Medical Resource Allocation

I introduce a distinction between health need and medical need, and raise several questions about their interaction. Health needs are needs that relate directly to our health condition. Medical needs are needs which bear some relation to medical institutions or processes. I suggest that the question of whether medical insurance or public care should cover medical needs, health needs, or only needs which fit both categories is a political question that cannot be resolved definitionally. I also argue against an overly (...) strict definition of medical need on the grounds that this presupposes, wrongly, that medical intervention should always be a last resort. (shrink)

Some philosophers and segments of the public think age is relevant to healthcare priority-setting. One argument for this is based in equity: “Old” patients have had either more of a relevant good than “young” patients or enough of that good and so have weaker claims to treatment. This article first notes that some discussions of age-based priority that focus in this way on old and young patients exhibit an ambiguity between two claims: that patients classified as old should have a (...) low priority, and that patients classified as young should have high priority. The author next argues, drawing on a problem raised by Christine Overall, that equity cannot justify giving “old” patients low priority, since there is wide variety in the total lifetime experiences of older people, partly influenced by gender, race, class, and disability injustice. Finally, the author suggests that there might be a limited role for age-based prioritization in the context of infant and childhood death, since those who die in childhood are always and uncontroversially among the worst-off. (shrink)

Discrimination is an important real-life issue that affects many individuals and groups. It is also a fruitful field of study that intersects several disciplines and methods. This Special Section brings together papers on discrimination and prioritization in healthcare from leading scholars in bioethics and closely related fields.

Introduction: There is currently no binding, internationally accepted and successful approach to ensure global equitable access to healthcare during a pandemic. The aim of this ethical analysis is to bring into the discussion a legally regulated vaccine allocation as a possible strategy for equitable global access to vaccines. We focus our analysis on COVAX (COVID-19 Vaccines Global Access) and an existing EU regulation that, after adjustment, could promote global vaccine allocation. -/- Methods: The main documents discussing the two strategies are (...) examined with a qualitative content analysis. The ethical values reasonableness, openness and transparency, inclusiveness, responsiveness and accountability serve as categories for our ethical analysis. -/- Results: We observed that the decision-making processes in a legal solution to expand access to vaccines would be more transparent than in COVAX initiative, would be more inclusive, especially of nation states, and the values responsiveness and accountability could be easily incorporated in the development of a new regulation. -/- Discussion: A legal strategy that offers incentives to the pharmaceutical industry in return for global distribution of vaccines according to the Fair Priority Model is an innovative way to achieve global and equitable access to vaccines. However, in the long term, achieving the Sustainable Development Goals will require from all nations to work in solidarity to find durable solutions for global vaccine research and development. Interim solutions, such as our proposed legal strategy for equitable access to vaccines, and efforts to find long-term solutions must be advanced in parallel. (shrink)

In 2020, the world faced a new pandemic. The corona infection hit an unprepared world, and there were no medicines and no vaccines against it. Research to develop vaccines started immediately and in a remarkably short time several vaccines became available. However, despite initiatives for global equitable access to COVID-19 vaccines, vaccines have so far become accessible only to a minor part of the world population. In this article, I discuss the global distribution of COVID-19 vaccines from an ethical point (...) of view. I reflect on what ethical principles should guide the global distribution of vaccines and what global justice and international solidarity imply for vaccine distribution and I analyse the reasons for states to prioritize their own citizens. My focus is on ethical reasons for and against ‘vaccine nationalism’ and ‘vaccine cosmopolitanism.’ My point of departure is the appeal for international solidarity from several world leaders, arguing that ‘Where you live should not determine whether you live’. I discuss the COVAX initiative to enable a global vaccination and the proposal from India and South Africa to the World Trade Organization to temporarily waive patent rights for vaccines. In the final section, I argue for global vaccine sufficientarianism, which is a modified version of vaccine cosmopolitanism. (shrink)

A considerable literature has emerged around the idea of using ‘personal responsibility’ as an allocation criterion in healthcare distribution, where a person's being suitably responsible for their health needs may justify additional conditions on receiving healthcare, and perhaps even limiting access entirely, sometimes known as ‘responsibilisation’. This discussion focuses most prominently, but not exclusively, on ‘luck egalitarianism’, the view that deviations from equality are justified only by suitably free choices. A superficially separate issue in distributive justice concerns the two–way relationship (...) between health and other social goods: deficits in health typically undermine one's abilities to secure advantage in other areas, which in turn often have further negative effects on health. This paper outlines the degree to which this latter relationship between health and other social goods exacerbates an existing problem for proponents of responsibilisation (the ‘harshness objection’) in ways that standard responses to this objection cannot address. Placing significant conditions on healthcare access because of a person's prior responsibility risks trapping them in, or worsening, negative cycles where poor health and associated lack of opportunity reinforce one another, making further poor yet ultimately responsible choices more likely. It ends by considering three possible solutions to this problem. (shrink)

Hun Chung argues for a theory of distributive justice – ‘prospect utilitarianism’ – that overcomes two central problems purportedly faced by sufficientarianism: giving implausible answers in ‘lifeboat cases’, where we can save the lives of some but not all of a group, and failing to respect the axiom of continuity. Chung claims that prospect utilitarianism overcomes these problems, and receives empirical support from work in economics on prospect theory. This article responds to Chung's criticisms of sufficientarianism, showing that they are (...) misplaced. It then shows that prospect utilitarianism faces independent problems, since it too requires a threshold, which Chung bases on the idea of ‘adequate functioning’. The article shows that there are problems with this as a threshold, and that it is not empirically supported by prospect theory. (shrink)

The need to better balance the promotion of scientific and technological innovation with risk management for consumer protection has inspired several recent reforms attempting to make regulations more flexible and adaptive. The pharmaceutical sector has a long, established regulatory tradition, as well as a long history of controversies around how to balance incentives for needed therapeutic innovations and protecting patient safety. The emergence of disruptive biotechnologies has provided the occasion for regulatory innovation in this sector. This article investigates the regulation (...) of advanced biotherapeutics in the European Union and shows that it presents several defining features of an adaptive regulation regime, notably institutionalized processes of planned adaptation that allow regulators to gather, generate, and mobilize new scientific and risk evidence about innovative products. However, our in-depth case analysis highlights that more attention needs to be paid to the consequences of the introduction of adaptive regulations, especially for critical stakeholders involved in this new regulatory ecosystem, the capacity and resource requirements placed on them to adapt, and the new tradeoffs they face. In addition, our analysis highlights a deficit in how we currently evaluate the performance and public value proposition of adaptive regulations vis-à-vis their stated goals and objectives. (shrink)

In the recent literature across philosophy, medicine and public health policy, many influential arguments have been put forward to support the use of randomization procedures to allocate scarce life-saving resources. In this paper, I provide a systematic categorization and a critical evaluation of these arguments. I shall argue that those arguments justify using RAND to allocate SLSR in fewer cases than their proponents maintain and that the relevant decision-makers should typically allocate SLSR directly to the individuals with the strongest claims (...) to these resources rather than use RAND to allocate such resources. (shrink)

Although machine intelligence is increasingly employed in healthcare, the realm of decision-making in medical ethics remains largely unexplored from a technical perspective. We propose an approach based on fuzzy cognitive maps (FCMs), which builds on Beauchamp and Childress’ prima-facie principles. The FCM’s weights are optimized using a genetic algorithm to provide recommendations regarding the initiation, continuation, or withdrawal of medical treatment. The resulting model approximates the answers provided by our team of medical ethicists fairly well and offers a high degree (...) of interpretability. Possible applications of such a system include informal guidance on medical ethics dilemmas as well as educational purposes. (shrink)

The genetic modification of pigs as a source of transplantable organs is one of several possible solutions to the chronic organ shortage. This paper describes existing ethical tensions in xenotransplantation (XTx) that argue against pursuing it. Recommendations for lifelong infectious disease surveillance and notification of close contacts of recipients are in tension with the rights of human research subjects. Parental/guardian consent for pediatric xenograft recipients is in tension with a child’s right to an open future. Individual consent to transplant is (...) in tension with public health threats that include zoonotic diseases. XTx amplifies concerns about justice in organ transplantation and could exacerbate existing inequities. The prevention of infectious disease in source animals is in tension with the best practices of animal care and animal welfare, requiring isolation, ethologically inappropriate housing, and invasive reproductive procedures that would severely impact the well-being of intelligent social creatures like pigs. (shrink)

Many healthcare agencies are producing evidence-based guidance and policy that may determine the availability of particular healthcare products and procedures, effectively rationing aspects of healthcare. They claim legitimacy for their decisions through reference to evidence-based scientific method and the implementation of just decision-making procedures, often citing the criteria of ‘accountability for reasonableness’; publicity, relevance, challenge and revision, and regulation. Central to most decision methods are estimates of gains in quality-adjusted life-years, a measure that combines the length and quality of survival. (...) However, all agree that the QALY alone is not a sufficient measure of all relevant aspects of potential healthcare benefits, and a number of value assessment frameworks have been suggested. I argue that the practical implementation of these procedures has the potential to lead to a distorted assessment of value. Undue weight may be ascribed to certain attributes, particularly those that favour commercial or political interests, while other attributes that are highly valued by society, particularly those related to care processes, may be omitted or undervalued. This may be compounded by a lack of transparency to relevant stakeholders, resulting in an inability for them to participate in, or challenge, the decisions. The makes it likely that costly new technologies, for which inflated prices can be justified by the current value frameworks, are displacing aspects of healthcare that are highly valued by society. (shrink)

When hospitals face surges of patients with COVID-19, fair allocation of scarce medical resources remains a challenge. Scarcity has at times encompassed not only hospital and intensive care unit beds—often reflecting staffing shortages—but also therapies and intensive treatments. Safe, highly effective COVID-19 vaccines have been free and widely available since mid-2021, yet many Americans remain unvaccinated by choice. Should their decision to forgo vaccination be considered when allocating scarce resources? Some have suggested it should, while others disagree. We offer a (...) framework for evaluating when it is ethical and briefly discuss its legality in American law. (shrink)

As hospitals in the US and elsewhere fill again with patients with covid-19, discussions about how to fairly allocate scarce medical resources have come to the fore once again. One frequently voiced concern is that non-covid-19 patients with urgent health needs are facing indefinitely postponed surgeries, long-distance hospital transfers, or even are unable to access medical treatment. In our view, a reserve or categorised priority system could help. It could be used to fairly distribute scarce medical capacity—such as staffing, physical (...) space, and medical treatments—between covid-19 and non-covid-19 patients, just as it has been used or proposed to allocate covid-19 therapeutics and vaccines. (shrink)

Medicines and medical devices containing animal-derived ingredients are frequently used on patients without their informed consent, despite a significant proportion of patients wanting to know if an animal-derived product is going to be used in their care. Here, I outline three arguments for why this practice is wrong. First, I argue that using animal-derived medical products on patients without their informed consent undermines respect for their autonomy. Second, it risks causing nontrivial psychological harm. Third, it is morally inconsistent to respect (...) patients’ dietary preferences and then use animal-derived medicines or medical devices on them without their informed consent. I then address several anticipated objections and conclude that the continued failure to address this issue is an ethical blind spot that warrants applying the principles of respect for autonomy and informed consent consistently. There are no data in this work. (shrink)

In the article Should rare diseases get special treatment? by Monica Q F de Magalhaes,1 it is argued that rarity is not a morally relevant feature to consider in prioritising treatment in healthcare, but severity is. A central conclusion in the article is that severity rather than prevalence should guide different cost-effectiveness thresholds. Hence, I take it, she answers no to the question in her own heading. I agree with all of this—and with most of her other arguments and conclusions (...) in the article—except for the clause ‘rather than prevalence’. For this reason, I find the article misses its’ mark. Let me explain by taking Sweden as an example. Sweden has a legally established ethics framework for priority setting in healthcare since 1997, comprising three principles: human-dignity principle, needs-solidarity principle and cost-effectiveness principle. The implication of these principles in practice is that the higher the severity—the higher the cost-effectiveness threshold acceptable.2 During the last 10 years or so, the highest accepted cost-effectiveness threshold for the most severe conditions have been in the order of €100 000/QALY. Until a few years ago rarity or prevalence was …. (shrink)

By 20 October 2021, the U.S. Food and Drug Administration (FDA) had amended its Emergency Use Authorizations for immunocompetent adults who previously received the Pfizer-BioNTech, Moderna, or Johnson & Johnson COVID-19 vaccines. For the 2-dose Pfizer-BioNTech and Moderna vaccines, the FDA permitted a single booster dose for adults aged 65 years or older and adults aged 18 to 64 years at high-risk for severe COVID-19 or at high risk for occupational or institutional COVID-19 exposure. For the single-dose Johnson & Johnson (...) vaccine, the FDA permitted a single booster dose for all adults aged 18 or older. These eligibility schemes were endorsed by the Centers for Disease Control and Prevention shortly after FDA approval. (shrink)

With the limited initial availability of COVID-19 vaccines in the first months of 2021, decision-makers had to determine the order in which different groups were prioritized. Our aim was to find out what normative approaches to the allocation of scarce preventive resources were embedded in the national COVID-19 vaccination schedules. We systematically reviewed and compared prioritization regulations in 27 members of the European Union, the United Kingdom, and Israel. We differentiated between two types of priority categories: groups that have increased (...) infection fatality rate (IFR) compared to the average for the general population and groups chosen because their members experience increased risk of being infected (ROI). Our findings show a clear trend: all researched schedules prioritized criteria referring to IFR (being over 65 years old and coexisting health conditions) over the ROI criteria (eg occupation and housing conditions). This is surprising since, in the context of treatment, it is common and justifiable to adopt different allocation principles (eg introducing a saving more life-year approach or prioritizing younger patients). We discuss how utilitarian, prioritarian, and egalitarian principles can be applied to interpret normative differences between the allocation of curative and preventive interventions. (shrink)

This article is about the potential justification for deploying some form of affirmative action (AA) in the context of healthcare, and in particular in relation to the pandemic. We call this Affirmative Action in healthcare Resource Allocation (AARA). Specifically, we aim to investigate whether the rationale and justifications for using prioritization policies based on race in education and employment apply in a healthcare setting, and in particular to the COVID-19 pandemic. We concentrate in this article on vaccines and ventilators because (...) these are both highly scarce resources in the pandemic, and there has been a need to develop policies for allocating them. However, as will become clear, the ethical considerations relating to them may diverge. We first set out two rationales for AAs and what they might entail in a healthcare setting. We then consider some disanalogies between AA and AARA, as well as the different implications of AARA for allocating ventilators as opposed to vaccines. Finally, we consider some of the practical ways in which AARA could be implemented, and conclude by responding to some key objections. (shrink)

Christian Munthe, David Fumagalli and Erik Malmqvist argue that well-known healthcare resource allocation principles, such as need, prognosis, equal treatment and cost-effectiveness, should be supplemented with a principle of sustainability.1 Employing such a principle would entail that the allocation of healthcare resources should take into account whether a specific allocation causes negative dynamics, which would limit the amount of resources available in the future. As examples of allocation decisions, which may have such negative dynamics, they mention those who cause a (...) lack of vaccines, anti-bioethics resistance and drug shortages. Thus, the overall thought is that we can spend and allocate healthcare resources in a certain way at t1, which means that we will have fewer resources available at a later point, t2. The authors argue that we should include a principle of sustainability to justify allocations, which avoids or diminishes the negative dynamics. The authors argue that existing principles cannot sufficiently include proper regard for how our current decisions affect future allocation decisions and, therefore, the people who need healthcare resources in the future. I am sympathetic to the developed argument and believe that the authors are correct that negative dynamics provide reasons to take our ability to meet future health needs …. (shrink)

Building on work by Peterman, Aas, and Wasserman (2021), we modify their prospective benefit analysis to include only medically-relevant information about patients as persons without reference to their broader lives. Because patients (not their lives) must be treated equally, we argue that patients are the appropriate targets of allocative justification. We go on to challenge some of our current data-collection practices on this basis.

The distribution of scarce critical care resources during public health emergencies in an ethically justified manner has been widely acknowledged as a major bioethics concern. The Center for Disease Control (CDC) recommends that critical care allocation during a pandemic emergency should uphold basic biomedical principles through maintenance of procedural justice which requires decision-making that is consistent, impartial, neutral, and nondiscriminatory. During the current COVID-19 pandemic, health systems, even in developed countries with robust existing health infrastructure, have experienced sustained demands that (...) have compelled the rationing of critical medical infrastructure, especially ventilators and intensive care beds. (shrink)

Should we allocate costly health care to patients diagnosed with disorders of consciousness (DoC), such as patients diagnosed as being in a vegetative state or minimally conscious state? Peterson, Aas, and Wasserman (2021) argue that we should in their paper “What justifies the allocation of health care resources to patients with disorders of consciousness?” Their key insight is that the expected benefits to this patient population helps to justify such allocations. However, their insight is attached to a consequentialist framework aimed (...) at maximizing aggregate social welfare. An alleged virtue of their framework over Braddock’s (2017) approach is their agnosticism about the moral status and rights of DoC patients. In this commentary, however, we argue that their agnosticism is the biggest problem with their approach: failing to treat DoC patients as persons with rights runs the moral risk of violating their rights, which is more serious than the risk of failing to maximize social utility. A better approach that reduces moral risk would incorporate Braddock’s (2017) precautionary presumption of personhood. We should stand in solidarity with DoC patients and treat them as persons with dignity and rights. (shrink)

As the USA contends with another surge in COVID-19 cases, hospitals may soon need to answer the unresolved question of who lives and dies when ventilator demand exceeds supply. Although most triage policies in the USA have seemingly converged on the use of clinical need and benefit as primary criteria for prioritisation, significant differences exist between institutions in how to assign priority to patients with identical medical prognoses: the so-called ‘tie-breaker’ situations. In particular, one’s status as a frontline healthcare worker (...) has been a proposed criterion for prioritisation in the event of a tie. This article outlines two major grounds for reconsidering HCW prioritisation. The first recognises trust as an indispensable element of clinical care and mistrust as a hindrance to any public health strategy against the virus, thus raising concerns about the outward appearance of favouritism. The second considers the ways in which proponents of HCW prioritisation deviate from the very ‘ethics frameworks’ that often preface triage policies and serve to guide resource allocation—a rhetorical strategy that may undermine the very ethical foundations on which triage policies stand. By appealing to trust and consistency, we re-examine existing arguments in favour of HCW prioritisation and provide a more tenable justification for adjudicating on tie-breaker events during crisis standards of care. (shrink)

John Rawls’s ‘just savings’ principle is among the better-known attempts to outline how we should balance the claims of the present with the claims of the future generations on resources. A central element of Rawls’s approach involves endorsing a sufficientarian approach, where our central obligation is to ensure ‘the conditions needed to establish and to preserve a just basic structure’.1 This engaging paper by Christian Munthe, Davide Fumagalli and Erik Malmqvist (‘the authors’) does not explicitly mention Rawls’s work on this (...) issue.2 Still, there are parallels in their aim to generate a ‘sustainability principle’ for healthcare systems. The authors defend the broadening of our focus to the relations between rounds—particularly, how decisions in one period can affect our choice range in the next, whereas current principles for allocating healthcare resources operate within ‘allocation rounds’. Where Rawls is concerned about future generations, the authors’ concern is with future sets of patients. Our present decisions may generate system ‘dynamics’ which are either positive—where ‘more resources per health need’ become available—or negative—where (otherwise justified) decisions taken now leave us with less bang for our buck in the future. The paper’s important and compelling central claim is that we have an obligation …. (shrink)

There is an ongoing increase in the use of mobile health technologies that patients can use to monitor health-related outcomes and behaviours. While the dominant narrative around mHealth focuses on patient empowerment, there is potential for mHealth to fit into a growing push for patients to take personal responsibility for their health. I call the first of these uses ‘medical monitoring’, and the second ‘personal health surveillance’. After outlining two problems which the use of mHealth might seem to enable us (...) to overcome—fairness of burdens and reliance on self-reporting—I note that these problems would only really be solved by unacceptably comprehensive forms of personal health surveillance which applies to all of us at all times. A more plausible model is to use personal health surveillance as a last resort for patients who would otherwise independently qualify for responsibility-based penalties. However, I note that there are still a number of ethical and practical problems that such a policy would need to overcome. The prospects of mHealth enabling a fair, genuinely cost-saving policy of patient responsibility are slim. (shrink)

When it comes to determining how healthcare resources should be allocated, there are many factors that could—and perhaps should—be taken into account. One such factor is a patient’s responsibility for his or her illness, or for the behavior that caused it. Policies that take responsibility for the unhealthy lifestyle or its outcomes into account—responsibility-sensitive policies—have faced a series of criticisms. One holds that agents often fail to meet either the control or epistemic conditions on responsibility with regard to their unhealthy (...) lifestyles or their outcomes. Another holds that even if patients sometimes are responsible for these items, we cannot know whether a particular patient is responsible for them. In this article, we propose a type of responsibility-sensitive policy that may be able to surmount these difficulties. Under this type of policy, patients are empowered to change to a healthier lifestyle by being given what we call a ‘Golden Opportunity’ to change. Such a policy would not only avoid concerns about patients’ fulfilment of conditions on responsibility for their lifestyles, it would also allow healthcare authorities to be justified in believing that a patient who does not change her lifestyle is responsible for the unhealthy lifestyle. We conclude with a discussion of avenues for further work, and place this policy in the broader context of the debate on responsibility for health. (shrink)

Aiming at the allocation of scarce medical resources, Immanuel and other scholars have put forward a set of influential ethical values and guiding principles. It assigns the priority of resource allocation to those whose lives can be saved and maximized, those who can bring the greatest instrumental value, and those who are the worse off. For other members of society, random selection under the same conditions is adopted. Following the Rawlsian "lexical order, lexicographical" rule, this priority arrangement requires that the (...) "utilitarian principle" should be placed before the "equality principle", and the "instrumental difference principle", the "integrity difference principle" and the "fair opportunity principle" in turn acts on specific distribution agents. Although the framework and its priority rules have obvious drawbacks when faced with Medical Resources Squeeze and other dilemmas, with the help of an understanding of its internal structure, it can effectively respond to the four core issues in the allocation of scarce medical resources. (shrink)

All parties involved in researching, developing, manufacturing, and distributing COVID-19 vaccines need guidance on their ethical obligations. We focus on pharmaceutical companies' obligations because their capacities to research, develop, manufacture, and distribute vaccines make them uniquely placed for stemming the pandemic. We argue that an ethical approach to COVID-19 vaccine production and distribution should satisfy four uncontroversial principles: optimising vaccine production, including development, testing, and manufacturing; fair distribution; sustainability; and accountability. All parties' obligations should be coordinated and mutually consistent. For (...) instance, companies should not be obligated to provide host countries with additional booster shots at the expense of fulfilling bilateral contracts with countries in which there are surges. Finally, any satisfactory approach should include mechanisms for assurance that all parties are honouring their obligations. This assurance enables countries, pharmaceutical companies, global organisations, and others to verify compliance with the chosen approach and protect ethically compliant stakeholders from being unfairly exploited by unethical behaviour of others. (shrink)

Many medical services lack robust evidence of effectiveness and may therefore be considered “unnecessary” care. Proactively withdrawing resources from, or de-funding, such services and redirecting the savings to services that have proven effectiveness would enhance overall health system performance. Despite this, governments have been reluctant to discontinue funding of services once funding is in place. The focus of this study is to understand how the framing of an issue or problem influences government decision-making related to de-funding of medical services. To (...) achieve this, a framework describing how problem frames, or explanatory naratives, influence government policy decisions was developed and applied to actual cases. The two cases selected were the Ontario government’s decisions to de-fund the drug Oxycontin and blood glucose test strips used by patients with diabetes. A qualitative content analysis of public discourse surrounding these two resource withdrawal examples was conducted and described using the framework. In the framework, government decision-making is a partial reflection of the visibility of the policy issue and complexity of the causal story told within a problem frame. By applying this framework and considering these two key characteristics of problem frames, we can better understand, and possibly predict, the shape and timing of government policy decisions to withdraw resources from medical services. (shrink)

Although a safe, effective, and licensed coronavirus vaccine does not yet exist, there is already controversy over how it ought to be allocated. Justice is clearly at stake, but it is unclear what justice requires in the international distribution of a scarce vaccine during a pandemic. Many are condemning ‘vaccine nationalism’ as an obstacle to equitable global distribution. We argue that limited national partiality in allocating vaccines will be a component of justice rather than an obstacle to it. For there (...) are role-based and community-embedded responsibilities to take care of one’s own, which constitute legitimate moral reasons for some identity-related prioritisation. Furthermore, a good form of vaccine nationalism prioritises one’s own without denying or ignoring duties derived from a principle of equal worth, according to which all persons, regardless of citizenship or identity, equally deserve vaccine-induced protection from COVID-19. Rather than dismissing nationalism as a tragic obstacle, it is necessary to acknowledge that a limited form of it is valuable and expresses moral commitments. Only then can one understand our world of competing obligations, a world where cosmopolitan duties of benevolence sometimes conflict with special obligations of community membership. Once these competing obligations are recognised as such, we can begin the work of designing sound ethical frameworks for achieving justice in the global distribution of a coronavirus vaccine and developing practical strategies for avoiding, mitigating or resolving conflicts of duty. (shrink)

In ‘Against vaccine nationalism’, Nicole Hassoun misrepresents our argument, distorts our position and ignores crucial distinctions we present in our article, ‘Love thy neighbor? Allocating vaccines in a world of competing obligations’. She has created a strawman that does not resemble our position. In this reply, we address two features of ‘Against vaccine nationalism’. First, we address a phantom premise. Hassoun misattributes to us a thesis, according to which citizen-directed duties are stronger than noncitizen-directed duties. This thesis is a figment (...) of her imagination, not a fragment of our argument. Second, we address a shape-shifting ism. Ambiguity attaches to ‘vaccine nationalism,’ ambiguity that Hassoun exploits despite our distinguishing various meanings of the phrase. As a result, the type of vaccine nationalism she argues against is not the type we defend. (shrink)

In this issue of the Journal of Medical Ethics arguments are cogently made that sustainability and solidarity should be considered as core medical ethical principles, and that more explicit attention should be given to the complex context in which a decision is made.

Rationing health care by ordeals is likely to have different effects on women and men, and on distinct groups of women. I show how such putative effects of ordeals are relevant to achieving gender justice. I explain why some ordeals may disproportionately set back women’s interest in discretionary time, health and access to health care, and may undermine equality of opportunity for positions of advantage. Some ordeals protect the interests of the worse-off women yet set back the interests of better-off (...) women in equal opportunities. I suggest how we can use ordeal design to advance particular aims of gender justice. (shrink)

The consideration of the problem of healthcare allocation as a special case of distributive justice is especially alluring when we only consider consequentialist theories. I articulate here an alternative Rawlsian non-consequentialist theory which prioritizes the fairness of healthcare allocation procedures rather than directly setting distributive parameters. The theory in question stems from Rawlsian commitments that, it is argued, have a better Rawlsian pedigree than those considered as such by Tännsjö. The alternative framework is worthy of consideration on its own merits, (...) but it also casts light on two related difficulties with Tännsjö’s approach: (i) the limits of his supposedly ecumenical methodology, which is revealed to be dialectically suspect and (ii) issues with the type of abstraction and idealization from actual judgements and preferences which the approach requires. (shrink)

This year marks the centenary of John Rawls's birth and the fiftieth anniversary of the publication of A Theory of Justice. The influence of Rawls's landmark book on the general fields of moral and political philosophy is undisputed and well-documented. It has also left a significant imprint on debates surrounding health policy, health care, and health inequalities. This article traces the changing ways in which Rawls's theory influenced debates about justice in health over the last five decades. Just as Rawls's (...) ideas have shaped debates about health, however, these debates can help us critically appraise the theory and its limitations. In that spirit, the article sketches three areas where a focus on health reveals challenges to the Rawlsian framework: the issue of priority setting among competing goods, the theory's egalitarian commitments, and its focus on the distribution of goods. (shrink)

The Covid-19 pandemic has led to a health crisis of a scale unprecedented in post-war Europe. In response, a large amount of healthcare resources have been redirected to Covid-19 preventive measures, for instance population-wide vaccination campaigns, large-scale SARS-CoV-2 testing, and the large-scale distribution of protective equipment to high-risk groups and hospitals and nursing homes. Despite the importance of these measures in epidemiological and economic terms, health economists and medical ethicists have been relatively silent about the ethical rationales underlying the large-scale (...) allocation of healthcare resources to these measures. The present paper seeks to encourage this debate by demonstrating how the resource allocation to Covid-19 preventive measures can be understood through the paradigm of the Rule of Rescue, without claiming that the Rule of Rescue is the sole rationale of resource allocation in the Covid-19 pandemic. (shrink)

This chapter introduces to the main topic of the volume, namely the influence of the changing nature of warfare on the provision of medical care and the ethical challenges that occur. It presents the main ideas of relevant concepts such as asymmetrical warfare, hybrid warfare, and complex emergencies before illustrating the ethical challenges that new forms of warfare create for military and humanitarian health care providers. Examples of ethical challenges include embedding medical personnel in combating forces, questions regarding the treatment (...) of detainees, the need to uphold medical neutrality, and pitfalls of using medicine to non-medical ends. The chapter concludes with a synopsis of the volume. (shrink)

Resumen En este trabajo se exponen veintiuna tesis sobre la asignación de recursos escasos en tiempos de pandemia o crisis sanitaria. El autor parte de la base de que nunca se justifica tratar a una persona como un mero medio. A partir de este principio fundamental, y de otras exigencias de justicia, procura determinar cuáles son los límites a las consideraciones, por lo demás legítimas, de eficiencia o de utilidad. Esto le permite discernir qué criterios de distribución son moral mente (...) aceptables y cuáles no lo son. -/- This work presents twenty one theses on the allocation of scarce resources in times ofpandemic or health crisis. The author assumes that treating a person as a mere means is never justified. On the basis of this fundamental principle, and other requirements of justice, he seeks to determine what are the limits to considerations, otherwise legitímate, of efficiency or utility. This allows him to discern which distribution criteria are morally acceptable and which are not. (shrink)

We propose a principle of sustainability to complement established principles used for justifying healthcare resource allocation. We argue that the application of established principles of equal treatment, need, prognosis and cost-effectiveness gives rise to what we call negative dynamics: a gradual depletion of the value possible to generate through healthcare. These principles should therefore be complemented by a sustainability principle, making the prospect of negative dynamics a further factor to consider, and possibly outweigh considerations highlighted by the other principles. We (...) demonstrate how this principle may take different forms, and show that a commitment to sustainability is supported by considerations internal to the ethical principles already guiding healthcare resource allocation. We also consider two objections. The first of these, we argue, is either based on implausible assumptions or begs the question, whereas the second can be adequately accommodated by the principle we propose. (shrink)

We argue that deliberative decision-making that is inclusive, transparent and accountable can contribute to more trustworthy and legitimate decisions on difficult ethical questions and political trade-offs during the pandemic and beyond.

We propose 4 equity-advancing operational improvements to eligibility and sign-up processes at mass vaccination sites: (1) preregistration using existing information, (2) eligibility rules that recognize the greater burden of COVID-19 in underserved neighborhoods, (3) appointment assignment that prioritizes those with disadvantage, and (4) socioculturally informed outreach to lottery selectees.

When life-saving medical resources are scarce and not everyone can be saved, is the only relevant goal saving the most lives? Or can other factors be considered, at least as tiebreakers, such as how early in life the people we don't save will die or how much future life they are likely to lose? This commentary defends a multiprinciple allocation approach that considers objectives in addition to saving more lives, including preventing early death and preventing harm in the form of (...) lost future life. Particularly compared to an arbitrary, coin-flip tiebreaker, this multiprinciple approach more effectively prevents harm, prioritizes the worst-off, mitigates socioeconomic and racial health disparities, and tracks public values regarding allocation under scarcity—and is legally sound. -/- . (shrink)

America’s COVID-19 pandemic has both devastated and disparately harmed minority communities. How can the allocation of scarce treatments for COVID-19 and similar public health threats fairly and legally respond to these racial disparities? Some have proposed that members of racial groups who have been especially hard-hit by the pandemic should receive priority for scarce treatments. Others have worried that this prioritization misidentifies racial disparities as reflecting biological differences rather than structural racism, or that it will generate mistrust among groups who (...) have previously been harmed by medical research. Still others complain that such prioritization would be fundamentally unjust. I argue that, to pass muster under current law, policymaking in this area must recognize a crucial distinction: prioritizing minority communities, such as hard-hit neighborhoods, without regard to individual race is typically legal, but prioritizing individuals on the basis of their racial identity faces is likely not. I also explain how prioritization on the basis of Native American status is allowable and legally distinct from prioritization on the basis of individual race. -/- In Part II, I provide a brief overview of current and proposed COVID-19 treatments and identify documented or likely scarcities and disparities in access. In Part III, I argue that randomly allocating scarce medical interventions, as some propose, will not effectively address disparities: it both permits unnecessary deaths and concentrates those deaths among people who are more exposed to infection. In Part IV, I explain why using individual-level racial classifications in allocation is precluded by current Supreme Court precedent. Addressing disparities will require focusing on factors other than race, or potentially considering race at an aggregate rather than individual level. I also argue that policies prioritizing members of Native American tribes can succeed legally even where policies based on race would not. In Part V, I examine two complementary strategies to narrow racial disparities. One would prioritize individuals who live in disadvantaged geographic areas or work in hard-hit occupations, potentially alongside race-sensitive aggregate metrics like neighborhood segregation. These approaches, like the policies school districts adopted after the Supreme Court rejected individualized racial classifications in education, would narrow disparities without classifying individuals by race. The other strategy would address the starkly disparate racial impact of deaths early in life by limiting the use of age-based exclusions from vaccine or treatment access that explicitly deprioritize the prevention of early deaths and so disparately exclude minorities, and by considering policies that prioritize the prevention of early deaths. (shrink)

In this Correspondence, I argue that given that scarcity has existed both for critical care resources and for vaccines, allocating critical care resources to prioritize the prevention of early COVID-19 deaths (i.e. COVID-19 deaths among younger patients) could valuably counterbalance the disproportionate exclusion of minority patients and those with life shortening disabilities that age-based vaccine allocation produces. -/- Covid-19 deaths early in life have overwhelmingly befallen minorities and people with life-shortening disabilities. Policies preventing early deaths prevent an outcome widely recognized (...) as worse—dying earlier in one’s life rather than later—while counteracting intersecting forms of injustice. Ultimately, prohibiting the use of age as a tiebreaker in critical care allocation, as Brown et al. propose, will worsen disparities and is not mandated by law. (shrink)

In this survey study of 4735 US adults, respondents of all demographic and political affiliations agreed with prioritizing COVID-19 vaccine access for health care workers, adults of any age with serious comorbid conditions, frontline workers (eg, teachers and grocery workers), and Black, Hispanic, Native American, and other communities that have been disproportionately affected by COVID-19. Older adult respondents were less likely than younger respondents to list healthy people older than 65 years as 1 of their top 4 priority groups. These (...) findings suggest that the US public agrees with the high-priority groups proposed by the National Academies of Science, Engineering, and Medicine but appears to disagree with approaches advanced by others that prioritize older adults but not essential workers or disproportionately affected communities. (shrink)

The U.S. FDA has issued emergency use authorizations for monoclonal antibodies for non-hospitalized patients with mild or moderate COVID-19 disease and for individuals exposed to COVID-19 as post-exposure prophylaxis. One EUA for an oral antiviral drug, molnupiravir, has also been recommended by FDA’s Antimicrobial Drugs Advisory Committee, and others appear likely in the near future. Due to increased demand because of the Delta variant, the federal government resumed control over the supply and asked states to ration doses. As future variants (...) with increased infectivity and/or severity emerge, further rationing may be required. We identify relevant ethical principles and priority groups for access to therapies based on an integrated approach to population health and medical factors. Using priority categories to allocate scarce therapies effectively operationalizes important ethical values. This strategy is preferable to the current approach of categorical rules based on vaccination, immunocompromise status, or older age, or the ad hoc consideration of clinical risk factors. (shrink)

Hundreds of millions of rare biospecimens are stored in laboratories and biobanks around the world. Often, the researchers who possess these specimens do not plan to use them, while other researchers limit the scope of their work because they cannot acquire biospecimens that meet their needs. This situation raises an important and underexplored question: how should scientists allocate biospecimens that they do not intend to use? We argue that allocators should aim to maximise the social value of the research enterprise (...) when allocating scarce biospecimens. We provide an ethical framework for assessing the social value of proposed research projects and describe how the framework could be implemented. (shrink)