A colleague recently had an article published in PLoS Medicine, entitled Priority Setting for Pandemic Influneza: An Analysis of National Preparedness Plans (open access article). This is an interesting comparative analysis of how countries are planning to distribute resources (specifically, vaccines and antivirals) in the event of a pandemic. One striking finding is the variation in how countries approach prioritization of scarce resources (indeed, whether they set out criteria for prioritization at all: 38% of the 45 plans analyzed did not prioritize vaccine, and 51% did not prioritize antiviral drugs).
There seems to be a reasonable degree of consensus around the prioritization of health care workers and those who provide other essential services (although what consitutes "essential" may vary from country to country). Less agreement exists around the prioritization of children for receipt of vaccines. Several countries do prioritize children (never at the top, but they appear somewhere in the prioritization scheme). Others explicitly exclude or de-priortize children (e.g., Canada and the United States).
Fewer countries prioritize antivirals than do so for vaccines. Granted, with existing production methods, vaccines will be more scarce than antivirals, and hence, we may need to think more carefully about how to ration a vaccine, but the article rightly points out:
...antivirals may be the first—and, perhaps, the only—pharmaceutical intervention available to many countries in a pandemic. Because it is estimated to take six months to mass produce strain-specific vaccine, and global antiviral production and stockpiling is increasing, priority setting for antivirals may prove to be more critical to pandemic preparedness. (Uscher-Pines L et al., p. 1724)
Another striking finding was that "No national plans including prioritization schemes for the distribution of nonpharmaceutical medical resources, such as ventilators and N95 maks. Indeed, it wouldn't require much of a surge in influenza-related illness for hospital beds and ventilators to become scarce (The CDC provides a tool for estimating surge in demand for such resources here). And rationing ventilators "at the bedside" (and rationing the beds themselves) may prove to be much more difficult than rationing vaccines and antivirals from afar.
Granted, the reason that national pandemic plans avoid discussing how to ration finite resources at the local level is precisely because these decisions need to be made at the local level, with local input. In that sense, silence is completely understandable, even preferable. But these discussions do need to be taken up sooner rather than later.