Allocation of scarce resources in Africa during COVID-19: Utility and justice for the bottom of the pyramid?

The COVID-19 pandemic has raised important universal public health challenges. Conceiving ethical responses to these challenges is a public health imperative but must take context into account. This is particularly important in sub-Saharan Africa (SSA). In this paper, we examine how some of the ethical recommendations offered so far in high-income countries might appear from a SSA perspective. We also reflect on some of the key ethical challenges raised by the COVID-19 pandemic in low-income countries suffering from chronic shortages in health care resources, and chronic high morbidity and mortality from non-COVID-19 causes. A parallel is drawn between the distribution of severity of COVID-19 disease and the classic "Fortune at the bottom of the pyramid" model that is relevant in SSA. Focusing allocation of resources during COVID-19 on the 'thick' part of the pyramid in Low-to-Middle Income Countries (LMICs) could be ethically justified on utilitarian and social justice grounds, since it prioritizes a large number of persons who have been economically and socially marginalized. During the pandemic, importing allocation frameworks focused on the apex of the pyramid from the global north may therefore not always be appropriate. In a post-COVID-19 world, we need to think strategically about how health care systems can be financed and structured to ensure broad access to adequate health care for all who need it. The root problems underlying health inequity, exposed by COVID-19, must be addressed, not just to prepare for the next pandemic, but to care for people in resource poor settings in non-pandemic times.

Chapitre 5. L'innovation frugale au service de systèmes de santé durables.

Bioethics is sometimes presented as a series of universal guidelines aimed at regulating health care practices and research on human beings. Such a presentation, however, does not hold water in the face of the history of the discipline. Bioethics was born in the ideological context that prevailed in the United States in the 1960s and 1970s. Should we then abandon all hope of universality for ethical benchmarks that have proven their usefulness in illuminating health practices? By carefully distinguishing the universal from the uniform, this contribution shows, based on the work of G. Tangwa, that it is possible to respect the specificities of cultures around the world, while maintaining a universal aim for bioethics.

Chapitre 5. L'innovation frugale au service de systèmes de santé durables.

Bioethics is sometimes presented as a series of universal guidelines aimed at regulating health care practices and research on human beings. Such a presentation, however, does not hold water in the face of the history of the discipline. Bioethics was born in the ideological context that prevailed in the United States in the 1960s and 1970s. Should we then abandon all hope of universality for ethical benchmarks that have proven their usefulness in illuminating health practices? By carefully distinguishing the universal from the uniform, this contribution shows, based on the work of G. Tangwa, that it is possible to respect the specificities of cultures around the world, while maintaining a universal aim for bioethics.

What Could "Fair Allocation" during the Covid-19 Crisis Possibly Mean in Sub-Saharan Africa?

The Covid-19 pandemic has sparked rapid and voluminous production of bioethics commentary in popular media and academic publications. Many of the discussions are new twists on an old theme: how to fairly allocate scarce medical resources, such as ventilators and intensive care unit beds. In this essay, we do not add another allocation scheme to the growing pile, partly out of appreciation that such schemes should be products of inclusive and transparent community engagement and partly out of recognition of their limited utility for physicians working in the field. Instead, we make the more modest claim that context matters when making such decisions and, more specifically, that recommendations from high-income countries about fair allocation during Covid-19 should not be cut and pasted into low-income settings. We offer a few examples of why seemingly universal, well-intentioned ethical recommendations could have adverse consequences if unreflectively applied in sub-Saharan Africa.

[The possibility of universalizing values in clinical ethics: questions and stakes]. / De la possibilité d'universaliser les valeurs en éthique clinique: questions et enjeux.

A derivative of modernity, bioethics is a torn between its legitimate desire to universalize the values to which it has traditionally adhered (for example: autonomy, beneficence, non-malfeasance, fairness) and the awareness of the very Western character of these ethical guidelines. Should one resolve to work in a relativist model? Bioethics arose through the necessity of having ethics to accompany the development of medical biotechnology in the aftermath of the Second World War And obviously Western bioethics was applied to serve Western biotechnological developments. Can these culturally based medical techniques and know-how be exported without equally exporting the ethical guidelines that have been gradually assigned to their development? To shed light on the issue, the author suggests linking free and informed consent to the concept of autonomy and to its corollary.

[Low vision in Madagascar and education in ethics]. / Chapitre 3. Basse vision à Madagascar et éducation à la réflexion éthique.

In this contribution, we analyze four clinical cases relating to low vision in Madagascar while insisting on the raised ethical questions. We identify several factors worsening the disabilities, including the low vision, by showing the importance of the environment in this field. In Madagascar, like elsewhere, laws and rules are dedicated to the alleviation of the difficulties lived by persons with disabilities, but the gap is huge between the intentions displayed by the public authorities and the measures taken concretely on the ground. A change of perception is necessary with regard to people with low vision while insisting on the value of solidarity. An education in ethics could contribute to such a change. Although concentrated on the Malagasy situation and the low vision, our analysis is applicable to other contexts and other disabilities.