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When is it ethical to randomize?

Randomizing is ethical when there is genuine uncertainty about which option is better. That is equipoise, and in global health it can be specific to a setting: the oral cholera vaccine worked in Asia, but how it would perform in Haiti and Ethiopia was still unknown. When a program can serve 500 of 2,000 eligible families, a lottery is often fairer than the usual alternatives of connections, convenience or staff discretion. The harder question is who benefits. The placebo-controlled AZT trials in Africa in the 1990s showed what happens when the people in a trial may never get what it tests.

Also covered: equipoise · oversubscription · post-trial access · standard-of-care and waiting-list designs