Casting and drawing lots: a time honoured way of dealing with uncertainty and ensuring fairness

Abstract

> The lot causeth disputes to cease, and it decideth between the mighty. > > Proverbs 18:18 What is the ethical basis for offering treatments within a controlled trial? It is either because the doctor and patient do not know which treatment is preferable or because it is the fairest way of deciding who will have a treatment that is in short supply. But what mechanisms should be used to decide who shall receive which treatment and to ensure that the hoped for benefits and unknown risks of inadequately tested treatments are distributed fairly? And how can we ensure that limited supplies of a treatment that may be beneficial are allocated fairly? A solution is found by turning to random allotment, the modern equivalent of one of the oldest practices in human history—the casting or drawing of lots.1 #### Summary points Casting or drawing of lots has been used for thousands of years to help deal with uncertainty and ensure fairness It was proposed in the 17th century and adopted in the 19th century for making fair comparisons between alternative medical treatments It has also been used for the fair distribution of limited resources It is a fair way of distributing the hoped for benefits and unknown risks of inadequately evaluated forms of health care Jewish law and the early Christian church outlawed the casting lots for divination—at least by the faithful masses, if not by God's authorities on earth.2 By contrast, casting or drawing lots to assure fairness in allocating duties or rewards has been acceptable for millennia. Human societies have used pebbles, nuts, barleycorn, bones, twigs, yarrow stalks, polished sticks, cards, coins, and dice—the list goes on and …