In this article, we propose the Fair Priority Model for COVID-19 vaccine distribution, and emphasize three fundamental values we believe should be considered when distributing a COVID-19 vaccine among countries: Benefiting people and limiting harm, prioritizing the disadvantaged, and equal moral concern for all individuals. The Priority Model addresses these values by focusing on mitigating three types of harms caused by COVID-19: death and permanent organ damage, indirect health consequences, such as health care system strain and stress, as well as (...) economic destruction. It proposes proceeding in three phases: the first addresses premature death, the second long-term health issues and economic harms, and the third aims to contain viral transmission fully and restore pre-pandemic activity. -/- To those who may deem an ethical framework irrelevant because of the belief that many countries will pursue "vaccine nationalism," we argue such a framework still has broad relevance. Reasonable national partiality would permit countries to focus on vaccine distribution within their borders up until the rate of transmission is below 1, at which point there would not be sufficient vaccine-preventable harm to justify retaining a vaccine. When a government reaches the limit of national partiality, it should release vaccines for other countries. -/- We also argue against two other recent proposals. Distributing a vaccine proportional to a country's population mistakenly assumes that equality requires treating differently situated countries identically. Prioritizing countries according to the number of front-line health care workers, the proportion of the population over 65, and the number of people with comorbidities within each country may exacerbate disadvantage and end up giving the vaccine in large part to wealthy nations. (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.

In the Global Burden of Disease study, disease burden is measured as disability-adjusted life years. The paramount assumption of the DALY is that it makes sense to aggregate years lived with disability and years of life lost. However, this is not smooth sailing. Whereas morbidity is something that happens to an individual, loss of life itself occurs when that individual’s life has ended. YLLs quantify something that involves no experience and does not take place among living individuals. This casts doubt (...) on whether the YLL is an individual burden at all. If not, then YLDs and YLLs are incommensurable. There are at least three responses to this problem, only one of which is tenable: a counterfactual account of harm. Taking this strategy necessitates a re-examination of how we count YLLs, particularly at the beginning of life. (shrink)

This report by the WHO Consultative Group on Equity and Universal Health Coverage addresses how countries can make fair progress towards the goal of universal coverage. It explains the relevant tradeoffs between different desirable ends and offers guidance on how to make these tradeoffs.

We offer a summary of the WHO Report "Making Fair Choices on the Path to Universal Health Coverage".

As health policy-makers around the world seek to make progress towards universal health coverage, they must navigate between two important ethical imperatives: to set national spending priorities fairly and efficiently; and to safeguard the right to health. These imperatives can conflict, leading some to conclude that rights-based approaches present a disruptive influence on health policy, hindering states’ efforts to set priorities fairly and efficiently. Here, we challenge this perception. We argue first that these points of tension stem largely from inadequate (...) interpretations of the aims of priority setting as well as the right to health. We then discuss various ways in which the right to health complements traditional concerns of priority setting and vice versa. Finally, we set out a three-step process by which policy-makers may navigate the ethical and legal considerations at play. (shrink)

We reply to critics of the World Health Organisation's Report "Making Fair Choices on the Path to Universal Health Coverage". We clarify and defend the report's key moral commitments. We also explain its role in guiding policy in the face of both financial and political constraints on making fair choices.

Which inequalities in longevity and health among individuals, groups, and nations are unfair? And what priority should health policy attach to narrowing them? These essays by philosophers, economists, epidemiologists, and physicians attempt to determine how health inequalities should be conceptualized, measured, ranked, and evaluated.

Clinical ethical support services (CESS) represent a multifaceted field of aims, consultancy models, and methodologies. Nevertheless, the overall aim of CESS can be summed up as contributing to healthcare of high ethical standards by improving ethically competent decision-making in clinical healthcare. In order to support clinical care adequately, CESS must pay systematic attention to all real-life ethical issues, including those which do not fall within the ‘favourite’ ethical issues of the day. In this paper we attempt to capture a comprehensive (...) overview of categories of ethical tensions in clinical care. We present an analytical exposition of ethical structural features in judgement-based clinical care predicated on the assumption of the moral equality of human beings and the assessment of where healthcare contexts pose a challenge to achieving moral equality. The account and the emerging overview is worked out so that it can be easily contextualized with regards to national healthcare systems and specific branches of healthcare, as well as local healthcare institutions. By considering how the account and the overview can be applied to i) improve the ethical competence of healthcare personnel and consultants by broadening their sensitivity to ethical tensions, ii) identify neglected areas for ethical research, and iii) clarify the ethical responsibility of healthcare institutions' leadership, as well as specifying required institutionalized administration, we conclude that the proposed account should be considered useful for CESS. (shrink)

In recent years, it has become commonplace among the Global Burden of Disease study authors to regard the disability-adjusted life year primarily as a descriptive health metric. During the first phase of the GBD, it was widely acknowledged that the DALY had built-in evaluative assumptions. However, from the publication of the 2010 GBD and onwards, two central evaluative practices—time discounting and age-weighting—have been omitted from the DALY model. After this substantial revision, the emerging view now appears to be that the (...) DALY is primarily a descriptive measure. Our aim in this article is to argue that the DALY, despite changes, remains largely evaluative. Our analysis focuses on the understanding of the DALY by comparing the DALY as a measure of disease burden in the two most significant phases of GBD publications, from their beginning to the most recent releases. We identify numerous assumptions underlying the DALY and group them as descriptive or evaluative. We conclude that while the DALY model arguably has become more descriptive, it remains, by necessity, largely evaluative. (shrink)

Enormous gaps between HIV burden and health care availability in low-income countries raise severe ethical problems. This article analyzes four HIV-priority dilemmas with interest across contexts and health systems. We explore principled distributive conflicts and use the Atkinson index to make explicit trade-offs between health maximization and equality in health. We find that societies need a relatively low aversion to inequality to favor treatment for children, even with large weights assigned to extending the lives of adults: higher inequality aversion is (...) needed to share resources equally between high-cost and low-cost treatment; higher inequality aversion is needed to favor treatment rather than prevention, and the highest inequality aversion is needed to favor sharing treatment between urban and rural regions rather than urban provision of treatment. This type of ethical sensitivity analysis may clarify the ethics of health policy choice. (shrink)

IntroductionHigh healthcare costs make illness precarious for both patients and their families’ economic situation. Despite the recent focus on the interconnection between health and financial risk at the systemic level, the ethical conflict between concerns for potential health benefits and financial risk protection at the household level in a low-income setting is less understood.MethodsUsing a seven-step ethical analysis, we examine a real-life dilemma faced by families and health workers at the micro level in Ethiopia and analyse the acceptability of limiting (...) treatment for an ill newborn to protect against financial risk. We assess available evidence and ethical issues at stake and discuss the dilemma with respect to three priority setting criteria: health maximisation, priority to the worse-off and financial risk protection.ResultsGiving priority to health maximisation and extra priority to the worse-off suggests, in this particular case, that limiting treatment is not acceptable even if the total well-being gain from reduced financial risk is taken into account. Our conclusion depends on the facts of the case and the relative weight assigned to these criteria. However, there are problematic aspects with the premise of this dilemma. The most affected parties—the newborn, family members and health worker—cannot make free choices about whether to limit treatment or not, and we thereby accept deprivations of people’s substantive freedoms.ConclusionIn settings where healthcare is financed largely out-of-pocket, families and health workers face tragic trade-offs. As countries move towards universal health coverage, financial risk protection for high-priority services is necessary to promote fairness, improve health and reduce poverty. (shrink)

The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision-making. These case studies (...) show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for the worse off, and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting. (shrink)

Next SectionBackground International and national agencies play a major role in setting HIV care-and-treatment priorities in low-income-countries. Little is known about priority setting at lower health-system levels. The objective of this article is to explore experiences of HIV priority decisions, at what levels these decisions are made and how they might influence the distribution of health benefits in a high-endemic region in Tanzania. Methods This is a qualitative study using observations, key documents and semistructured focus-group and individual interviews (43) with (...) health workers, patients and administrators at one regional and one district hospital. The analysis was based on an editing analysis style. Results Health workers did not perceive themselves as bedside rationing agents and they reported following national recommendations and felt they have little impact on important priority decisions. Health benefit distributions were largely determined by priority decisions made at a national level. External factors, such as eligibility criteria, inadequate funding and barriers to access seemed to play a major role in the actual distribution of health services and benefits in the region. Patient groups who were actually given high priority were the sickest patients, those living near a facility and those who could afford long journeys and frequent visits. Low-priority groups were those experiencing other co-morbidities or treatment failure, children, asymptomatic patients and the poorest. Conclusions/significance The interaction of priority setting across health-system levels and their impact on distribution of health outcomes in the population has been underestimated. The distributional pattern of health outcomes calls for further normative assessment. (shrink)

La cobertura universal de salud está en el centro de la acción actual para fortalecer los sistemas de salud y mejorar el nivel y la distribución de la salud y los servicios de salud. Este documento es el informe fi nal del Grupo Consultivo de la OMS sobre la Equidad y Cobertura Universal de Salud. Aquí se abordan los temas clave de la justicia (fairness) y la equidad que surgen en el camino hacia la cobertura universal de salud. Por lo (...) tanto, el informe es pertinente para cada agente que infl uye en ese camino y en particular para los gobiernos, ya que se encargan de supervisar y guiar el progreso hacia la cobertura universal de salud. (shrink)

Assessment of evidence is becoming a centralpart of health policy decisions – not least inlimit setting decisions. Limit-settingdecisions can be defined as the withholding ofpotentially beneficial health care. Thisarticle seeks to explore the value choicesrelated to the use of evidence in limit-settingdecisions at the political level. To betterspecify the important but restricted role ofevidence in such decisions, the value choicesof relevance are discussed explicitly. Fourcriteria are often considered when settinglimits:1. The severity of disease if untreated or treatedby standard care2. The (...) effectiveness of the new technology3. The cost-effectiveness of the new technology4. The quality of evidence on –The production and assessment of evidence isimportant for each criterion, but severalpoints are identified where the practice ofevidence-based medicine could be furtherdeveloped to capture a broader spectrum ofethical and political concerns that suchdecisions naturally evoke among citizens. (shrink)

The health care systems are fairly similar in theScandinavian countries. The exact details vary, but inall three countries the system is almost exclusivelypublicly funded through taxation, and most hospitals are also publicly owned and managed. Thecountries also have a fairly strong primary caresector,with family physicians to various degrees acting asgatekeepers to specialist services. In Denmark most ofthe GP services are free. For the patient in Norwayand Sweden there are out-of-pocket co-payments for GPconsultations, with upper limits, but consultations forchildren are free. (...) Hospital treatment is free inDenmark while the other countries use a system without-of-pocket co-payment. There is a very strongpublic commitment to access to high quality healthcare for all. Solidarity and equality form theideological basis for the Scandinavian welfare state.Means testing, for instance, has been widely rejectedin the Scandinavian countries on the grounds thatpublic services should not stigmatise any particulargroup. Solidarity also means devoting specialconsideration to the needs of those who have lesschance than others of making their voices heard orexercising their rights. Issues of limited access arenow, however, challenging the thinking about a healthcare system based on solidarity. (shrink)

Is it possible to use the courts - or rights instruments - to advance fair access to health care? This article examines this question within the context of the Norwegian public health care system - one special example of the Scandinavian welfare system. In particular, it asks four basic questions: What are the normative justifications for rights to health care? What were the political processes and concerns leading up to the current Patients Rights Act in Norway? What kind of legal (...) status do these rights have? How can rights to access be implemented?Patient rights do not only concern the right to access to health care; they also include the right to information, the right to participate in decision-making, and informed consent. This article examines only the former aspect, the use of the legal system to secure access to prioritized specialized health care services. (shrink)

Is it possible to use the courts - or rights instruments - to advance fair access to health care? This article examines this question within the context of the Norwegian public health care system - one special example of the Scandinavian welfare system. In particular, it asks four basic questions: What are the normative justifications for rights to health care? What were the political processes and concerns leading up to the current Patients Rights Act in Norway? What kind of legal (...) status do these rights have? How can rights to access be implemented?Patient rights do not only concern the right to access to health care; they also include the right to information, the right to participate in decision-making, and informed consent. This article examines only the former aspect, the use of the legal system to secure access to prioritized specialized health care services. (shrink)

It is a central political goal to secure disabled individuals the same opportunities as others to pursue their conception of a good life. This goal reflects an ambition to combine an egalitarian and a liberal moral intuition. In this article, we analyse how disabled individuals who take part in economic activity should be compensated in order to respect these two intuitions. The article asks how a system of disability compensation should be structured and what the level of such compensation should (...) be. It also analyses how the answers to these questions depend on whether the disabled individuals are held responsible for their choice of work effort. (shrink)

Research Group in Global Health: Ethics, Culture and Economics, Department of Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018The WHO Commission on Social Determinants of Health has documented pervasive inequalities in health in many countries. These are clearly associated with unfair distribution of the social determinants of health. Policies directed at reducing this unfair distribution should be promoted across all sectors and institutions responsible for securing equal opportunities and freedom for all citizens. This article argues that such (...) policies will need to balance the competing goals of reducing social group inequalities in health and improving average health. We need a public debate about how to make such difficult choices. This paper outlines a framework that can help us structure our thinking about this dilemma. CiteULike Connotea Del.icio.us What's this? (shrink)

ABSTRACTBackground: Studies from Western countries show that doctors working in neonatal intensive care units find withdrawal of treatment to be their most difficult ethical dilemma. There is less knowledge of how this is experienced in other economic, cultural, religious and educational contexts.Objectives: To explore and describe how Indian doctors experience ethical dilemmas concerning the withdrawal of treatment among critically sick and/or premature neonates.Method: Qualitative data from interviews was analysed according to Giorgi's phenomenological approach. The subjects were 14 doctors with various (...) levels of neonatal experience, recruited from two state‐owned NICUs in India. Main outcome measures: description reflecting the nature of ethical dilemmas and how they are experienced.Results: All doctors reported situations where the question of withdrawal of treatment was experienced as the worst part of their job. They felt that they lacked training in how to handle such dilemmas, and some had never talked about ethics before. They were especially concerned about non‐medical considerations that do not feature in current treatment guidelines. In describing their personal experiences, the informants mentioned their sense of responsibility in situations where they were aware that their decisions would influence a family's economy and reputation, availability of food and education for siblings, other children's access to equipment in the unit, and the use of resources in an underprivileged population. Sometimes lack of resources, usually ventilators, forced them to make decisions about which babies should get the chance to live. Other reported dilemmas included difficulties co‐operating with uneducated and poor parents.Conclusion: While Western doctors seem to focus on the rights and problems of the individual child, Indian doctors tend to refer to consequences for other children, for parents and society. There is a need for further research in this field, and for the development of guidelines on how to cope with differences in resources, and how to handle different patient groups’ cultural and religious concerns. (shrink)

This report from the WHO Consultative Group on Equity and Universal Health Coverage offers advice on how to make progress fairly towards universal health coverage.

Global health is at a crossroads. The 2030 Agenda for Sustainable Development has come with ambitious targets for health and health services worldwide. To reach these targets, many more billions of dollars need to be spent on health. However, development assistance for health has plateaued and domestic funding on health in most countries is growing at rates too low to close the financing gap. National and international decision-makers face tough choices about how scarce health care resources should be spent. Should (...) additional funds be spent on primary prevention of stroke, treating childhood cancer, or expanding treatment for HIV/AIDS? Should health coverage decisions take into account the effects of illness on productivity, household finances, and children's educational attainment, or just focus on health outcomes? Does age matter for priority setting or should it be ignored? Are health gains far in the future less important than gains in the present? Should higher priority be given to people who are sicker or poorer? Global Health Priority-Setting provides a framework for how to think about evidence-based priority-setting in health. Over 18 chapters, ethicists, philosophers, economists, policy-makers, and clinicians from around the world assess the state of current practice in national and global priority setting, describe new tools and methodologies to address establishing global health priorities, and tackle the most important ethical questions that decision-makers must consider in allocating health resources. (shrink)

BackgroundIn precision medicine biomarkers stratify patients into groups that are offered different treatments, but this may conflict with the principle of equal treatment. While some patient characteristics are seen as relevant for unequal treatment and others not, it is known that they all may influence treatment decisions. How biomarkers influence these decisions is not known, nor is their ethical relevance well discussed.MethodsWe distributed an email survey designed to elicit treatment preferences from Norwegian doctors working with cancer patients. In a forced-choice (...) conjoint analysis pairs of hypothetical patients were presented, and we calculated the average marginal component effect of seven individual patient characteristics, to estimate how each of them influence doctors’ priority-setting decisions.ResultsA positive biomarker status increased the probability of being allocated the new drug, while older age, severe comorbidity and reduced physical function reduced the probability. Importantly, sex, education level and smoking status had no significant influence on the decision.ConclusionBiomarker status is perceived as relevant for priority setting decisions, alongside more well-known patient characteristics like age, physical function and comorbidity. Based on our results, we discuss a framework that can help clarify whether biomarker status should be seen as an ethically acceptable factor for providing unequal treatment to patients with the same disease. (shrink)

This paper presents the Norwegian national health care system and the manner in which the problems of rationing and pluralism of values create new ethical and political challenges. The paper concludes with some doubts about the feasibility of the transformation taking place within this kind of health care system, with special reference to governmental control and consumer preference. Keywords: national health care, pluralism, rationing, two-tier system CiteULike Connotea Del.icio.us What's this?

Objective The objective of this article is to provide an ethical analysis of a high-risk, advanced treatment case where the patient received transcatheter aortic valve insertion, for aortic valve stenosis. Particular emphasis will be placed upon the significance of evidence and the implications for priority setting. Method One paradigmatic case involving a TAVI patient from a large university hospital in Norway is described and analysed. The method used was ethical case analysis modified after Kymlicka by Miljeteig et al. Perioperative mortality (...) risk was estimated using the Euroscore risk-logarithm and the Society of Thoracic Surgeons’ risk model, STS. These predict the risk of operative mortality and morbidity associated with adult cardiac surgery. GRADE, the Grading of Recommendations Assessment, Development and Evaluation, was used to evaluate the evidence. Results In the case analysis, we found that it would be ethically justifiable not to recommend TAVI treatment for this patient. Although the patient had a severe condition in need of treatment, the expected improvement was marginal, the quality of evidence was low and the opportunity costs for other patients and society were higher than usually deemed appropriate. Conclusions Decision-making in the absence of high quality evidence from randomized trials is a complex process involving difficult ethical judgments. Novel high-risk devices often enter the European market with limited clinical evidence. Transparency and improved clinical evaluation are required so patient safety is not jeopardized. We argue that implementation of high risk, high cost interventions should be better regulated at a national level. Background All clinical decisions imply priority setting and therefore indirectly affect other patients and other patient groups. The use of expensive, innovative health technologies has an affect on individual patients as well as on other patient groups competing for the same resources. (shrink)

In a recent paper— The disvalue of death in the global burden of disease 1—we question the commensurability of the two components of the disability-adjusted life year — years lived with disability and years of life lost —and offer a tentative solution to this problem. In an exciting and constructive reply— Is consistency overrated? 2—philosopher S Andrew Schroeder argues that our concern about the DALY may be missing the mark by accepting the DALY as what he refers to as an (...) index reflecting nothing ‘beyond the importance we place in each ’. According to Schroeder, our consistency requirement is then made redundant. Recall our main argument: the DALY is the arithmetical sum of two components, YLDs and YLLs. The YLDs represents the individual disease burden that occurs while we are alive, while YLLs represents the individual disease burden resulting from our death. ‘Death’, in this context, is not the process of dying, which happens within life and which is captured by YLDs, but rather the incidence in which the life of a person has ended. Understood this way, the DALY is the aggregate of life and death, and we argue that these are incommensurables. Why are YLDs and YLLs incommensurables? In our article, we present several reasons for this. Briefly, YLDs measure disease burden that happens to an individual, whether it be painful experiences or loss of function. YLDs have a duration and are usually something we experience, such as pain. YLLs, on the other hand, are instantly generated when the life of that individual has expired. We do not experience YLLs, and they happen where we are not. When YLLs are generated, the life in question has already ended. On a secular account, death is the irreversible cessation of the mind and the senses, and …. (shrink)

Background In the context of limited health care budgets in countries where Neglected Tropical Diseases are endemic, scaling up disease control interventions entails the setting of priorities. However, solutions based solely on cost-effectiveness analyses may lead to biased and insufficiently justified priorities. Objectives The objectives of this paper are to 1) demonstrate how a range of equity concerns can be used to identify feasible priority setting criteria, 2) show how these criteria can be fed into a multi-criteria decision-making matrix, and (...) 3) discuss the conditions under which this decision-making procedure should be carried out in a real-world decision-making context. Methods This paper draws on elements from theories of decision analysis and ethical theories of fair resource allocation. We explore six typical NTD interventions by employing a modified multi-criteria decision analysis model with predefined criteria, drawn from a priority setting guide under development by the WHO. To identify relevant evidence for the six chosen interventions, we searched the PubMed and Cochrane databases. Discussion Our in vitro multi-criteria decision analysis suggested that case management for visceral leishmaniasis should be given a higher priority than mass campaigns to prevent soil-transmitted helminthic infections. This seems to contradict current health care priorities and recommendations in the literature. We also consider procedural conditions that should be met in a contextualised decision-making process and we stress the limitations of this study exercise. Conclusion By exploring how several criteria relevant to the multi-facetted characteristics of NTDs can be taken into account simultaneously, we are able to suggest how improved priority settings among NTDs can be realised. (shrink)

Background and objectives: Summary measures of overall health inequality are independent of group membership and enable international comparisons of distribution of health. We compare inequality between and within countries over time and identify normative issues underlying such comparisons. Methods: We used a set of modeled historical life tables for 193 World Health Organization member states from the years 1990, 2000 and 2008 and calculated inequality in age at death and inequality-adjusted life expectancy. Results: Our calculations suggest that overall health inequalities (...) in age at death have been decreasing in the period 1990–2008 in most countries of the world. Only 20 countries experienced increasing distribution in age at death. Simultaneously, overall life expectancy has increased in 85 per cent of all countries. Thus, the combined measure IALE has improved globally. The same overall trend of reduced health inequality applies to all groups of countries stratified by income level. Conclusion: Overall health inequalities, in addition to average health outcomes, could be reported regularly to monitor the health status of populations and the performance of health systems. We find, on normative grounds, the combined measure IALE to be preferable to measuring trends in inequality only. Likewise, we find the Absolute GiniH to be preferable to Relative GiniH. (shrink)

Progress towards Universal Health Coverage (UHC) requires making difficult trade-offs. In this journal, Dr. Margaret Chan, the WHO Director-General, has endorsed the principles for making such decisions put forward by the WHO Consultative Group on Equity and UHC. These principles include maximizing population health, priority for the worse off, and shielding people from health-related financial risks. But how should one apply these principles in particular cases and how should one adjudicate between them when their demands conflict? This paper by some (...) members of the Consultative Group and a diverse group of health policy professionals addresses these questions. It considers three stylized versions of actual policy dilemmas. Each of these cases pertains to one of the three principal dimensions of progress towards UHC: which services to cover first, which populations to prioritize for coverage, and how to move from out-of-pocket expenditures to pre-payment with pooling of funds. Our cases are simplified to highlight common trade-offs. While we make specific recommendations, our primary aim is to demonstrate both the form and substance of the reasoning involved in striking a fair balance between competing interests on the road to UHC. (shrink)

Reducing inequalities in health and the determinants of health is a widely acknowledged health policy goal, and methods for measuring inequalities and inequities in health are well developed. Yet, the evidence base is weak for how to achieve these goals. There is a lack of high-quality randomised controlled trials reporting impact on the distribution of health and non-health benefits and lack of methodological rigour in how to design, power, measure, analyse and interpret distributional impact in RCTs. Our overarching aim in (...) this paper is to contribute to the emerging effort to improve transparency and coherence in the theoretical and conceptual basis for RCTs on effective interventions to reduce health inequity. We endeavour to achieve this aim by pursuing two more specific objectives. First, we propose an overview of three broader health equity frameworks and clarify their implications for the measurement of health inequality in RCTs. Second, we seek to clarify the relationship between theory and translational challenges that researchers would need to attend to, in order to ensure that equity-relevant RCTs are coherently grounded in theory. (shrink)