Borgar Jølstad

Fair priority setting is based on morally sound criteria. Still, there will be cases when these criteria, our primary considerations, are tied and therefore do not help us in choosing one allocation over another. It is sometimes suggested that such cases can be handled by tiebreakers. In this paper, we discuss two versions of tiebreakers suggested in the literature. One version is to preserve fairness or impartiality by holding a lottery. The other version is to allow secondary considerations, considerations that are not part of our primary priority setting criteria, to be decisive. We argue that the argument for preserving impartiality by holding a lottery is sound, while the argument for using tiebreakers as secondary considerations is not. Finally, we argue that the instances where a tiebreaker seems necessary are precisely the situations where we have strong reasons for preferring a lottery. We conclude that factors that we consider valuable should all be included among the primary considerations, while ties should be settled by lotteries.

Health equity matters, but there is no universally accepted definition of this or associated terms, such as inequities, inequalities, and disparities. Given the flexibility of these terms, investigating how policymakers understand them is important to observe priorities and perhaps course correct. Accordingly, this study analyzed the perceptions high-level policymakers within the WHO African Region. An online survey was distributed to attendees of the WHO’s Fifth Health Sector Directors’ Policy and Planning Meeting for the WHO African Region by email. After responses were collected, both inductive and deductive coding were applied. Inductive coding was undertaken to glean central concepts from free-form responses on understandings of health equity and deductive coding was used to assess alignment with four theories of distributive justice using a coding framework. In analyzing central concepts, three became apparent: access to health services and/or health care, financial protection, and recognizing subgroups. And when we investigated alignment with theory, most respondents’ understandings of health equity aligned with Rawls’ ‘Theory of Justice’ (95%). Of these responses, 70% were exclusively aligned with Rawls’ ‘Theory of Justice’ and 30% aligned also with another theory (this 30% was split 55% utilitarianism and 45% Sen’s Capabilities Approach). Respondent understandings of health equity showed limited alignment with other theories of distributive justice, which were: utilitarianism (n = 7/39; 17.95%), Sen’s Capabilities Approach (n = 5/39; 12.82%), and libertarianism (n = 2/39; 5.13%). Our study demonstrates that alignment with certain theories is tied to specific themes (i.e., theoretical underpinnings may guide policymakers to favour certain policy approaches). For instance, a utilitarian-minded policymaker may be focused on a widespread vaccination campaign, whereas a Rawlsian-aligned policymaker may focus on a targeted approach to reach communities that have lower vaccination rates, and a Senian-aligned policymaker may focus on health literacy programs targeted at addressing vaccine-hesitant individuals within communities with lower vaccination rates. These findings can guide high-level policymakers and international organizations to optimize decision-making by clarifying ethical alternatives.

During the recent debates on whether to prioritize health care workers for COVID-19 vaccines, two main lines of arguments emerged: one centered on maximizing health and one centered on reciprocity. In this article, we scrutinize the argument from reciprocity. The notions of fittingness and proportionality are fundamental for the act of reciprocating. We consider the importance of these notions for various arguments from reciprocity, showing that the arguments are problematic. If there is a plausible argument for reciprocity during the pandemic, this is most likely one that centers on the risk that health care workers take on while working. We argue that the scope of this argument is not plausibly extended only to health care workers. Other essential workers at risk are in the position to make the same arguments. We also argue that there is no compelling argument from reciprocity that makes reciprocating with vaccines, rather than by other means, necessary. Furthermore, allocating vaccines based on reciprocity will conflict with utility-maximizing. Given the weak state of the arguments, overriding concerns for utility seem unreasonable.

It has become increasingly common to conduct research on popular views on ethical questions. In this paper, we discuss when and to what extent popular views should be included in a reflective equilibrium process, thereby influencing normative theory. We argue that popular views are suitable for inclusion in a reflective equilibrium if they approximate considered judgments and examine some factors that plausibly contribute to the consideredness of popular views. We conclude that deliberation and familiarity contribute to the consideredness of popular views, whereas prevalence does not. Furthermore, we raise the “fair trial” objection: that expert deliberation on popular views might fail to respect the consideredness of these views. Eliciting views approximating considered judgments directly from participants is therefore preferable to refining popular views or treating them as “bare” intuitions in the reflective process. These conclusions have important implications for which research methods will likely elicit popular views suitable for a reflective equilibrium process. Research focusing on the prevalence of views is unlikely to yield popular views suitable for a reflective equilibrium, whereas deliberative and in-depth work is more promising.

Adaptation to illness, and its relevance for distribution in health care, has been the subject of vigorous debate. In this paper I examine an aspect of this discussion that seems so far to have been overlooked: that some illnesses are difficult, or even impossible, to adapt to. This matters because adaptation reduces suffering. Illness severity is a priority setting criterion in several countries. When considering severity, we are interested in the extent to which an illness makes a person worse-off. I argue that no plausible theory of well-being can disregard suffering when determining to what extent someone is worse-off in terms of health. We should accept, all else equal, that adapting to an illness makes the illness less severe by reducing suffering. Accepting a pluralist theory of well-being allows us to accept my argument, while still making room for the possibility that adaptation is sometimes, all things considered, bad. Finally, I argue that we should conceptualize adaptability as a feature of illness, and thereby account for adaptation on a group level for the purposes of priority setting.

Illness severity is a priority setting criterion in several countries. Age seems to matter when considering severity, but perhaps not small age differences. In the following article we consider Small Differences : small differences in age are not relevant when considering differential illness severity. We show that SD cannot be accommodated within utilitarian, prioritarian or egalitarian theories. Attempting to accommodate SD by postulating a threshold model becomes exceedingly complex and self-defeating. The only way to accommodate SD seems to be to accept some form of relevance view, where some age differences are irrelevant. This view can accommodate SD, but at the expense of consistent priority orderings. Severity thus becomes unsuitable for systematic decision-making. We argue that SD should be dismissed and that we should accept a continuous relationship between severity of illness and age.