Dilemmas in access to medicines: a humanitarian perspective - Authors' reply

Socially optimal dosing for scarce vaccines: Ethical analysis through the principlism framework

RATIONALE, AIMS, AND OBJECTIVES

Under conditions of vaccine scarcity, the socially optimal dosing (SOD) strategy administers a lower dose of vaccine to a larger number of people than the individually optimal dosing (IOD) strategy, which administers a higher dose of vaccine to a smaller number of people. In the context of vaccines that generate diminishing returns of effectiveness with each additional dose beyond the first, SOD therefore generates a greater total amount of vaccine-induced protection than IOD and, as such, constitutes the socially optimal strategy. While the clinical and public health arguments in favour of SOD have previously been outlined, this article conducts an ethical analysis of SOD for scarce vaccines through the ethical framework of principlism.

METHODS

SOD is examined with regard to each principle within the principlism framework-nonmaleficence, beneficence, autonomy, and justice.

RESULTS

SOD is found to satisfy each of the ethical requirements under examination. Regarding nonmaleficence, SOD induces less iatrogenic harm than IOD since the dose of vaccine administered to each individual is lower in the former than the latter. Furthermore, both the good and bad effects of SOD are foreseen while only the good effects are intended, meaning this strategy simultaneously satisfies the doctrine of double effect. Regarding autonomy, SOD makes vaccine-induced protection available to a greater number of individuals who wish to receive it, thereby respecting their capacity for self-determination and to make independent decisions. Regarding beneficence, SOD renders the good-namely the protection of health-more widely available to the individuals that constitute the population in question. Finally, SOD promotes theories of justice that treat individuals equally and is unlikely to reduce the effectiveness of other distribution policies that allocate scarce vaccines in a just manner.

CONCLUSION

In conditions of vaccine scarcity, SOD favourably satisfies the ethical framework of principlism.

Considering Quality of Life while Repudiating Disability Injustice: A Pathways Approach to Setting Priorities

This article proposes a novel strategy, one that draws on insights from antidiscrimination law, for addressing a persistent challenge in medical ethics and the philosophy of disability: whether health systems can consider quality of life without unjustly discriminating against individuals with disabilities. It argues that rather than uniformly considering or ignoring quality of life, health systems should take a more nuanced approach. Under the article's proposal, health systems should treat cases where (1) quality of life suffers because of disability-focused exclusion or injustice differently from cases where (2) lower quality of life results from laws of nature, resource scarcity, or appropriate tradeoffs. Decisionmakers should ignore quality-of-life losses that result from injustice or exclusion when ignoring them would improve the prospects of individuals with disabilities; in contrast, they should consider quality-of-life losses that are unavoidable or stem from resource scarcity or permissible tradeoffs. On this proposal, while health systems should not amplify existing injustice against individuals with disabilities, they are not required to altogether ignore the potential effects of disability on quality of life.