Nir Eyal

Telic egalitarians believe that health inequalities are inherently bad in one way at least. According to the levelling down objection to telic egalitarianism, when blinding the sighted is the only possible way to equalize their condition with that of the blind, intuitively there remains _no_ reason to blind them. To do so would add nothing of value—despite adding to equality. Telic egalitarian Larry Temkin has responded that this intuition probably rests on a view which he called the _Slogan_, and which he argued cannot be true. However, the intuition may also rest on what I shall call the _Targeted Slogan_: the position that one situation cannot be inherently worse than another _in terms of concern for the worse-off as such_, when it is in no respect worse for any individual than the other situation. Temkin did not address the _Targeted Slogan_. I put forward four counter-examples to it and conclude that the _Targeted Slogan_ is false, and that telic egalitarianism is _probably true. I also give a preliminary account of why we neverthele_ss had the intuition that there is nothing to recommend levelling down by blinding the sighted.

Essays in this book address a wide range of ethical issues that bear on health inequalities. This introduction identifies these issues and discusses them in relation to broader notions of distributive justice, fairness, choice, and welfare. Since health has many determinants, these essays focus on inequalities in health rather than only on disparities in access to health services. The aim of this chapter is not to summarize or repeat the arguments examined in this book, but rather to ask the right questions and stimulate interest in these crucial issues about how we organize our societies, how we live and die, and how health is distributed by nature and by us. The introduction is organized around five key topics, including: concepts and measures of health inequality; what inequalities in health that matter, as seen from different normative perspectives; how to understand inequalities between individuals and between groups; inequality and discrimination; and how egalitarian theories deal with uncertainty.

Under what I call ”Near-Universal Basic Income,” or NUBI, everyone receives a high level of basic income, except for the rich. NUBI is therefore only near-universal and it requires means-testing. It is an economic hybrid: a cross between Universal Basic Income (UBI) and conservative social relief. My thesis is that if standard considerations that are often advanced to support UBI against social relief are successful, then these combined considerations probably lend NUBI even greater support. Thus, UBI supporters should consider becoming NUBI supporters. The considerations I examine focus on (1) sufficiency; (2) cost cuts; (3) equality; (4) freedom; (5) the social bases of self-respect; and (6) political resilience.

In the increasingly likely event of an engineered-virus outbreak or pandemic of catastrophic potential, managing infectious aerosols to reduce transmission will be crucial. Now is the time to start preparing our buildings, public opinion, and regulatory environments for the infectious aerosol management interventions necessary to protect the public. But which interventions should governments and institutions invest in the most? We review the leading candidate methods for infectious aerosol management and discuss their respective advantages, disadvantages, and suitable settings. There is strong emerging evidence that two recently explored technologies, direct exposure to far-ultraviolet-C (UVC) light and triethylene glycol, are particularly efficacious and safe, but there remain open questions about the long-term safety and efficacy of these interventions. In the meantime, we recommend other interventions-especially upper-room UVC and in-room air cleaners-for settings where most occupants regularly spend more than a small fraction of their day. We conclude by listing research questions about these interventions that still need to be researched in social science, product development, medicine, engineering, economics, and ethics.

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 (through no fault of my own) 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.

Although informed consent is important in clinical research, questions persist regarding when it is necessary, what it requires, and how it should be obtained. The standard view in research ethics is that the function of informed consent is to respect individual autonomy. However, consent processes are multidimensional and serve other ethical functions as well. These functions deserve particular attention when barriers to consent exist. We argue that consent serves seven ethically important and conceptually distinct functions. The first four functions pertain principally to individual participants: (1) providing transparency; (2) allowing control and authorization; (3) promoting concordance with participants' values; and (4) protecting and promoting welfare interests. Three other functions are systemic or policy focused: (5) promoting trust; (6) satisfying regulatory requirements; and (7) promoting integrity in research. Reframing consent around these functions can guide approaches to consent that are context sensitive and that maximize achievable goals.

On August 5, 2010, a cave-in left thirty-three Chilean miners trapped underground. The Chilean government embarked on a massive rescue effort, with assistance from multiple international teams, experts, and donors that cost an estimated USD $10-20 million. There is a puzzle here. Many mine safety measures that would have been more cost effective had not been taken in Chile earlier by any of the parties either by the Chilean government or by international donors. The Chilean story is a vivid, real illustration of a persistent problem, the identified lives effect. Human beings show a greater inclination to assist (and avoid harming) persons and groups identified as those at high risk of great harm than to assist (and avoid harming) persons and groups who will suffer (or already suffer) similar harm but are not identified (as yet). The problem touches almost every aspect of human life and politics: health, the environment, the law. This volume is the first book to tackle the effect from all necessary perspectives. What can social and cognitive sciences teach us about the origin and triggers of the effect? On the philosophical and bioethical level, is the effect a "bias" to be eliminated or is it morally justified? What implications does the law have for health care, law, the environment, and other domains?

This essay proposes a simple way to incentivize states not to develop pathogens with enhanced pandemic potential (PEPPs) as bioweapons: to tip all state actors that all of them stand to lose from developing such highly lethal, highly transmissible bioweapons. Being highly transmissible, a PEPP used as a weapon could easily spread, infecting a state’s own citizens and leaders. Therefore, no state concerned for its own citizens or leaders can afford to use a PEPP weapon, even having developed or acquired it. We then show that when this is commonly known between states, having PEPPs provides no useful deterrent to a state, and there is no point getting into an arms race. Developing and stockpiling PEPP weapons gives states no gain, only risk. We end by assessing three objections to our thesis.

Often, a health resource distribution (or, more generally, a health policy) ranks higher than another on one value, say, on promoting total population health; and lower on another, say, on promoting that of the worst off. Then, some opine, there need not be a rational determination as to which of the multiple distributions that partially fulfill both one ought to choose. Sometimes, reason determines only partially, intransitively, or contentiously which of the many “compromises” between these two values is best or most choiceworthy. Norman Daniels, Ruth Chang, Martijn Boot, and Anders Herlitz affirm this opinion, which I shall call “value incommensurability,” “rational underdeterminacy,” or “reasonable disagreement.” To decide between the multiple reasonable compromises on health resource distribution, these philosophers recommend a deliberative democratic process, on two main grounds. First, in such situations, deliberation can produce the determinacy needed for decisionmaking. Second, by treating respectfully and justly even those patients or communities for whom the distributive compromise selected is bad, deliberation shields the legitimacy of that policy. Increasingly, practically-oriented bioethics recommends democratic deliberation even more expansively than these philosophers do—for nearly every decision on health resource distribution and not only when values are incommensurate—on these two grounds and on others. And one could propose a more modest variant on this expansive move as the justification of democratic deliberation. I argue that none of these moves warrants democratic deliberation on health policy.

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.

The world’s first COVID-19 human challenge trial using the D614G strain of SARS-CoV-2 is underway in the United Kingdom. The Wellcome Trust is funding challenge stock preparation of the Beta variant (B.1.351) for a follow-up human challenge trial, and researchers at Imperial College London are considering conducting that trial. However, little has been written thus far about the ethical justifiability of human challenge trials with SARS-CoV-2 variants of concern. While vaccine resistance as such does not increase risks for volunteers in COVID-19 challenge trials, we explore two specific characteristics of some variants that may initially be thought to make such trials unethical and conclude that SARS-CoV-2 variant challenge trials can remain ethical.

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.

John Roemer’s pragmatic proposal for luck-egalitarian planners normalizes risky choices for individuals’ social “types,” such that risk takers from types where the same risky behaviors are prevalent retain their just entitlements to societal redress, and ones from types where they are rare encounter just penalties. This chapter shows, however, that risky behaviors that are prevalent in one’s type do not always intuitively retain rights to redress, and that ones that are rare in one’s type do not always intuitively deserve a penalty. The chapter puts forth a pragmatic proposal that may complement and partly replace Roemer’s.

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.

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.

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.

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.

We analyse three moral dilemmas involving resource allocation in care for HIV-positive patients. Ole Norheim and Kjell Arne Johansson have argued that these cases reveal a tension between egalitarian concerns and concerns for better population health. We argue, by contrast, that these cases reveal a tension between, on the one hand, a concern for equal *chances*, and, on the other hand, both a concern for better health and an egalitarian concern for equal *outcomes*. We conclude that, in these cases, there is much less tension than Norheim and Johansson claim between egalitarian concerns and concerns for better population health.

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.

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.