989), the Supreme Court emphasised the importance of immediate medical treatment in emergencies. The case established that preservation of life must receive priority and that procedural or administrative obstacles cannot ordinarily justify refusal of emergency medical assistance.

The principle becomes especially relevant where hospitals develop allocation policies for scarce emergency treatment. Priority criteria must remain connected with legitimate medical considerations rather than arbitrary personal characteristics.

Equality and non-arbitrariness

Article 14 does not require identical treatment in every circumstance. It permits reasonable classification, provided that the classification is based on an intelligible differentia and has a rational relationship with the objective being pursued.

Therefore, allocating a scarce treatment to patients who are medically more urgent may be lawful. Allocating the same treatment based on wealth, caste, religion, gender, social status, or personal connections may raise serious constitutional concerns where such distinctions lack a legitimate legal basis.

The Supreme Court's decision in E.P. Royappa v. State of Tamil Nadu (1974) expanded the understanding of Article 14 by connecting equality with the prohibition of arbitrariness. Arbitrary governmental action can therefore itself constitute a constitutional violation.

In Maneka Gandhi v. Union of India (1978), the Court further developed the principle that State action affecting fundamental rights must satisfy requirements of fairness and reasonableness.

Together, these principles provide an important framework for examining unequal allocation of publicly provided healthcare.

Right to health and public authorities

In Consumer Education & Research Centre v. Union of India (1995), the Supreme Court recognised the importance of health protection as part of the constitutional framework concerning life and dignity.

Healthcare allocation decisions by government institutions must therefore take into account constitutional obligations. A government hospital cannot simply adopt a discriminatory allocation policy without considering equality, dignity and the protection of life.

However, courts also recognise that healthcare resources are finite. The existence of a constitutional right to health does not necessarily create an unlimited right to every available treatment. Courts may examine whether the State has acted reasonably within available resources.

Medical negligence and allocation decisions

Unequal treatment may also produce civil liability where the allocation decision amounts to medical negligence.

Medical negligence generally requires a failure to meet the applicable standard of care resulting in legally recognised harm. The fact that one patient receives treatment before another does not by itself establish negligence. There must be evidence that the provider acted contrary to the applicable professional or institutional standard.

The traditional standard was discussed in Bolam v. Friern Hospital Management Committee (1957), under which professional conduct was assessed with reference to responsible medical practice. Modern law, however, also requires attention to patient autonomy and informed decision-making.

In Montgomery v. Lanarkshire Health Board (2015), the UK Supreme Court significantly strengthened the principle of patient autonomy and disclosure of material risks. Although Montgomery concerned informed consent rather than allocation, its broader emphasis on patient-centred healthcare is relevant when examining decisions that substantially affect access to treatment.

Consumer protection and private hospitals

Where healthcare services fall within applicable consumer-protection legislation, arbitrary or deficient medical services may potentially result in consumer liability.

In Indian Medical Association v. V.P. Shantha (1995), the Supreme Court held that medical services rendered for consideration can fall within the consumer-protection framework, subject to the principles recognised in the judgment.

Consequently, where a private healthcare provider adopts an unreasonable allocation policy or fails to provide services according to its contractual or professional obligations, an affected patient may potentially have a consumer remedy.

Nevertheless, mere dissatisfaction with treatment priority does not automatically establish deficiency in service. Medical necessity, resource availability and legitimate triage considerations remain relevant.

International human-rights perspective

International human-rights law also places substantial emphasis on equality in access to healthcare.

Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) recognises the right to the highest attainable standard of physical and mental health. The Committee on Economic, Social and Cultural Rights has stressed principles of non-discrimination and equality in healthcare access.

The European Court of Human Rights has also addressed discrimination in access to healthcare in cases involving vulnerable groups. In Kiyutin v. Russia (2011), the Court examined discriminatory treatment associated with HIV status and emphasised the need for particularly strong justification when differential treatment is connected with health status.

The principle is relevant to treatment allocation because health conditions should not automatically become grounds for exclusion from healthcare unless the distinction has a legitimate and proportionate justification.

Case law on discrimination and medical information

Privacy and medical confidentiality also influence allocation decisions. In Z v. Finland (1997), the European Court of Human Rights recognised the particularly sensitive nature of medical information and the importance of protecting confidentiality.

Similarly, Justice K.S. Puttaswamy (Retd.) v. Union of India (2017) recognised privacy as a fundamental right under the Indian Constitution. Healthcare allocation systems that use genetic, biometric, medical or other sensitive information must therefore ensure that such information is collected and used lawfully.

For example, using a patient's medical information to determine clinical priority may be legitimate. Using unrelated private information to exclude a patient from treatment could raise privacy and equality concerns.

Liability in emergency and scarcity situations

Scarcity creates one of the most difficult legal questions. During pandemics, disasters or shortages of specialised medicines, healthcare providers may have to prioritise patients.

A legally defensible allocation framework should ordinarily be based on objective and medically relevant criteria rather than social worth. Criteria may include urgency, clinical suitability, expected therapeutic benefit and availability of alternatives.

The existence of scarcity does not provide unlimited immunity from liability. Hospitals and public authorities should be able to demonstrate that allocation decisions followed a predetermined and consistently applied policy.

Where two similarly situated patients are treated differently without a legitimate reason, the decision becomes more vulnerable to judicial review.

Remedies and liability

Depending on the circumstances, unequal allocation can generate several forms of legal consequence:

1. Constitutional remedy: A person may approach a constitutional court where State action violates fundamental rights.
2. Compensation: Courts may award monetary compensation where unlawful State action causes serious violation of constitutional rights.
3. Consumer remedy: Applicable consumer law may provide relief against deficient healthcare services.
4. Professional disciplinary action: Medical regulators may intervene where professional standards are breached.
5. Civil liability: Negligence or breach of contractual duties may create a claim for damages.
6. Administrative review: Public authorities may be required to reconsider discriminatory or arbitrary allocation policies.

Conclusion

Liability for unequal allocation of treatments depends principally upon why the allocation was unequal and whether the distinction was legally justified. Resource scarcity and clinical urgency can justify differentiated treatment, but arbitrary, discriminatory, commercially motivated or medically indefensible allocation can create legal liability.

Indian constitutional jurisprudence, particularly E.P. Royappa, Maneka Gandhi, Parmanand Katara, Paschim Banga Khet Mazdoor Samity, Consumer Education & Research Centre, and Puttaswamy, provides a strong framework based on equality, non-arbitrariness, dignity, privacy and the right to life. International authorities such as Montgomery and Kiyutin further reinforce patient autonomy and non-discrimination.

Ultimately, a defensible treatment-allocation system should be transparent, medically grounded, consistently applied, proportionate and subject to accountability. Where these safeguards are absent and unequal allocation causes legally recognised harm, constitutional, civil, consumer or professional liability may follow.