A comprehensive understanding of the ethics of the COVID-19 pandemic priorities must be sensitive to the influence of social inequality. We distinguish between ex-ante and ex-post relevance of social inequality for COVID-19 disadvantage. Ex-ante relevance refers to the distribution of risks of exposure. Ex-post relevance refers to the effect of inequality on how patients respond to infection. In the case of COVID-19, both ex-ante and ex-post effects suggest a distribution which is sensitive to the prevalence social inequality. On this basis, (...) we provide a generic fairness argument for the claim that welfare states ought to favour a healthcare priority scheme that gives particular weight to protecting the socially disadvantaged. (shrink)

As vaccines against COVID-19 are scarce, many countries have developed vaccination prioritisation strategies focusing on ethical and epidemiological considerations. However, public acceptance of such strategies should be monitored to ensure successful implementation. In an experiment withN=1379 German participants, we investigated whether the public’s vaccination allocation preferences matched the prioritisation strategy approved by the German government. Results revealed different allocations. While the government had top-prioritised vulnerable people (being of high age or accommodated in nursing homes for the elderly), participants preferred exclusive (...) allocation of the first available vaccines to medical staff and personnel caring for the elderly. Interestingly, allocation preferences did not change when participants were told how many individuals were included in each group. As differences between allocation policies and public preferences can affect trust in the government and threaten the social contract between generations, we discuss possible strategies to align vaccination prioritisations. (shrink)

Accelerated COVID-19 vaccine development represents an important accomplishment and a milestone in the history of vaccine evolution. However, the vaccine’s scarcity made its equitable global allocation and distribution ambiguous. Despite the initial pledges from wealthy countries for fairness and inclusivity towards the poorer ones, the policies followed diverged significantly. Wealthy countries have vastly superior access to vaccines in a reality likened to an ethical disaster. This paper calls for the need for fair global vaccine allocation and distribution and examines the (...) barriers that were met along the way, originating from different points, such as the nationalistic approach on the matter that most wealthy countries have adopted or the inability of poor countries to purchase or manufacture vaccines. Further, a suggestion regarding the ethical principles and values that ought to guide global vaccine allocation and distribution is provided with a higher priority given to helping the worst-off, saving the most lives, protecting people in high risk, such as frontline healthcare professionals, and minimising social gaps, along with an ethical theoretical background for each prioritisation. It is not too late for wealthy countries to realise that vaccine inequity prolongs pandemics, so that they change their policies in favour of the global common good that will not only provide immediate universal benefits but will also serve as a guide for future pandemic crises. (shrink)

Studying the most ethical way to allocate scarce medical resources has been of interest within the last year, due to shortages associated with the COVID-19 pandemic. This study aimed to establish differences between what healthcare providers (HCP) and laypeople consider to be the most ethical way to prioritise the distribution of scarce resources. Healthcare providers ( n = 100) and laypeople ( n = 102) were asked to rank ethical principles from most to least ethical for the allocation of ICU (...) beds in a COVID-19 outbreak, COVID-19 vaccinations and organ transplantation, and the rankings from each scenario across the two groups were compared. Results indicated that HCPs preferred utilitarian principles informed by medical knowledge, such as ‘prognosis’, whereas laypeople preferred less situation-specific and prioritarian principles, such as ‘sickest first’, replicating pre-pandemic findings. Laypeople showed increased in-group agreement when ranking principles, potentially due to the collective experience of the pandemic. Demographic variables such as older age, identifying as Black, Asian or minority ethnic and greater experience with COVID-19, were also associated with a preference for ‘prognosis’. (shrink)

This research aims to examine access to medical treatment during the COVID-19 pandemic for people living with disabilities. During the COVID-19 pandemic, the practical and ethical problems of allocating limited medical resources such as intensive care unit beds and ventilators became critical. Although different countries have proposed different guidelines to manage this emergency, these proposed criteria do not sufficiently consider people living with disabilities. People living with disabilities are therefore at a higher risk of exclusion from medical treatments as physicians (...) tend to assume they have poor quality of life, whereas access to medical treatment should be based on several parameters, including clinical data and prognosis. However, the COVID-19 pandemic shifts the medical paradigm from person-centred medicine to community-centred medicine, challenging the main ethical theories. We reviewed the main guidelines and recommendations for resources allocation and examined their position toward persons with disabilities. Based on our findings, we propose criteria for not discriminating against people with disabilities in allocating resources. The shift from person-centred to community-centred medicine offers opportunities but also risks sacrificing the most vulnerable people. The principle of reasonable accommodation must always be considered to guarantee the rights of persons with disabilities. (shrink)

The World Health Organization (WHO) is currently in advanced stages of developing a ‘WHO convention, agreement, or other international instrument on pandemic prevention, preparedness and response’ (also known as WHO CA+, referred to below as: Pandemic Agreement).1 Rightly, the instrument places equity at the centre. Yet, it currently also omits reference to an impactful tool to promote equity that has been adopted in an unprecedented manner during COVID-19—a set of measures known as disadvantage indices. Embedding disadvantage indices would provide concrete (...) constructive guidance; align the Pandemic Agreement with the use of indices by other United Nations (UN) agencies; help realise the Agreement’s goal of addressing social and other determinants of health within countries, and furthermore offer feasible ways improving equity in allocation across countries. WHO member states began work on a Pandemic Agreement in December 2021. The current timeline envisages a final version to be considered by the May 2024 World Health Assembly.1 The publicly available version of the Pandemic Agreement at the time of writing comprises 36 articles under three separate chapters (Bureau’s Text, A/INB/7/3, 30 Oct 2023).1 Chapter 1 provides general scene setting describes objectives, and highlights key terms. While the concept of equity is still somewhat implicit and would benefit from further articulation,2 overall, there seems to be a latent understanding that inequity obtains when there are unfair differences in health outcomes and opportunities within and across countries. Correspondingly, ‘[e]quity is at the centre of pandemic prevention, preparedness, response, both at the national level within States and at the international level between States. It requires, inter alia, specific measures to protect persons in vulnerable situations’.1 Chapter 3 addresses procedural issues, such as the establishment and rules of interactions of different types of advisory committees. Chapter 2 is titled ‘The world together equitably: …. (shrink)

The National Health Service (NHS) in the UK is currently facing a significant waiting list backlog following the disruption of the COVID-19 pandemic, with millions of patients waiting for elective surgical procedures. Effective treatment prioritisation has been identified as a key element of addressing this backlog, with NHS England's delivery plan highlighting the importance of ensuring that those with ‘the clinically most urgent conditions are diagnosed and treated most rapidly’. Indeed, we describe how the current clinical guidance on prioritisation issued (...) by The Federation of Surgical Specialty Associations serves this aim. However, whilst there are strong reasons to prioritise elective surgery in accordance with clinical need, we argue that it would be a mistake to assume that prioritisation in accordance with clinical need requires only a clinical or scientific judgement. The understanding of clinical need that we choose to employ in a prioritisation system will be grounded by some key ethical judgements. Moreover, we may also have to make trade-offs between addressing clinical need, safeguarding equality, and achieving other benefits. As the UK faces up to the backlog, it is important that surgical prioritisation guidelines enshrine a broad range of values that we believe ought to determine access to care in non-emergency circumstances. Our analysis suggests that the current approach to prioritisation is not a sufficiently nuanced way of balancing the different moral values that are operative in this context. (shrink)

Torbjörn Tännsjö has written a clear and thought-provoking book on healthcare priority setting. He argues that different branches of ethical theory—utilitarianism, egalitarianism, and prioritarianism—are in general agreement on real-world healthcare priorities, and that it is human irrationality that stands in the way of complying with their recommendations. While I am generally sympathetic to the overall project and line of argumentation taken by the book, this paper raises two concerns with Tännsjö’s argument. First, that he is wrong to set aside deontic (...) constraints as irrelevant or as pointing in the same direction as consequentialism. Secondly, that his argument against prioritarianism in favor of utilitarianism is insufficient and under-developed. Given these problems, I conclude that we should welcome Tännsjö’s contribution but with these qualifications in mind. (shrink)

Cost-benefit analysis (CBA) is inappropriate as an aid to Covid policy-making because the plural, incommensurable values at stake are not all amenable to monetary measurement. CBA for Covid policy is also undermined by pervasive uncertainty and ignorance, and has some troubling distributional implications. However, non-consequentialist alternatives to CBA tend towards implausibly absolutist prohibitions on risk imposition. Arguments for setting aside consequentialism for special circumstances (the precautionary principle, or a medical rule of rescue) are also problematic when applied to Covid policy. (...) A broad consequentialist approach to policy guidance is defended, one which does not demand commensuration on a common monetary scale. Despite the absence of commensuration, policy guidance is still possible. (shrink)

In Norway, priority for health interventions is assigned on the basis of three official criteria: health benefit, resources, and severity. Responses to the COVID-19 pandemic have mainly happened through intersectoral public health efforts such as lockdowns, quarantines, information campaigns, social distancing and, more recently, vaccine distribution. The aim of this article is to evaluate potential priority setting criteria for public health interventions. We argue in favour of the following three criteria for public health priority setting: benefit, resources and improving the (...) well-being of the worse off. We argue that benefits and priority to the worse off may reasonably be understood in terms of individual well-being, rather than only health, for public health priority setting. We argue that lessons from the COVID-19 pandemic support our conclusions. Keywords: COVID-19, Prioritarianism, Priority Setting, Public Health, Severity. (shrink)

In recent years, the concept of vulnerability has emerged in bioethics eroding the primacy of the autonomous and self-sufficient individual of the mainstream approach, regarding vulnerability as an obstacle to be removed. The Covid-19 pandemic has underscored an awareness that is not new, yet often little considered, namely that vulnerability is both a universal condition, and a special state dependent on social and economic causes, making the traditional concept of health inadequate to provide answers in the healthcare field. The aim (...) of the work is to examine how the pandemic has challenged the well-being conception of health, and the impact on healthcare and healthcare workers of a definition of health based on vulnerability. Indeed, the connection between health and vulnerability has some practical implications. Particularly, it can shift the focus to vulnerability of healthcare professionals, who have always been considered almost immune from it with the effect of obscuring the dimension of reciprocity between the patient and the physician. The Covid-19 pandemic has made a contribution in the process already began of rethinking health in the light of vulnerability, by bringing out the notion of relational health, and stressing the need to educate to a new approach, in order to increase the wellbeing of all subjects involved in the caring relationship. (shrink)