Nir Eyal

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.

Distributive theories evaluate distributions of goods based on candidate recipients’ characteristics, e.g. how well off candidates are, how deserving they are, and whether they fare below sufficiency. But such characteristics vary across possible worlds, so distributive theories may differ in terms of the world which for them settles candidates’ characteristics. This paper examines how distributive theories differ in terms of whether candidate recipients’ relevant characteristics are grounded in the possible world that would take place if the distributor does not intervene (call it the “input” world) or if they are grounded in each possible world that the distributor can bring about through different decisions (call each an “output” world). We illustrate the importance of this distinction in relation to one distributive theory, prioritarianism. As we show, both input and output versions of prioritarianism are plausible interpretations of the literature, and there are good reasons to take input prioritarianism seriously. Ultimately, however, we argue that input prioritarianism should be rejected.

In many countries, the COVID‐19 pandemic varied starkly between different racial and ethnic groups. Before vaccines were approved, some considered assigning priority access to worse‐hit racial groups. That debate can inform rationing in future pandemics and in some of the many areas outside COVID‐19 that admit of racial health disparities. However, concerns were raised that “race‐responsive” prioritizations would be ruled unlawful for allegedly constituting wrongful discrimination. This legal argument relies on an understanding of discrimination law as demanding color‐blindness. We argue that a, color‐blind understanding of discrimination would be hostile only to one of two rationales for prioritizing the relevant racial minorities in settings of racial health disparities. We also propose a method for incorporating appropriate race‐responsive concerns that is in many ways ethically and legally superior to ones suggested thus far. That method turns artificial intelligence, thanks precisely to its artificial and “black box” nature (features that underlie recent concerns about artificial intelligence's discriminatory potential), into an instrument of social justice.

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

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.

Research with enhanced potential pandemic pathogens (ePPP) makes pathogens substantially more lethal, communicable, immunosuppressive or otherwise capable of triggering a pandemic. We briefly relay an existing argument that the benefits of ePPP research do not outweigh its risks and then consider why proponents of these arguments continue to confidently endorse them. We argue that these endorsements may well be the product of common cognitive biases—in which case they would provide no challenge to the argument against ePPP research. If the case against ePPP research is strong, the views of professional experts do little to move the needle in favour of ePPP research.

Notwithstanding the success of conventional field trials for vaccines against COVID-19, human challenge trials that could obtain more information about these and about other vaccines and further strategies against it are about to start in the UK. One critique of COVID-19 HCTs is their distinct paucity of information on crucial population groups. For safety reasons, these HCTs will exclude candidate participants of advanced age or with comorbidities that worsen COVID-19, yet a vaccine should protect such populations. We turn this cliché on its head. The truth is that either an HCT or a field trial has intrinsic generalisability limitations, that an HCT can expedite protection of high-risk participants even without challenging them with the virus, and that an important route to obtaining results generalisable to high-risk groups under either strategy is facilitated by HCTs. There are no data in this work.

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.

Sometimes, offering someone beneficial care is likely to thwart the similar or more serious medical needs of more people. For example, when acute shortage is strongly predicted to persist, providing the long period on scarce intensive care that a certain COVID‐19 patient needs is sometimes projected to block several future COVID‐19 patients from receiving the shorter periods on intensive care that they will need. Expected utility is typically higher if the former is denied intensive care. A tempting initial account of such cases is that consequentialism supports denying care to that patient and nonconsequentialism supports providing that care. This paper argues that the consequentialist case is more complicated than it may initially seem and that nonconsequentialism sides more readily with denial of the beneficial treatment. It also shows that when denying it would directly enhance public health by a lot, either ethical approach would normally recommend denying it. Practical implications are discussed, including how to address conscientious objection to this shared recommendation.