Nir Eyal

Despite their clearly demonstrated safety and effectiveness, approved vaccines against COVID-19 are commonly mistrusted. Nations should find and implement effective ways to boost vaccine confidence. But the implications for ethical vaccine development are less straightforward than some have assumed. Opponents of COVID-19 vaccine challenge trials, in particular, made speculative or empirically implausible warnings on this matter, some of which, if applied consistently, would have ruled out most COVID-19 vaccine trials and many non-pharmaceutical responses.

In spring, summer and autumn 2020, one abiding argument against controlled human infection studies of SARS-CoV-2 vaccines has been their impact on local communities. Leading scientists and bioethicists expressed concern about undue usage of local residents’ direly needed scarce resources at a time of great need and even about their unintended infection. They recommended either avoiding CHI trials or engaging local communities before conducting any CHIs. Similar recommendations were not made for the alternative—standard phase III field trials of these same vaccines. We argue that the health effects of CHI studies on local residents not participating in the study tend to be smaller and more positive than those of field trials. That is all the more so now that tested vaccines are being rolled out. Whether or not local community engagement is necessary for urgent vaccine studies in the pandemic, the case for its engagement is stronger prior to field trials than prior to CHI studies.

The ethics of research on human subjects is often construed as a fine balance between the interests of patients in need of novel health interventions, and those of study participants who should remain safe in the process. But there is a third group in the mix. Some people belong to neither category, yet research can affect or jeopardize them. Call such people “bystanders.” This article shows that thinking about bystander protection can question whether there is an upper limit on the risks that studies may legitimately visit upon their participants. Thus, thinking about appropriate bystander protection can shed light on the appropriate protection of study participants. Core research ethics, which focuses on the latter, must consider the former as well.

The Global Burden of Disease Study is one of the largest-scale research collaborations in global health, producing critical data for researchers, policy-makers, and health workers about more than 350 diseases, injuries, and risk factors. Such an undertaking is, of course, extremely complex from an empirical perspective. But it also raises complex ethical and philosophical questions. In this volume, a group of leading philosophers, economists, epidemiologists, and policy scholars identify and discuss these philosophical questions. Better appreciating the philosophical dimensions of a study like the GBD can make possible a more sophisticated interpretation of its results, and it can improve epidemiological studies in the future, so that they are better suited to produce results that help us to improve global health.

Recent observations associate naturally occurring trace levels of Lithium in ground water with significantly lower suicide rates. It has been suggested that adding trace Lithium to drinking water could be a safe and effective way to reduce suicide. This article discusses the many ethical implications of such population-wide Lithium medication. It compares this policy to more targeted solutions that introduce trace amounts of Lithium to groups at higher risk of suicide or lower risk of adverse effects. The question of mass treatment with Lithium recalls other choices in public health between population-wide and more targeted interventions. The framework we propose could be relevant to some of these other dilemmas.

In this article, we provide a comprehensive analysis and a normative assessment of rationing through inconvenience as a form of rationing. By “rationing through inconvenience” in the health sphere, we refer to a nonfinancial burden that is either intended to cause or has the effect of causing patients or clinicians to choose an option for health-related consumption that is preferred by the health system for its fairness, efficiency, or other distributive desiderata beyond assisting the immediate patient. We argue that under certain conditions, rationing through inconvenience may turn out to serve as a legitimate and, compared to direct rationing, even a preferable tool for rationing; we propose a research agenda to identify more precisely when that might be the case and when, alternatively, rationing through inconvenience remains ethically undesirable. After defining and illustrating rationing through inconvenience, we turn to its moral advantages and disadvantages over other rationing methods. We take it as a starting assumption that rationing, understood as scarce-resource prioritization, is inevitable and, in a society that has goals beyond optimizing health care for individual patients—such as improving societal health care, education, or overall welfare—prudent and fair.

With the expansion of antiretroviral treatment programmes, many children and adolescents with HIV in sub-Saharan Africa could expect to live healthy lives. Yet adolescents have the highest levels of poor antiretroviral adherence and of loss to follow-up compared with other age groups. This can lead to increased morbidity and mortality, to the development of drug-resistant strains, and to high societal costs. While financial incentives have been extensively used to promote medication adherence among adults, their use among adolescents remains rare. And while there is a large body of ethical literature exploring financial incentives among adults, little philosophical thought has gone into their use among adolescents. This paper explores three oft-mentioned ethical worries about financial incentives for health behaviours and it asks whether these concerns are more serious in the context of incentives for improving adolescent adherence. The three worries are that such incentives would unduly coerce adolescents' decision-making, would compromise distributive justice and would crowd out intrinsic motivations and non-monetary values. Our tentative conclusion is that more empirical investigation of these concerns is necessary, and that at this point they are not compelling enough to rule out trials in which adolescents are incentivised for antiretroviral adherence.

Both left libertarians, who support the redistribution of income and wealth through taxation, and right libertarians, who oppose redistributive taxation, share an important view: that, looming catastrophes aside, the state must never redistribute any part of our body or our person without our consent. Cécile Fabre rejects that view. For her, just as the undeservedly poor have a just claim to money from their fellow citizens in order to lead a minimally flourishing life, the undeservedly ‘medically poor’ have a just claim to help from fellow citizens in order to lead such a life. Such obligatory help may in principle involve even the supply of body parts for transplantation. The state ought to exact such resources from the medically rich whenever doing so would secure the prospect of a minimally flourishing life to the medically poor without denying that prospect to anyone else. Fabre criticizes Ronald Dworkin's belief in ‘a prophylactic line that comes close to making the body inviolate, that is, making body parts not parts of social resources at all’. For her, ‘Duties to help. . . do not stop at material resources: they involve the body. . . in invasive ways’.

Gillian Hadfield and Stephen Macedo argue that late-Rawlsian stability for the right reasons, that is, stability based on participants’ reciprocal cooperation, can arise even if participants start out only economically rational and indifferent to justice. As they explain, even purely rational actors have an interest in having a neutral “shared logic” to coordinate decentralized enforcement of social cooperation and in internalizing that logic. Once developed and internalized, they add, that logic renders their reasoning public, and their persons, reasonable and responsive to Rawlsian justice considerations. Hadfield and Macedo’s account seeks to lend Rawlsian contractualism a contractarian foundation. I raise five challenges to their account, focusing on the sense in which actors “start out” purely rational; on illiberal means that may serve rational citizens’ joint ends; on the counterexample of Martin Luther King; on the difficulty of specifying the mechanism for shared logic-internalization; and on the further counterexample of a medical student who internalizes compassion, only upon the condition that it serves his rational aims

Commentators on the ethics of translational research find it morally problematic. Types of translational research are said to involve questionable benefits, special risks, additional barriers to informed consent, and severe conflicts of interest. Translational research conducted on the global poor is thought to exploit them and increase international disparities. Some commentators support especially stringent ethical review. However, such concerns are grounded only in pre-approval translational research (now called T1 ). Whether or not T1 has these features, translational research beyond approval ( T2 : phase IV, health services, and implementation research) is unlikely to and, when conducted on the global poor, may support development. Therefore, insofar as T1 is morally problematic, and no independent objections to T2 exist, the ethics of translational research is diverse: while some translational research is problematic, some is not. Funding and oversight should reflect this diversity, and T2 should be encouraged, particularly when conducted among the global poor

Next SectionAccess to medicines, vaccination and care in resource-poor settings is threatened by the emigration of physicians and other health workers. In entire regions of the developing world, low physician density exacerbates child and maternal mortality and hinders treatment of HIV/AIDS. This article invites philosophers to help identify ethical and effective responses to medical brain drain. It reviews existing proposals and their limitations. It makes a case that, in resource-poor countries, ’locally relevant medical training’—teaching primarily locally endemic diseases and practice in scarcity conditions, training in rural communities and admitting rural students preferentially—could help improve retention. Locally relevant training would arguably diminish medical brain drain in five ways. It would (i) make graduates less attractive for Western employers, (ii) align graduates’ expectations with actual practice, diminishing ‘burn-out’, (iii) enhance the professional prestige of local practice, (iv) hold rotations in, and recruit applicants from, rural areas, which is known to improve retention there, and (v) create local career development options that attract practitioners to stay. Such educational reform may raise worries about poor-quality care, breach of the freedom of education and occupation, breach of the freedom of movement, unequal distribution of opportunities among students, hypocrisy and resistance from influential actors. We address these worries

Patients’ medical conditions can result from their own avoidable risk taking. Some lung diseases result from avoidable smoking and some traffic accidents result from victims’ reckless driving. Although in many nonmedical areas we hold people responsible for taking risks they could avoid, it is normally harsh and inappropriate to deny patients care because they risked needing it. Why? A popular account is that protecting everyone’s "decent minimum," their basic needs, matters more than the benefits of holding people accountable. This account is deficient. Protecting the decent minimum is not always served by offering noncompliant patients either nonbasic or basic care. Nor is protecting that minimum always served by unconditional medical care better than by nonmedical interventions. To interpret the decent minimum in democratic terms is a futile response to these challenges. Ideas for new accounts are suggested

The article begins by reconstructing the just distribution of the social bases of self-respect, a principle of justice that is covert in Rawls’s writing. I argue that, for Rawls, justice mandates that each social basis for self-respect be equalized. Curiously, for Rawls, that principle ranks higher than Rawls’s two more famous principles of justice - equal liberty and the difference principle. I then recall Rawls’s well-known confusion between self-respect and another form of self-appraisal, namely, confidence in one’s determinate plans and capacities. Correcting that confusion forces Rawls to accept objectionable and illiberal politics. Surprisingly, a consistent Rawls must endorse absolute economic equality, deny liberty any priority whatsoever, or sponsor still other illiberal political views - evidence of a flaw in the ethical basis of Rawls’s politics.

In political philosophy and in economics, unfair inequality is usually assessed between individuals, nowadays often on luck-egalitarian grounds. You have more than I do and that's unfair. By contrast, in epidemiology and sociology, unfair inequality is traditionally assessed between groups. More is concentrated among people of your class or race than among people of mine, and that's unfair. I shall call this difference the egalitarian ‘divorce’. Epidemiologists, and their ‘divorce lawyers’ Paula Braveman, Norman Daniels, and Iris Marion Young, explain that not every inequality between individuals is an inequity. Only inequality between social status groups is unfair. Only such inequality stems from problems like partiality, discrimination, oppression, inequality-related population health problems, and unfair distribution of prospects. And it alone is actionable. By contrast, inequality between individuals, e.g. in longevity, is natural, inevitable, less important, or otherwise less informative — not unjust. In ‘divorce trial’ mode, I respond to epidemiologists that group inequalities lack the intrinsic disvalue that they ascribe them. They may be instrumentally or contingently bad or wrong, not essentially so. I then shift to ‘remarriage’: although group inequalities lack intrinsic badness or wrongness, for multiple reasons they remain useful to measure.

Most books on ethics are boring. Against Autonomy 1 is fun to read because its helpful and profound points are made without a fuss. Author Sarah Conly is right that “when individuals engage in behavior that undercuts their own chances of happiness, state interference may be justified”. In what follows I argue that Conly misinterprets that thesis in three ways. First, she says that her paternalism seeks to “help people get where they want to go... live the lives they truly want to live”. That's a different idea from the one I quoted earlier. Why? Because people do not always (truly) want to live in the way that (in fact) would give them the highest chance of happiness. Conly is surely right that when we “habitually choose the large fries”, that's not always because large fries is what we want truly. Such choice can also reflect ignorance and miscalculation on our parts—when we simply “choose ineffective means to our ends”. But Conly fails to recognise another potential source. Sometimes self-harming choice reflects what we truly want at the time. Many young people do not care much about health problems in their older years. They habitually choose large fries not because they …