This paper is concerned with a problem of an equitable allocation. We consider the concept of ψ‐equity, which is a general concept of equity. We provide a series of examples of equity concepts that are captured by ψ‐equity. We show the existence of an efficient and ψ‐equitable allocation by employing Kakutani's fixed‐point theorem.

Shortages of new therapeutics to treat coronavirus disease (COVID-19) have forced clinicians, public health officials, and health systems to grapple with difficult questions about how to fairly allocate potentially life-saving treatments when there are not enough for all patients in need (1). Shortages have occurred with remdesivir, tocilizumab, monoclonal antibodies, and the oral antiviral Paxlovid (2) -/- Ensuring equitable allocation is especially important in light of the disproportionate burden experienced during the COVID-19 pandemic by disadvantaged groups, including Black, (...) Hispanic/Latino and Indigenous communities, individuals with certain disabilities, and low-income persons. However, many health systems have resorted to first-come, first-served approaches to allocation, which tend to disadvantage individuals with barriers in access to care (3). There is mounting evidence of racial, ethnic, and socioeconomic disparities in access to medications for COVID-19 (4, 5). -/- One potential method to promote equitable allocation is to use a weighted lottery, which is an allocation strategy that gives all eligible patients a chance to receive the scarce treatment while also allowing the assignment of higher or lower chances according to other ethical considerations (6). We sought to assess the feasibility of implementing a weighted lottery to allocate scarce COVID-19 medications in a large U.S. health system and to determine whether the weighted lottery promotes equitable allocation. (shrink)

Inequity has been a hallmark of the COVID-19 pandemic in the United States, especially in the sharply disproportionate impacts among people of color. Recent studies have confirmed that t...

With the world grappling with continued spread of monkeypox internationally, vaccines play a crucial role in mitigating the harms from infection and preventing spread. However, countries with the greatest need - particularly historically endemic countries with the highest monkeypox case-fatality rates - are not able to acquire scarce vaccines. This is unjust, and requires rectification through equitable allocation of vaccines globally. We propose applying the Fair Priority Model for such allocation, which emphasizes three key principles: 1) preventing (...) harm; 2) prioritizing the disadvantaged; and 3) treating people with equal moral concern. Post-exposure prophylaxis (PEPV) has the most potential to mitigate harm, and so ensuring countries have sufficient supply for PEPV should be the first priority. And historically endemic countries, which face disadvantages that compound potential harms from monkeypox, should be the first recipients of such vaccines. Once sufficient supply is allocated for countries to apply PEPV, global allocation could move on to pre-exposure prophylaxis (PrEP), again prioritizing historically endemic countries first before distribution to the rest of the global community, based on projected number of cases and vulnerability to harm. (shrink)

Accelerated COVID-19 vaccine development represents an important accomplishment and a milestone in the history of vaccine evolution. However, the vaccine’s scarcity made its equitable global allocation and distribution ambiguous. Despite the initial pledges from wealthy countries for fairness and inclusivity towards the poorer ones, the policies followed diverged significantly. Wealthy countries have vastly superior access to vaccines in a reality likened to an ethical disaster. This paper calls for the need for fair global vaccine allocation and distribution (...) and examines the barriers that were met along the way, originating from different points, such as the nationalistic approach on the matter that most wealthy countries have adopted or the inability of poor countries to purchase or manufacture vaccines. Further, a suggestion regarding the ethical principles and values that ought to guide global vaccine allocation and distribution is provided with a higher priority given to helping the worst-off, saving the most lives, protecting people in high risk, such as frontline healthcare professionals, and minimising social gaps, along with an ethical theoretical background for each prioritisation. It is not too late for wealthy countries to realise that vaccine inequity prolongs pandemics, so that they change their policies in favour of the global common good that will not only provide immediate universal benefits but will also serve as a guide for future pandemic crises. (shrink)

Equity was—and is—central in the US policy response to COVID-19, given its disproportionate impact on disadvantaged communities of colour. In an unprecedented turn, the majority of US states used place-based disadvantage indices to promote equity in vaccine allocation (eg, through larger vaccine shares for more disadvantaged areas and people of colour).We conducted a nationally representative survey experiment (n=2003) in April 2021 (before all US residents had become vaccine eligible), that examined respondents’ perceptions of the acceptability of disadvantage indices relative (...) to two ways of prioritising racial and ethnic groups more directly, and assessed the role of framing and expert anchors in shaping perceptions.A majority of respondents supported the use of disadvantage indices, and one-fifth opposed any of the three equity-promoting plans. Differences in support and opposition were identified by respondents’ political party affiliation. Providing a numerical anchor (that indicated expert recommendations and states’ actual practices in reserving a proportion of allocations for prioritised groups) led respondents to prefer a lower distribution of reserved vaccine allocations compared with the randomised condition without this anchor, and the effect of the anchor differed across the frames.Our findings support ongoing uses of disadvantage indices in vaccine allocation, and, by extension, in allocating tests, masks or treatments, especially when supply cannot meet demand. The findings can also inform US allocation frameworks in future pandemic planning, and could provide lessons on how to promote equity in clinical and public health outside of the pandemic setting. (shrink)

Research has consistently shown ‘ability’ grouping (tracking) to be prey to poor practice, and to perpetuate inequity. A feature of these problems is inequitable and inaccurate practice in allocation to groups or ‘tracks’. Yet little research has examined whether such practices might be improved. Here, we examine survey and interview findings from a large-scale intervention study of grouping practices in 126 English secondary schools. We find that when schools are encouraged to allocate students and move them between groups according (...) to equitable principles by participation in a ‘best practice’ intervention, there is some increased equity of practice (i.e. a reduction in non-attainment factors used in allocation). However, the majority of schools continue to use subjective and potentially biased information to group students. Furthermore, some schools that claim to be using attainment setting appear to be using the inequitable practice of streaming. Our findings show that improvements in equity are constrained by operational and strategic factors, including timetabling, finance, and teachers’ values and beliefs relating to student ability and progression. We suggest strategies for encouraging schools to change their grouping practices, drawing on approaches for working with complex organisations. (shrink)

Countermeasures for mpox (formerly known as monkeypox), primarily vaccines, have been in limited supply in many countries during outbreaks. Equitable allocation of scarce resources during public health emergencies is a complex challenge. Identifying the objectives and core values for the allocation of mpox countermeasures, using those values to provide guidance for priority groups and prioritisation tiers, and optimising allocation implementation are important. The fundamental values for the allocation of mpox countermeasures are: preventing death and illness; (...) reducing the association between death or illness and unjust disparities; prioritising those who prevent harm or mitigate disparities; recognising contributions to combating an outbreak; and treating similar individuals similarly. Ethically and equitably marshalling available countermeasures requires articulating these fundamental objectives, identifying priority tiers, and recognising trade-offs between prioritising the people at the highest risk of infection and the people at the highest risk of harm if infected. These five values can provide guidance on preferable priority categories for a more ethically sound response and suggest methods for optimising allocation of countermeasures for mpox and other diseases for which countermeasures are in short supply. Properly marshalling available countermeasures will be crucial for future effective and equitable national responses to outbreaks. (shrink)

This paper presents a procedure to select equitable stable allocations in two-sided matching markets without side payments. The Equitable set is computed using the Equitable algorithm. The algorithm limits the set of options available for each agent throughout the procedure. The stable matchings selected are generally not extreme, form a lattice and satisfy the condition of being “Ralwsian” in each partition of the market. The Equitable algorithm can also be used to select a particular matching from (...) the Equitable Set favoring particular agents independent of the side of the market to which they belong. (shrink)

In the Canadian health care system, the Government is responsible for allocating scarce resources in a fair and equitable manner. A proposal to implement managed care as a method of reimbursing physicians in Alberta, Canada, needs careful ethical consideration, because physicians are not well prepared, and should not be asked, to make the resulting difficult allocation decisions. The Government must continue to be held responsible for ensuring that all citizens have equal access to necessary medical services, and we (...) must find ways to encourage the public to become more involved in deciding how resources are best allocated. Health professionals other than physicians must take an interest and enter into this debate. (shrink)

The principles of equality and equity, respectively in the Bill of Rights and the white paper on health, provide the moral and legal foundations for future health care for children in South Africa. However, given extreme health care need and scarce resources, the government faces formidable obstacles if it hopes to achieve a just allocation of public health care resources, especially among children in need of highly specialised health care. In this regard, there is a dearth of moral analysis (...) which is practically useful in the South African situation. We offer a set of moral considerations to guide the macro-allocation of highly specialised public health care services among South Africa's children. We also mention moral considerations which should inform micro-allocation. (shrink)

Reserve systems are a tool to allocate scarce resources when stakeholders do not have a single objective. This paper introduces some basic concepts about reserve systems for pandemic medical resource allocation. At the onset of the Covid-19 pandemic, we proposed that reserve systems can help practitioners arrive at compromises between competing stakeholders. More than a dozen states and local jurisdictions adopted reserve systems in initial phases of vaccine distribution. We highlight several design issues arising in some of these implementations. (...) We also offer suggestions about ways practitioners can take advantage of the flexibility offered by reserve systems. (shrink)

The COVID-19 pandemic has helped to clarify the fair and equitable allocation of scarce medical resources, both within and among countries. The ethical allocation of such resources entails a three-step process: (1) elucidating the fundamental ethical values for allocation, (2) using these values to delineate priority tiers for scarce resources, and (3) implementing the prioritisation to faithfully realise the fundamental values. Myriad reports and assessments have elucidated five core substantive values for ethical allocation: maximising benefits (...) and minimising harms, mitigating unfair disadvantage, equal moral concern, reciprocity, and instrumental value. These values are universal. None of the values are sufficient alone, and their relative weight and application will vary by context. In addition, there are procedural principles such as transparency, engagement, and evidence-responsiveness. Prioritising instrumental value and minimising harms during the COVID-19 pandemic led to widespread agreement on priority tiers to include health-care workers, first responders, people living in congregate housing, and people with an increased risk of death, such as older adults and individuals with medical conditions. However, the pandemic also revealed problems with the implementation of these values and priority tiers, such as allocation on the basis of population rather than COVID-19 burden, and passive allocation that exacerbated disparities by requiring recipients to spend time booking and travelling to appointments. This ethical framework should be the starting point for the allocation of scarce medical resources in future pandemics and other public health conditions. For instance, allocation of the new malaria vaccine among sub-Saharan African countries should be based not on reciprocity to countries that participated in research, but on maximally reducing serious illness and deaths, especially among infants and children. (shrink)

Although a safe, effective, and licensed coronavirus vaccine does not yet exist, there is already controversy over how it ought to be allocated. Justice is clearly at stake, but it is unclear what justice requires in the international distribution of a scarce vaccine during a pandemic. Many are condemning ‘vaccine nationalism’ as an obstacle to equitable global distribution. We argue that limited national partiality in allocating vaccines will be a component of justice rather than an obstacle to it. For (...) there are role-based and community-embedded responsibilities to take care of one’s own, which constitute legitimate moral reasons for some identity-related prioritisation. Furthermore, a good form of vaccine nationalism prioritises one’s own without denying or ignoring duties derived from a principle of equal worth, according to which all persons, regardless of citizenship or identity, equally deserve vaccine-induced protection from COVID-19. Rather than dismissing nationalism as a tragic obstacle, it is necessary to acknowledge that a limited form of it is valuable and expresses moral commitments. Only then can one understand our world of competing obligations, a world where cosmopolitan duties of benevolence sometimes conflict with special obligations of community membership. Once these competing obligations are recognised as such, we can begin the work of designing sound ethical frameworks for achieving justice in the global distribution of a coronavirus vaccine and developing practical strategies for avoiding, mitigating or resolving conflicts of duty. (shrink)

The British National Health Service (BNHS) was founded, to quote Minister of Health Aneurin Bevan, to ‘universalise the best’. Over time, however, financial constraints forced the BNHS to turn to incrementalist budgeting, to rationalise care and to ask its practitioners to act as gatekeepers. Seeking a way to ration scarce tertiary care resources, BNHS gatekeepers began to use chronological age as a rationing criterion. Age-rationing became the ‘done thing’ without explicit policy directives and in a manner largely invisible to patients, (...) to Parliament, and to the public. The invisibility of the practice, however, violates the publicity principle that John Rawls and other philosophers believe essential to fairness. BNHS invisible age-rationing practices are thus a test case of the principle that fairness presupposes publicity; they raise the question: is it possible to preserve equitability in a system that uses non-public criteria to allocate scarce resources? To seek an answer, published data on access to end-stage renal disease (ESRD) treatment in Britain and the European Community (EC) are analysed. Among the findings are: that BNHS age-rationing acts as an excuse for denying care to those most likely to need ESRD treatment; and is, moreover, arbitrary and inequitable. It is further argued that no age-rationing policy can sustain visibility, and that, if the BNHS is to be fair to its patients, it must reform its present age-rationing practices, replacing them by a publicly visible, outcome-based rationing policy that rations either in terms of QALYs or triage categories. (shrink)

This article examines the inherently ethical nature of resource allocation in policing. Decision-makers must make trade-offs between values such as efficiency vs. equity, individual vs. collective benefit, and adopt principles of distribution which allocate limited resources fairly. While resource allocation in healthcare has been the subject of extensive discussion in both practitioner and academic literature, ethical resource allocation in policing has received almost no attention. We first consider whether approaches used in healthcare settings would be suitable for (...) policing. Whilst there are some high-level similarities in the relevant ethical considerations and processes—such as aiming for efficient and equitable resource deployment—there are also fundamental differences between the two settings, which we argue necessitate a different approach. These differences include: (1) greater diversity and incommensurability of the benefits of policing, (2) more frequent non-linearity in returns on policing investment, (3) greater “ethical divisibility” (permissible scaling down) of programs in policing, (4) a requirement to assess “need” for policing resources at the collective (rather than individual) level, and (5) clearer primacy of equity considerations in policing. Having drawn out the implications of these differences, we sketch some tentative proposals for ethical resource allocation in policing. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Ethics and the Allocation of Organs for TransplantationJames F. Childress (bio)A quarter of a century ago, in my second year of teaching at the University of Virginia, I began to explore the emerging field of biomedical ethics through a seminar on “Artificial and Transplanted Organs,” which included both faculty and students from law, medicine, and the humanities. My paper for the seminar was entitled “Who Shall Live When (...) Not All Can Live?” This experience drew me into biomedical ethics, because of the complex mix of ethical, legal, and medical issues and the fruitfulness of interdisciplinary and interprofessional dialogue.Several of the major problems confronting that seminar have persisted, often in altered form. In the area of organ transplantation, two significant issues continue to require society’s attention: (1) how can the organ supply be increased, and (2) how should the available organs be allocated? I want to make a few points about ethical criteria in the allocation of donated organs, as a way to indicate some directions for organ allocation policies in the twenty-first century. I will focus on the second question because I believe that a tremendous and ever-widening gap will persist between the need for transplantable organs and the supply of human cadaveric organs.Community Ownership of Donated Organs and Public ParticipationSince the mid-1980s, the operative conception of the ownership of donated organs has shifted, with major implications for the procedures used to formulate policies for organ allocation. As vice-chair of the federal Task Force on Organ Transplantation in the mid-1980s, I did not immediately realize that debates about allocation policies often reflected different conceptions of the ownership of donated organs. More specifically, organ allocation policies largely presupposed that donated organs belonged to, or were under the dispositional authority of, transplant surgeons, with only limited public accountability. However, the Task Force (1986) held that donated organs belong to the community, and that transplant professionals are only trustees and stewards of those organs for the [End Page 397] community’s welfare. This conception of ownership implies that the public should participate in setting the criteria for organ allocation.According to Jeffrey Prottas (1994), another member of the Task Force, these shifts represent the “socialization” of organ transplantation. Although professional dominance, through knowledge and power, continues in the United Network for Organ Sharing (UNOS)—the national organ procurement and transplantation network that was established in the late 1980s—that dominance is now more circumscribed and accountable, particularly because UNOS, in developing any allocation policy, has to respond “to public criticisms with public answers.” Not only is organ allocation policy now in the public domain—and thus a matter of public ethics rather than medical ethics—the terms of the debate have changed, as Prottas further notes, so that equity must be considered along with efficiency.Balancing Several Ethical Principles or ValuesThe main ethical criteria for organ allocation express principles that are prominent in the major competing theories of justice, particularly libertarian, egalitarian, utilitarian, and communitarian theories. The principles of liberty, equality, utility, and community all play important roles, and organ allocation policies often seek to balance these competing principles, which frequently are specified or circumscribed—for instance, utility is specified as medical utility. Just or equitable policies are found in the process of balancing.UNOS (1994) attempts to develop an equitable organ allocation system in light of a “set of basic principles” and “specific measurable objectives” that have been derived from these principles. It uses the metaphor of “balance” for its efforts to relate these different principles and objectives. For instance, it holds that balancing requires that “equal consideration” be given to both medical utility and to justice, so that neither can be ranked a priori over the other. However, it may not be possible to “give equal weight to [both] medical utility and justice” (UNOS 1994, p. 123) because trade-offs appear to be unavoidable in many policies and are consistent with the metaphor of balancing.Medical Utility and EqualityMedical utility—maximizing the welfare of patients suffering from end-stage organ failure—includes, at a minimum, attention to the factors that influence both graft and patient survival, as well... (shrink)

Given the significant disparities in health and health related disadvantage between Aboriginal andnon-Aboriginal Australians, the application of somenotion of equity has a role to play in the formulationof policy with respect to Aboriginal health. Aboriginal andTorres Strait Islander has been abbreviated to Aboriginal. There has been considerable debate in Australia as to what the principles of equity should be. This paper discussesthe relevance of the principle of vertical equity (theunequal, but equitable, treatment of unequals) toAboriginal health funding. In particular, (...) the paperadvocates pursuing procedural justice as the basis forvertical equity where the focus is on the fairness ofhow things are done rather than on the distribution ofoutcomes per se (i.e. distributive justice).Particular attention is paid to how the principle ofvertical equity might be handled at a practical level.Details of the approach used in a number of Australianindigenous communities are discussed. It is concludedthat there are strong arguments for pursuingprocedural justice under vertical equity particularlywhen there are cultural differences in the ways healthis defined and when there is importance attached toindigenous involvement in the health care decisionmaking process. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Organ Transplant AllocationPat Milmoe McCarrick (bio)The introduction of the antibiotic, cyclosporin, which enhances the success rate of transplantation surgery, has resulted in the steady growth of organ transplantation since the mid-1980s. This growth increasingly focuses ethical interest on both the procurement and the allocation of human organs. Not everyone who might benefit from organ transplants can receive them since the number of patients in need of organs far (...) exceeds the number of organs available. Each year the waiting list for transplants increases by 20 percent, but the number of donated organs has remained stable for the past five years (Lawry 1994).Organ transplantation surgery performed on rock stars, sports heroes, politicians, and television celebrities brings questions about the fair allocation of scarce resources to the attention of everyone. Abigail Trafford, editor of Washington Post Health, wonders whether "new livers for hard livers" can be deserved when not enough organs are available for everyone who needs them. Writing about the dilemma of just allocation of organs, she calls famous recipients "poster patients" or "health care celebrities of medical catastrophe" (Trafford 1994). Personal responsibility—the viewpoint that "medical treatment should not be an entitlement program for profligate living"—is an emerging moral consideration according to Trafford. Deciding whose standards and values should apply to the allocation of organs raises many questions. Popular arguments for keeping the current criteria for allocation include: these patients are sick and therefore should be treated, regardless of the cause of their illness; former substance abusers should be able to benefit from their present abstention; physicians should treat anyone who is ill; and although many human illnesses may be caused by individual behavior, such behavior is not always used as a reason to deny care (Trafford 1995).Prior to 1984, when the government established regulations governing organ transplantation, organs routinely were given to the patients of the surgeons who excised them (Prottas 1994). In an effort to achieve a more equitable method of distribution, Congress passed the National Organ Transplant Act of 1984 (Pub. [End Page 365] L. No. 98-507, amended by Pub. L. No. 100607 and Pub. L. No. 101-616), which established a national Organ Procurement and Transplantation Network (OPTN) to improve the effectiveness of organ procurement, organ distribution, and transplant activities. The United Network for Organ Sharing (UNOS) received the federal government contract to be the OPTN.UNOS and its 66 regional organ procurement organizations (OPOs) around the nation have carried out the mandate since 1986. It requires hospitals that receive Medicare or Medicaid funds and perform transplants to belong to the network and to allocate organs according to network policies. UNOS maintains the national computer registry to match donor organs with individual recipients. In distributing organs, UNOS is required by law to use a fair and equitable system based on accepted medical criteria. UNOS regularly reevaluates its policies to ensure that organ donation and recipient selection meet criteria of efficiency and equity (UNOS Update 11 (8), 1995).At the end of June 1995, 278 transplant centers were in operation in the United States: almost all of them (247 centers) transplanted kidneys; 167 did hearts; 119, pancreases; 114, livers; 93, heart-lung; 88, lungs; 26, intestines; and only 19 centers performed pancreas islet cell transplants (UNOS Update 11 (8): 28, 1995). The number of patients waiting for organ transplants in July 1995 totalled 41,075: 29,274 were waiting for a kidney transplant; 4,937, liver; 3,298, heart; 1,816, lung; 1,223 kidney-pancreas; 240, pancreas; and 211, heart-lung (UNOS Update 11 (8): 40-41, 1995).OPOs are located in different geographic areas across the country, each with different organ needs, lengths of waiting lists, or with lists in areas with large older populations making it more difficult to find suitable donors. Black recipients often wait longer due to complex reasons including sensitization or rarer blood and antigen types (UNOS 11 (8): 31-32, 1995). When an organ becomes available, the OPO involved identifies a potential recipient from the UNOS list and offers it to the patient's surgeon. If no match can be made locally, the organ is next offered within a UNOS region, and finally, to... (shrink)

One of the societal problems in a new influenza pandemic will be how to use the scarce medical resources that are available for prevention and treatment, and what medical, epidemiological and ethical justifications can be given for the choices that have to be made. Many things may become scarce: personal protective equipment, antiviral drugs, hospital beds, mechanical ventilation, vaccination, etc. In this paper I discuss two general ethical principles for priority setting (utility and equity) and explain how these principles will (...) often point in diverging directions. Moreover, each of these principles can be understood in different, again often competing, ways. Notwithstanding these controversies and conflicts, in the context of pandemic response there are at least some points of convergence: several policies can be justified by appeal to different ethical principles and theories. Convergence may be found with respect to a focus on saving the most lives (instead of other aggregative accounts); giving priority antiviral prophylaxis and therapy for life-saving pandemic responders; and, partly depending on epidemiology of the pandemic, to prioritise vaccination of children. Although decision-making about access to intensive care will involve choices with immediate tragic implications, the ethical complexity of these choices is relatively modest (although decisions will not be easy): there are persuasive moral reasons for giving priority to patients who are expected to benefit most within the shortest time. Finally, in the last section I tentatively argue that constraints on people’s freedom, as necessary for an effective public health approach, may support giving somewhat more weight to saving the most lives, than to concerns of equity. (shrink)

Inequities in health and health care are one of the greatest challenges facing the international community today. This problem raises serious questions for health care planners, politicians and ethicists alike. The major world religions can play an important role in this discussion. Therefore, interreligious dialogue on this topic between ethicists and health care professionals is of increasing relevance and urgency. This article gives an overview on the positions of Islam and Christianity on equity and the distribution of resources in health (...) care. It has been written in close collaboration and constant dialogue between the two authors coming from the two religions. Although there is no specific concept for the modern term equity in either of the two religions, several areas of agreement have been identified: All human beings share the same values and status, which constitutes the basis for an equitable distribution of rights and benefits. Special provisions need to be made for the most needy and disadvantaged. The obligation to provide equitable health services extends beyond national and religious boundaries. Several areas require intensified research and further dialogue: the relationship between the individual and the community interms of rights and responsibilities, how to operationalize the moral duty to decrease global inequalities in health, and the understanding and interpretation of human rights in regard to social services. (shrink)

By the law of the 8 August 1980 concerning the institutional reform of the state, the Belgian political system is becoming a federalistic country. Nevertheless, after three years of implementation, most of political scientists state that these constitutional reform is incomplete and inadequate to solve functionally the economical, political and cultural complexities of the relationships between Flanders, W allonia and Brussels. A confederation based on three components equally autonomous by preserving economic integration and monetary unity could be a better framework (...) to establish equitable relationships between the three regional components of the belgian political structure. These proposal of creating a Belgian confederation presents specific adaptations in allocation tasks, functions and competences that are the results of historical factorsand cultural caracteristics of the Belgian community. (shrink)

The urgent drive for vaccine development in the midst of the current COVID-19 pandemic has prompted public and private organisations to invest heavily in research and development of a COVID-19 vaccine. Organisations globally have affirmed the commitment of fair global access, but the means by which a successful vaccine can be mass produced and equitably distributed remains notably unanswered. Barriers for low-income countries include the inability to afford vaccines as well as inadequate resources to vaccinate, barriers that are exacerbated during (...) a pandemic. Fair distribution of a pandemic vaccine is unlikely without a solid ethical framework for allocation. This piece analyses four allocation paradigms: ability to develop or purchase; reciprocity; ability to implement; and distributive justice, and synthesises their ethical considerations to develop an allocation model to fit the COVID-19 pandemic. (shrink)

BackgroundThe coronavirus 2019 pandemic placed unprecedented pressures on healthcare services and magnified ethical dilemmas related to how resources should be allocated. These resources include, among others, personal protective equipment, personnel, life-saving equipment, and vaccines. Decision-makers have therefore sought ethical decision-making tools so that resources are distributed both swiftly and equitably. To support the development of such a decision-making tool, a systematic review of the literature on relevant ethical values and principles was undertaken. The aim of this review was to identify (...) ethical values and principles in the literature which relate to the equitable allocation of resources in response to an acute public health threat, such as a pandemic.MethodsA rapid systematic review was conducted using MEDLINE, EMBASE, Google Scholar, LitCOVID and relevant reference lists. The time period of the search was January 2000 to 6th April 2020, and the search was restricted to human studies. January 2000 was selected as a start date as the aim was to capture ethical values and principles within acute public health threat situations. No restrictions were made with regard to language. Ethical values and principles were extracted and examined thematically.ResultsA total of 1,618 articles were identified. After screening and application of eligibility criteria, 169 papers were included in the thematic synthesis. The most commonly mentioned ethical values and principles were: Equity, reciprocity, transparency, justice, duty to care, liberty, utility, stewardship, trust and proportionality. In some cases, ethical principles were conflicting, for example, Protection of the Public from Harm and Liberty.ConclusionsAllocation of resources in response to acute public health threats is challenging and must be simultaneously guided by many ethical principles and values. Ethical decision-making strategies and the prioritisation of different principles and values needs to be discussed with the public in order to prepare for future public health threats. An evidence-based tool to guide decision-makers in making difficult decisions is required. The equitable allocation of resources in response to an acute public health threat is challenging, and many ethical principles may be applied simultaneously. An evidence-based tool to support difficult decisions would be helpful to guide decision-makers. (shrink)

In the context of the global COVID-19 pandemic, the fast and equitable distribution of effective vaccines worldwide is one of the challenges faced by international institutions in charge, as global equity in vaccine supply has not yet been achieved. Our paper explains the current state of ethical research on equity in global COVID-19 vaccine allocation, focusing on the COVAX Facility established by the WHO, acting as the global vaccine distributor. The article presents a detailed analysis of the first (...) year of COVAX allocation in 2021 identifying problematic aspects of its allocation framework regarding the implementation of COVAX’s fundamental allocation principles. We argue that the COVAX Facility has developed a proper concept to deal with global vaccine allocation—but to address uncovered defaults, we introduce the ‘Prioritized Distribution of Equal Shares’ model—a both ethical and practically feasible alternative allocation framework to protect the value of human lives in both high- and low-income countries through fair and fast global vaccine distribution in health emergencies. Nonetheless, we argue that the COVAX Facility remains the main organization to provide equitable access to vaccines. Yet, the global community has to consider further aspects such as patent protection, vaccine production and the lack of power of global structures to address the inequities that have arisen. Since new wars and further crises have arisen, a shift in public global attention endangers the processing of COVID-19-related issues. That is why now more than ever extensive efforts to achieve vaccine equity are needed. (shrink)

Organs for transplantation are a scarce resource. Markedly, the transplant community’s primary challenge is the stark disparity between the number of patients awaiting deceased donor organ transplants and the rate at which organs become available. However, the allocation of a limited number of organs poses another constant challenge: maintaining an equilibrium between renal transplant utility and equity, that is, striking a balance between the utilitarian argument of medical efficiency and the principle of equity. In this comprehensive overview, the authors (...) delve into the challenge of maintaining an acceptable balance between equity and efficiency and elaborate on some of the factors that might inform a decisionmaker’s evaluation of the extent to which a given allocation scheme is efficient or equitable. (shrink)

We respond to recent comments on our proposal to improve justice in ventilator triage, in which we used as an example New Jersey’s publicly available and legally binding Directive Number 2020-03. We agree with Bernard Lo and Doug White that equity implications of triage frameworks should be continually reassessed, which is why we offered six concrete options for improvement, and called for monitoring the consequences of adopted triage models. We disagree with their assessment that we mis-characterised their Model Guidance, as (...) included in the NJ Directive, in ways that undermine our conclusions. They suggest we erroneously described their model as a two-criterion allocation framework; that recognising other operant criterion reveals it ‘likely mitigate[s] rather than exacerbate[s] racial disparities during triage’, and allege that concerns about inequitable outcomes are ‘without evidence’. We highlight two major studies robustly demonstrating why concerns about disparate outcomes are justified. We also show that White and Lo seek to retrospectively—and counterfactually—correct the version of the Model Guideline included in the NJ Directive. However, as our facsimile reproductions show, neither the alleged four-criteria form, nor other key changes, such as dropping the Sequential Organ Failure Assessment score, are found in the Directive. These points matter because our conclusions hence stand, because the public version of the Model Guidance had not been updated to reduce the risk of inequitable outcomes until June 2021 and NJ’s Directive still does not reflect these revisions, and, hence, represents a less equitable version, as acknowledged by its authors. We comment on broader policy implications and call for ways of ensuring accurate, transparent and timely updates for users of high-stakes guidelines. (shrink)

What is immediately striking about the general problem of how to allocate resources equitably is that although the task cannot be done, it nevertheless requires to be done. Imperfection is the most we can hope for. But of course some instances of imperfection are considerably worse than others: and those evidenced in all too much of the thinking of medical specialists, whether in the current discussion concerning cancer care or, for instance, by those involved in the management of kidney transplants (...) are frightening in their resolute refusal even to consider, let alone take adequately into account, the impact on the wider polity of their policies and practices. (shrink)

Normative criteria adopted to assure just, equitable, and efficient allocation of donor organs to potential recipients has been widely praised as a model for the allocation of scarce medical resources. Because the organ transplantation program relies upon voluntary participation by potential donors, all such programs necessarily rely upon public confidence in allocation decision making protocols. Several well publicized cases have raised questions in North America about the efficacy of allocation procedures. An analysis of those cases, (...) and the relevant technical literature, suggest consistent structural deficits exist in the organ allocation process as it is applied by many individual transplantation centres. These irregularities are based upon both the failure of rank waiting as a method to guarantee just treatment and a general failure to recognize the extent to which prescriptive criteria — social values — are commonly used to screen potential organ transplant candidates. Resulting idiosyncratic determinations, and a devaluation of rank waiting as a criterion, raise fundamental questions regarding justice, fairness, and equability in the application procedure at large. To correct these structural problems in organ allocation procedures, a multicriterion model defining prescriptive criteria through the Analytic Hierarchy Process (AHP) is proposed. (shrink)

When health budgets are insufficient to provide care for all, allocating resources to treat a person with a rare and expensive disorder entails that we cannot treat at least one person with a more common, less expensive disorder. Since any allocation scheme will entail such trade‐offs, how should prudent policy‐makers, concerned about justice and fairness, allocate their community's health resources? In their article in this issue of the Hastings Center Report, Emily Largent and Steven Pearson frame this problem as (...) a conflict between the “rule of rescue” and utilitarian allocation schemes that try to maximize the benefits produced by a given budget. In his article, Norman Daniels discusses the related problem of the “identified victim bias.” I doubt that the problem of crafting an equitable health policy regarding orphan diseases maps onto either of these factors in a way that sheds light on the key moral issues. (shrink)

This commentary focuses on two moral values implied by the case study but not specified in the working party's conclusions, namely equitable treatment of the most vulnerable and the value of political government.

Background:To date, most research on aggression in mental disorders focused on active-aggressive behavior and found self-directed and other-directed active aggression to be a symptom and risk-factor of psychopathology. On the other hand, passive-aggressive behavior has been investigated less frequently and only in research on psychodynamic defense mechanisms, personality disorders, and dysfunctional self-control processes. This small number of studies primarily reflects a lack of a reliable and valid clinical assessment of passive-aggressive behavior. To address this gap, we developed the Test of (...) Passive Aggression (TPA), a 24-item self-rating scale for the assessment of self-directed and other-directed passive-aggressive behavior.Method:Study 1 examined the internal consistency and factorial validity of the TPA in an inpatient sample (N= 307). Study 2 investigated the retest-reliability, internal consistency, and construct validity (active aggression, personality traits, impulsivity) of the TPA in a student sample (N= 180).Results:In line with our hypothesis, Exploratory Structural Equation Modeling revealed an acceptable to good fit of a bi-factorial structure of the TPA (Chi-square-df-ratio= 1.98;RMSR= 0.05, fit.off = 0.96). Both TPA scales showed good to excellent internal consistency (α= 0.83–0.90) and 4-week retest-reliability (rtt= 0.86). Correlations with well-established aggression scales, measures of personality, and impulsivity support discriminant and convergent validity of the TPA.Conclusions:The TPA is a reliable and valid instrument for the assessment of self-directed and other-directed passive-aggressive behavior. (shrink)

The issue of directed donation of organs from deceased donors for transplantation has recently risen to the fore, given greater significance by the relatively stagnant rate of deceased donor donation in the UK. Although its status and legitimacy is explicitly recognized across the USA, elsewhere a more cautious, if not entirely negative, stance has been taken. In England, Wales and Northern Ireland, the Human Tissue Act 2004, and in Scotland the Human Tissue (Scotland) Act 2006, are both silent in this (...) regard. Although so-called conditional donation, donation to (or perhaps withheld from) a specific class, has been outlawed as a product of guidance issued by the Secretary of State for Health issued in the wake of the controversial incident occurring in the North of England in 1998, its intended application to ‘directed’ donation is less certain. Directed and conditional donations challenge the traditional construct of altruistic donation and impartial (equitable) allocation in a very immediate and striking fashion. They implicitly raise important questions as to whether the body or parts of the body are capable of being owned, and by whom. This paper attempts to explore the notion of donor ownership of body parts and its implications for both directed and conditional donation. (shrink)

Medical care of critically ill and injured infants and children globally should be based on best research evidence to ensure safe, efficacious treatment. In South Africa and other low and middle-income countries, research is needed to optimise care and ensure rational, equitable allocation of scare paediatric critical care resources.

In response to theJournal of Religious Ethics(JRE) editors' request for reflections on “how religious ethicists have interacted with, and ought to interact with, public policy decision makers,” this essay focuses on doing religious ethics in the context of doing public bioethics, especially through participating in public bioethics bodies (PBBs) established to provide advice to public policymakers in what might be called “mediated advocacy.” Drawing heavily on the author's experience as a member of and a consultant to several PBBs, it features (...) case studies of PBBs deliberating about and recommending public policies to address the scarcity of postmortem organs for transplantation, the equitable allocation of COVID‐19 vaccine, cloning humans, and human embryonic stem cell research. (shrink)

An important problem for decision-makers in society deals with the efficient and equitable allocation of scarce resources to individuals and groups. The significance of this problem is rapidly growing since there is a rising demand for scarce resources all over the world. Such resource dilemmas belong to a conceptually broader class of situations known as social dilemmas. In this type of dilemma, individual choices that appear ‘‘rational’’ often result in suboptimal group outcomes. In this article we study how (...) people make monetary allocation decisions between the community where they live and a neighbouring community, with the aim of finding out to what extent these decisions are subject to biased over-weighting. The manuscript reports four experiments that deal with the way individuals make such allocation decisions when the potential beneficiaries are such communities. The specific goal of these experiments is to gauge the amount of bias in the weights that people assign to the various beneficiaries. Taken together, the results from all the four experiments suggest that making the gain of the neighbouring community prominent to a higher extent de-biases the outcomes (the prominence effect) compared to when own community gain is made prominent. Place identity is discussed as a potentially important factor in this connection. Hence, it may be argued that there seems to be some kind of a pro-self component that is able to explain a large part of the variance observed for the prominence effect. Connections between such a factor and in-group favouritism are discussed. A strength of the study was that these major results appeared to be quite robust when considered as task effects, as the salience of the manipulated context factors in the studies (in terms of reliable main or interaction effects) did not distort them. (shrink)

English summary: The degree of law will determine how goods are distributed and balanced in legal relationships. The selected essays take up the question of how to understand law, and especially how to behave within the extent of the law. The lawyer is always confronted with the righteousness within and of the law. Justice within the law is not his work. If the lawyer is not satisfied with this kind of justice, he can respond as a moral personality. Justice before (...) the law offers some leeway in which one can make decisions. Therein lies the appeal of the work of the lawyer, and also his considerable responsibility. The legal decision is closely related to legal ethics. This builds on solid traditional values, which must necessarily expand in terms of affairs of time and space, as well as towards the responsibility of future generations. The German and English writings reprinted here are divided into six groups: (I) The equitable allocation as the core of law, (II) probation of law and rule of law, (III) responsible legal decisionmaking, (IV) the correlativity of justice, (V) dialogical nature of jurisprudence, and (VI) from the Slovenian tradition of thought. German and English text. German description: Vom Mass des Rechts hangt es ab, wie die Gueter und Lasten in Rechtverhaltnissen verteilt und ausgeglichen werden. Die ausgewahlten Abhandlungen stellen sich der Frage, wie man Recht verstehen soll - und besonders, wie man sich gegenueber dem Mass des Rechts verhalten soll.Der Jurist ist immer mit der Gerechtigkeit im Gesetz und vor dem Gesetz konfrontiert. Die Gerechtigkeit im Gesetz ist nicht sein Werk. Wenn der Jurist mit dieser Art der Gerechtigkeit nicht einverstanden ist, kann er als Moralpersonlichkeit reagieren. Die Gerechtigkeit vor dem Gesetz bietet einen Spielraum, in dem man Entscheidungen trifft. Darin liegt der Reiz der Arbeit des Juristen und auch seine betrachtliche Verantwortung.Das juristische Entscheiden ist eng mit der Rechtsethik verbunden. Diese baut auf einer festen Wertetradition auf, die sie notwendigerweise im Hinblick auf das Zeit- und Raumgeschehen und auf die Verantwortung gegenueber kuenftigen Generationen erganzen und ausbauen muss.Die hier wieder abgedruckten deutschen und englischen Schriften sind in sechs Gruppen unterteilt: (I) Die gerechte Zurechnung als Kern des Rechts, (II) Bewahrung von Recht und Rechtsstaatlichkeit, (III) Verantwortliches Rechtsentscheiden, (IV) Die Korrelativitat des Rechts, (V) Dialogische Natur der Jurisprudenz und (VI) Aus der slowenischen Denktradition. (shrink)

Professional autonomy interferes at a structural level with the various aspects of the health care system. The health care systems that can be distinguished all feature a specific design of professional autonomy, but experience their own governance problems. Empirical health care systems in the West are a nationally coloured blend of ideal type healthcare systems. From a normative perspective, the optimal health care system should consist of elements of all the ideal types. A workable optimum taking national values into account (...) could be attained by governance structures that also introduce elements from other ideal type systems. Thus a normative approach to medical practice guaranteeing an essential degree of professional autonomy for a relationship of trust between the patient and the physician, could be combined with an efficient and equitable allocation of health care resources. (shrink)

In this paper we argue that the responsibility for systematic community-based preventive medicine should not be made part of the role of the general practitioner (GP). Preventive medicine cannot be shown to be more effective than curative or supportive medicine. Therefore, the allocation of the large amount of general practice staff time and resources required for systematic preventive medicine should not come at the expense of the care of the sick and the suffering. The traditional healing role of the (...) GP requires a cooperative patient-centred approach, whereas systematic preventive medicine is driven by rigid pre-set protocols and is intrinsically paternalistic. Trying to merge the two approaches is detrimental to the doctor-patient relationship. Furthermore, a number of potential pitfalls are identified that may be encountered in the implementation of preventive medicine programmes in general practice: interference with the course of the consultation; inadequate explanation and consent; distortion of practice priorities as reflected in quality indicators; temptation to record inaccurate data; conflict of interests where the doctor is rewarded for performance; patient blaming; exacerbation of the health gap. We suggest that a more justifiable strategy would be for GPs to identify patients at high risk and offer them specific preventive advice when the opportunity presents itself and at a time when the patient is likely to be most amenable to cooperate. Opportunistic health promotion offers higher expectations of benefit, as well as a more equitable allocation of the risks associated with preventive medicine, than a systematic community-based approach. (shrink)

Introduction: There is currently no binding, internationally accepted and successful approach to ensure global equitable access to healthcare during a pandemic. The aim of this ethical analysis is to bring into the discussion a legally regulated vaccine allocation as a possible strategy for equitable global access to vaccines. We focus our analysis on COVAX (COVID-19 Vaccines Global Access) and an existing EU regulation that, after adjustment, could promote global vaccine allocation. -/- Methods: The main documents discussing (...) the two strategies are examined with a qualitative content analysis. The ethical values reasonableness, openness and transparency, inclusiveness, responsiveness and accountability serve as categories for our ethical analysis. -/- Results: We observed that the decision-making processes in a legal solution to expand access to vaccines would be more transparent than in COVAX initiative, would be more inclusive, especially of nation states, and the values responsiveness and accountability could be easily incorporated in the development of a new regulation. -/- Discussion: A legal strategy that offers incentives to the pharmaceutical industry in return for global distribution of vaccines according to the Fair Priority Model is an innovative way to achieve global and equitable access to vaccines. However, in the long term, achieving the Sustainable Development Goals will require from all nations to work in solidarity to find durable solutions for global vaccine research and development. Interim solutions, such as our proposed legal strategy for equitable access to vaccines, and efforts to find long-term solutions must be advanced in parallel. (shrink)

The rapidly increasing numbers of elderly people in our society have raised some important moral questions: How should we distribute social resources among different age groups? What does justice require from both the young and the old? In this book, Norman Daniels offers the first systematic philosophical discussion of these urgent questions, advocating what he calls a "lifespan" approach to the problem: Since, as they age, people pass through a variety of institutions, the challenge of caring for the elderly becomes (...) the prudent allocation of public resources among the various stages of people's lives. Using this philosophical approach, Daniels addresses specific public policy issues such as the allocation of medical funds, the adequacy of long-term care, current Medicare cost-containment measures, and the equitable distribution of income support over the lifespan and between generations. (shrink)

Cet article examine les objections de Thomas Nagel au principe de différence. Quoiqu’il partage les thèses égalitaristes de Rawls, il relève des failles internes au principe de différence : il renforce des asymétries entre favorisés et défavorisés, est psychologiquement inacceptable pour des individus réels, et ne suffit pas à définir un système fiscal pleinement égalitariste. Nous présentons et discutons alors les analyses et propositions que Nagel avance sur le plan de la justice distributive et fiscale. Elles constituent des correctifs et (...) prolongements de la théorie de Rawls, dans une perspective toutefois distincte : il s’agit non plus de définir la structure de base d’une société bien ordonnée, juste et équitable, mais de réaliser l’égalité dans une société démocratique actuelle. (shrink)

Most ethics guidelines for distributing scarce medical resources during the coronavirus pandemic seek to save the most lives and the most life‐years. A patient’s prognosis is determined using a SOFA or MSOFA score to measure likelihood of survival to discharge, as well as a consideration of relevant comorbidities and their effects on likelihood of survival up to one or five years. Although some guidelines use age as a tiebreaker when two patients’ prognoses are identical, others refuse to consider age for (...) fear of discriminating against the elderly. In this paper, I argue that age is directly relevant for maximizing health benefits, so current ethics guidelines are wrongly excluding or deemphasizing life‐stage in their triage algorithms. Research on COVID‐19 has shown that age is a risk factor in adverse outcomes, independent of comorbidities. And limiting a consideration of life‐years to only one or five years past discharge does not maximize health benefits. Therefore, based on their own stated values, triage algorithms for coronavirus patients ought to include life‐stage as a primary consideration, along with the SOFA score and comorbidities, rather than excluding it or using it merely as a tiebreaker. This is not discriminatory because patients ought to have equal opportunity to experience life‐stages. The equitable enforcement of that right justifies unequal treatment based on age in cases when there is a scarcity of life‐saving resources. A consideration of life‐stage would thus allow healthcare workers to responsibly steward public resources in order to maximize lives and life‐years saved. (shrink)

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity (...) criteria in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda. (shrink)

In discussions about responsibility for climate change, it is often suggested that the historical use of natural resources is in some way relevant to our current attempts to address this problem fairly. In particular, both theorists and actors in the public realm have argued that historical high-emitters of greenhouse gases (GHGs) – or the beneficiaries of those emissions – are in possession of some form of debt, deriving from their overuse of a natural resource that should have been shared more (...) equitably. These accounts of what might be termed ‘natural debt’ generally focus on one particular natural resource (global GHG sink capacity); invoke a principle of justice by which rights to consume this resource should have been allocated (most commonly, equal per capita shares); and then argue that historical violations of this principle give rise to certain rectificatory duties in the present (generally, duties on the part of those who have historically consumed an excessive amount of the world’s GHG sink capacity, or who have benefitted from such excess consumption, to offer some form of compensation to those who have not – such compensation usually taking the form of emission credits or cash). Though many seem to find it intuitively plausible that historical high-emissions have incurred some form of debt, significant challenges arise in rendering the concept of natural debt both coherent and defensible. Such problems are not, however, my focus in this piece. Instead, I here suggest that discussions about historical responsibility for climate change commonly fail to recognise certain other past injustices concerning natural resources that appear to hold contemporary relevance. In particular, I argue that it is not just the unequal consumption of global GHG sink capacity that may be of moral significance here; but also the way in which the world’s resources have more generally been governed. (shrink)

In medical ethics, business ethics, and some branches of political philosophy (multi-culturalism, issues of just allocation, and equitable distribution) the literature increasingly combines insights from ethics and the social sciences. Some authors in medical ethics even speak of a new phase in the history of ethics, hailing "empirical ethics" as a logical next step in the development of practical ethics after the turn to "applied ethics." The name empirical ethics is ill-chosen because of its associations with "descriptive ethics." (...) Unlike descriptive ethics, however, empirical ethics aims to be both descriptive and normative. The first question on which I focus is what kind of empirical research is used by empirical ethics and for which purposes. I argue that the ultimate aim of all empirical ethics is to improve the context-sensitivity of ethics. The second question is whether empirical ethics is essentially connected with specific positions in meta-ethics. I show that in some kinds of meta-ethical theories, which I categorize as broad contextualist theories, there is an intrinsic need for connecting normative ethics with empirical social research. But context-sensitivity is a goal that can be aimed for from any meta-ethical position. (shrink)

Most of us have two strong intuitions (or sets of intuitions) in relation to fairness in health care systems that are funded by public money, whether through taxation or compulsory insurance. The first intuition is that such a system has to treat patients (and other users) fairly, equitably, impartially, justly and without discrimination. The second intuition is that doctors, nurses and other health care professionals are allowed to, and may even in some cases be obligated to give preference to the (...) interests of their particular patients or clients over the interests of other patients or clients of the system. These two intuitions are in potential conflict. One of the most obvious ways in which to ensure impartiality in a health care system is to require impartiality of all actors in the system, i.e. to give health care professionals a duty to treat everyone impartially and to deny them the ‘right’ to give their patients preferential treatment. And one of the possible side-effects of allowing individual health care professionals to give preference to ‘their clients’ is to create inequality in health care. This paper explores the conflict and proposes that it can be right to give preference to ‘your’ patients in certain circumstances. (shrink)

Throughout March and April 2020, debate raged about how best to allocate limited intensive care unit resources in the face of a growing COVID-19 pandemic. The debate was dominated by utility-based arguments for saving the most lives or life-years. These arguments were tempered by equity-based concerns that triage based solely on prognosis would exacerbate existing health inequities, leaving disadvantaged patients worse off. Central to this debate was the assumption that ICU admission is a valuable but scarce resource in the pandemic (...) context.In this paper, we argue that the concern about achieving equity in ICU triage is problematic for two reasons. First, ICU can be futile and prolong or exacerbate suffering rather than ameliorate it. This may be especially true in patients with COVID-19 with emerging data showing that most who receive access to a ventilator will still die. There is no value in admitting patients with poor prognostic indicators to ICU to meet an equity target when intensive critical care is contrary to their best interests. Second, the focus on ICU admission shifts focus away from important aspects of COVID-19 care where there is greater opportunity for mitigating suffering and enhancing equitable care.We propose that the focus on equity concerns during the pandemic should broaden to include providing all people who need it with access to the highest possible standard of end-of-life care. This requires attention to culturally safe care in the following interlinked areas: palliative care, communication and decision support and advanced care planning. (shrink)

Implementing equity principles in resource allocation is challenging. In one approach, some US states implemented race-based prioritisation of COVID-19 vaccines in response to vast racial inequities in COVID-19 outcomes, while others used place-based allocation. In a nationally representative survey of n=2067 US residents, fielded in mid-April 2021, we explored the public acceptability of race-based prioritisation compared with place-based prioritisation, by offering vaccines to harder hit zip codes before residents of other zip codes. We found that in general, a (...) majority of respondents supported the place-based approach, and a substantial proportion supported the race-based plan. Support was higher among Democrats compared with Republicans. All US residents became eligible for vaccines on 19 April 2021 but as of this writing, equitable uptake of vaccines remains urgent not only for first doses for adults but also for boosters and for children. Our findings also provide a benchmark for future pandemic planning that racial and social justice in vaccine allocation are salient considerations for the public. The findings may furthermore be of interest to policy makers designing vaccine allocation frameworks in countries with comparable health disparities across social, ethnic and racial groups, and more broadly, for those exploring ways of promoting equity in resource allocation outside of a pandemic setting. (shrink)