Nancy Jecker

The COVID-19 pandemic has highlighted the question, ‘What do we owe each other as members of a global community during a global health crisis?’ In tandem, it has raised underlying concerns about how we should prepare for the next infectious disease outbreak and what we owe to people in other countries during normal times. While the prevailing bioethics literature addresses these questions drawing on values and concepts prominent in the global north, this paper articulates responses prominent in sub-Saharan Africa. The paper first introduces a figurative ‘global health village’ to orient readers to African traditional thought. Next, it considers ethical requirements for governing a global health village, drawing on the ethic of ubuntu to formulate African renderings of solidarity, relational justice and sufficiency. The final section of the paper uses these values to critique current approaches, including COVAX, the vaccines pillar of the Access to COVID-19 Tools (ACT) accelerator, and a proposed international Pandemic Treaty. It proposes a path forward that better realizes ubuntu in global health.

In Ending Midlife Bias: New Values for Old Age, I argued that dignity can give practical guidance for patient care, especially dementia care.1 Using a capability-informed analysis, I detailed threats to central human capabilities that undermine dignity for people with dementia and provide practical suggestions for managing these threats in paradigm cases. In an article in this issue, Hojjat Soofi argues that a capability-informed account of dignity is exclusionary of people with dementia and does not translate into practical ethics guidance.2 Soofi maintains that people with intellectual impairment ‘might not be able to exercise (or even have access to)’ the capabilities in question (Soofi, p4).2 Focusing on Nussbaum’s capability view, Soofi cautions, it gives a narrow, blinkered assessment of what it means to live a full and flourishing human life. In this commentary, I argue that Soofi’s critique of the capability view hastily generalises from a narrow set of premises to expansive, unwarranted conclusions. Soofi’s first objection, that a capability view of dignity excludes people with dementia, is a sweeping and strong claim. In its support, Soofi cites dignity of the Kantian sort, which requires ‘cognitive competence to exercise rational agency,’ to argue that ‘if we want to include people with dementia in the circle of human beings …

The Aging Self and the Aging Society Ethical issues involving the elderly have recently come to the fore. This should come as no surprise: Since the turn of the century, there has been an eightfold in crease in the number of Americans over the age of sixty five, and almost a tripling of their proportion to the general population. Those over the age of eighty-five- the fastest growing group in the country-are twenty one more times as numerous as in 1900. Demographers expect this trend to accelerate into the twenty-first century. The aging of society casts into vivid relief a num ber of deep and troubling questions. On the one hand, as individuals, we grapple with the immediate experience of aging and mortality and seek to find in it philosophical or ethical significance. We also wonder what responsi bilities we bear toward aging family members and what expectations of others our plans for old age can reasona bly include. On the other hand, as a community, we must decide: What special role, if any, do older persons occupy in our society? What constitutes a just distribution of medical resources between generations? And, How can institutions that serve the old foster imperiled values, such as autonomy, self-respect, and dignity? Only recently have we begun to explore these themes, yet already a rich and fruitful literature has grown up around them.

In ‘Does zero-COVID neglect health disparities?’ we made the case that strict zero-COVID policies implemented during the coronavirus 2019 disease (COVID-19) pandemic raise health equity concerns so serious that these policies are not ethically sustainable.1 Zero-COVID, which has dominated many Pacific Rim societies, sets zero deaths from COVID-19 as a goal, and aims to reach it by forcefully containing transmission through short-term lockdowns, followed by stringent find, test, trace and isolate methods. Since the paper appeared in 2021, the Omicron variant and subvariants took hold, making a strict zero goal unattainable and leading many countries to abandon it. Careful ethical analysis of zero-COVID’s impact remains crucially important, however, not only because the novel coronavirus continues to surprise us, but also to ensure lessons learnt from this pandemic are carried forward to future pandemics. In ‘Zero-COVID and health inequities’,2 Schaefer argues that it is possible to pursue zero-COVID yet offset any negative impacts on disadvantaged groups. Citing Singapore, where zero-COVID led to outbreaks in crowded and unsanitary migrant workers dormitories, Schaefer notes the government offset these effects, setting up less densely populated ‘quick build dormitories’ that caused daily case counts to drop, even while zero-COVID remained …

During the coronavirus disease 2019 (COVID‐19) pandemic, bioethical analyses often emphasized population health and societal benefit. Hospital policies frequently focused on reducing risk of transmitting SARS‐CoV‐2 by restricting visitors; requiring protective equipment; and screening staff, patients and visitors. While restrictions can be burdensome, they are often justified as essential measures to protect the whole population against a virus with high rates of transmission, morbidity and mortality. Yet communities are not monolithic, and the impacts of these restrictions affect different groups differently. An ophthalmological unit outreach program in Ethiopia serves to illustrate. Pre‐operative screening policies were designed to protect as many patients as possible but had adverse impacts on underserved communities. As this case study demonstrates, creating hospital policies that truly serve the good of the society may require a more holistic review of impacts on inequitably positioned communities.

This chapter discusses three types of sociable robots for older adults: robotic caregivers ; robotic friends ; and sex robots. The central argument holds that society ought to make reasonable efforts to provide these types of robots and that under certain conditions, omitting such support not only harms older adults but poses threats to their dignity. The argument proceeds stepwise. First, the chapter establishes that assisting care-dependent older adults to perform activities of daily living is integral to respecting dignity. Here, the argument establishes the vital role that carebots-of-the-future might play in aged societies as the supply of working age adults falls shy of demand. Next, the chapter extends this analysis to designing friendbots for socially isolated older adults. The argument holds that reasonable efforts to provide access to friendbots for socially isolated adults is also a future societal responsibility. Finally, the chapter applies similar reasoning to show that societies ought to make reasonable efforts to support sexual capabilities for older adults who want to be sexual but are bereft of sex partners. The argument draws on capability accounts of justice to show that when central human capacities, such as bodily integrity; intimate relationships; and the use of senses, imagination and thought, are at risk of falling below a threshold level, society should intercede.

This paper questions an exclusively state-centred framing of global health justice and proposes a multilateral alternative. Using the distribution of COVID-19 vaccines to illustrate, we bring to light a broad range of global actors up and down the chain of vaccine development who contribute to global vaccine inequities. Section 1 (Background) presents an overview of moments in which diverse global actors, each with their own priorities and aims, shaped subsequent vaccine distribution. Section 2 (Collective action failures) characterises collective action failures at each phase of vaccine development that contributed to global vaccine disparities. It identifies as critical the task of establishing upstream strategies to coordinate collective action at multiple stages across a range of actors. Section 3 (A Multilateral model of global health governance) takes up this task, identifying a convergence of interests among a range of stakeholders and proposing ways to realise them. Appealing to a responsibility to protect (R2P), a doctrine developed in response to human rights atrocities during the 1990s, we show how to operationalise R2P through a principle of subsidiarity and present ethical arguments in support of this approach.

This paper argues for global sharing of COVID‐19 treatments during the COVID‐19 pandemic and beyond based on principles of global solidarity. It starts by distinguishing two types of COVID‐19 treatments and models sharing strategies for each in small‐group scenarios, contrasting groups that are solidaristic with those composed of self‐interest maximizers to show the appeal of solidaristic reasoning. It then extends the analysis, arguing that a similar logic should apply within and between nations. To further elaborate global solidarity, the paper distinguishes morally voluntary, sliding‐scale, and mandatory versions. It argues for an all‐hands‐on‐deck approach and gives examples to illustrate. The paper concludes that during the COVID‐19 crisis, global solidarity is a core value, and global sharing of COVID‐19 treatments should be considered a duty of justice, not of charity.

This paper argues for global sharing of COVID‐19 treatments during the COVID‐19 pandemic and beyond based on principles of global solidarity. It starts by distinguishing two types of COVID‐19 treatments and models sharing strategies for each in small‐group scenarios, contrasting groups that are solidaristic with those composed of self‐interest maximizers to show the appeal of solidaristic reasoning. It then extends the analysis, arguing that a similar logic should apply within and between nations. To further elaborate global solidarity, the paper distinguishes morally voluntary, sliding‐scale, and mandatory versions. It argues for an all‐hands‐on‐deck approach and gives examples to illustrate. The paper concludes that during the COVID‐19 crisis, global solidarity is a core value, and global sharing of COVID‐19 treatments should be considered a duty of justice, not of charity.

Global scarcity of COVID-19 vaccines raises ethical questions about their fair allocation between nations. Section I introduces the question and proposes that wealthy nations have a duty of justice to share globally scarce COVID-19 vaccines. Section II distinguishes justice from charity and argues that beneficiaries of unjust structures incur duties of justice when they are systematically advantaged at others expense. Section III gives a case-based argument describing three upstream structural injustices that systematically advantaged wealthy countries and disadvantaged poorer countries, contributing to global disparities of COVID-19 vaccines. Section IV examines more closely the duties of justice owed, including a duty to relinquish holdings, restitute victims, and restore relationships. Section V concludes that wealthy nations have a duty of justice to share COVID-19 vaccines with poor nations and to restore relationships damaged by injustice. All nations should take steps to transform unjust structures.

This paper presents an African relational view of social robots’ moral standing which draws on the philosophy of ubuntu. The introduction places the question of moral standing in historical and cultural contexts. Section 2 demonstrates an ubuntu framework by applying it to the fictional case of a social robot named Klara, taken from Ishiguro’s novel, Klara and the Sun. We argue that an ubuntu ethic assigns moral standing to Klara, based on her relational qualities and pro-social virtues. Section 3 introduces a second fictional case, taken from McKeown’s novel, Machines Like Me, in which a social robot named Adam displays intrinsic qualities, such as sentience, rationality, and deductive moral reasoning, yet lacks close social ties to particular people. We argue that Adam is not a person in the African sense; however, he qualifies as a person according to many standard Western views, such as Kantian and utilitarian ethics. Section 4 further elaborates the African relational view by comparing the moral standing of social robots and humans in a forced choice scenario. Section 5 replies to objections. We conclude that an African relational approach captures important insights about the moral standing of social robots that many Western accounts miss and should be better incorporated into global frameworks for designing and deploying social robots.

This chapter sets forth an interpretation of public reason that appeals to our central capabilities as human beings. I argue that appealing to central human capabilities and to the related idea of respect for threshold capabilities is the best way to understand public reason. My defense of this position advances stepwise: first, I consider a central alternative to a capability account, which regards public reason as a matter of contracting; next, I describe central concerns with contract views and show how a capability view can avoid them; lastly, I consider extending public reason beyond national borders and test the two views in this context.

Since the World Health Organization first declared the novel coronavirus a pandemic, diverse strategies have emerged to address it. This paper focuses on two leading strategies, elimination and mitigation, and examines their ethical basis. Elimination or ‘Zero-COVID’ dominates policies in Pacific Rim societies. It sets as a goal zero deaths and seeks to contain transmission using stringent short-term lockdowns, followed by strict find, test, trace and isolate methods. Mitigation, which dominates in the US and most European nations, sets targets for community transmission and lifts restrictions once targets are met. This approach takes calculated risks and regards a certain amount of disease and death as ethically justified. Section I examines different societal responses to risk that underlie these different policy approaches. Section II focuses on ethical arguments favouring Zero-COVID and raises health equity objections. Section III proposes a long-term strategy that balances the twin goals of promoting population health and health equity. There are no data available for this work.

Should the nation provide expensive care and scarce organs to convicted felons? We distinguish between two fields of justice: Medical Justice and Societal Justice. Although there is general acceptance within the medical profession that physicians may distribute limited treatments based solely on potential medical benefits without regard to nonmedical factors, that does not mean that society cannot impose limits based on societal factors. If a society considers the convicted felon to be a full member, then that person would be entitled to at least a decent minimum level of care — which might include access to scarce life-saving organs. However, if criminals forfeit their entitlement to the same level of medical care afforded to all members of society, they still would be entitled to a kind of rudimentary decent minimum granted to all persons on simple humanitarian grounds. Almost certainly this entitlement would not include access to organ transplants.

Two recent policy statements by providers of critical care representing the United States and Europe have rejected the concept and language of “medical futility,” on the ground that there is no universal consensus on a definition. They recommend using “potentially inappropriate” or “inappropriate” instead. As Bosslet and colleagues state: The term “potentially inappropriate” should be used, rather than futile, to describe treatments that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them. Clinicians should explain and advocate for the treatment plan...

Partly because physicians can “never say never,” partly because of the seduction of modern technology, and partly out of misplaced fear of litigation, physicians have increasingly shown a tendency to undertake treatments that have no realistic expectation of success. For this reason, we have articulated common sense criteria for medical futility. If a treatment can be shown not to have worked in the last 100 cases, we propose that it be regarded as medically futile. Also, if the treatment fails to restore consciousness or alleviate total dependence on intensive care, we propose such treatment be judged futile. This definition provides clear end points and encourages the profession to review data from the past and perform, prospective clinical studies that not only report treatments that work but also treatments that do not work. We have also argued that, in a variety of settings, physicians have no ordinary ethical obligation to offer futile interventions. Although physicians should inform, and discuss all decisions to withhold or withdraw medical treatments with patients, they need not obtain the patient's permission to desist from futile interventions

Controlled human infection (CHI) studies involve the deliberate exposure of healthy research participants to infectious agents to study early disease processes and evaluate interventions under controlled conditions with high efficiency. Although CHI studies expose participants to the risk of infection, they are designed to offer investigators unique advantages for studying the pathogenesis of infectious diseases and testing potential vaccines or treatments in humans. One of the central challenges facing investigators involves the fair selection of research subjects to participate in CHI studies. While there is widespread agreement that investigators have a duty to select research participants fairly, this principle also yields conflicting ethical imperatives, for example requiring investigators to both exclude potential participants with co‐morbidities since they face increased risks, but also to include them in order to ensure generalizability. In this paper we defend an account of fair subject selection that is tailored to the context of CHI studies. We identify the considerations of fairness that bear directly on selecting participants for CHI studies and provide investigators and members of IRBs and RECs with a principled way to navigate the conflicting imperatives to which these considerations give rise.