Proposed Principles for International Bioethics Conferencing: Anti-Discriminatory, Global, and Inclusive.

This paper opens a critical conversation about the ethics of international bioethics conferencing and proposes principles that commit to being anti-discriminatory, global, and inclusive. We launch this conversation in the Section, Case Study, with a case example involving the International Association of Bioethics' (IAB's) selection of Qatar to host the 2024 World Congress of Bioethics. IAB's choice of Qatar sparked controversy. We believe it also may reveal deeper issues of Islamophobia in bioethics. The Section, Principles for International Bioethics Conferencing, sets forth and defends proposed principles for international bioethics conferencing. The Section, Applying Principles to Site Selection applies the proposed principles to the case example. The Section, Applying Principles Beyond Site Selection addresses other applications of the proposed principles. The Section, Objections responds to objections. We close (in the Section, Conclusion) by calling for a wider discussion of our proposed principles. One-Sentence Capsule Summary: How should bioethicists navigate the ethics of global bioethics conferencing?

War, Bioethics, and Public Health.

This paper argues that bioethics as a field should broaden its scope to include the ethics of war, focusing on war's public health effects. The "Introduction" section describes the bioethics literature on war, which emphasizes clinical and research topics while omitting public health. The section, "War as a public health crisis" demonstrates the need for a public health ethics approach by framing war as a public health crisis. The section, "Bioethics principles for war and public health" proposes six bioethics principles for war that address its public health dimensions: health justice, accountability, dignified lives, public health sustainability, nonmaleficence, and public health maximization. The section, "Justifying and applying bioethical principles" shows how these principles inform ethical analysis, including just war theory and military ethics. The section, "From principles to practice" envisions ways in which bioethicists can promote these principles in practice through research, teaching, and service. The "Conclusion" section urges bioethicists to engage with war as a public health crisis, including calling attention to war's impact on civilians, especially women, children, and other vulnerable groups.

PRESIDENTIAL ADDRESS: Lessons from Africa: Ubuntu, solidarity, dignity, kinship, and humility.

This paper addresses bioethics in the context of the coronavirus disease 2019 (COVID-19) pandemic. The Introduction (Section 1) highlights that at the field's inception, infectiousness was not front and center. Instead, infectious disease was widely perceived as having been conquered. This made it possible for bioethicists to center values such as individual autonomy, informed consent, and a statist conception of justice. Section 2 urges shifting to values more fitting for the moment the world is in. To find these, it directs attention to the Global South, and in particular, Africa, and to the values of ubuntu, solidarity, dignity, kinship, and humility. The paper concludes (in Section 3) that 21st-century challenges facing bioethics are increasingly global, and calls on bioethicists themselves to be more globally inclusive in their approaches.

Personhood: An emergent view from Africa and the West.

African understandings of personhood are complex, with different accounts emphasizing distinct aspects of what it means to be a person. Some accounts stress excellence of character and performing well in social roles and relationships, while others focus on innate moral qualities of individuals independent of their conduct and character. This paper sheds new light on these twin aspects of personhood. It proposes a way to navigate these dual features by bringing African and Western personhood into conversation, building on the strengths of each approach, and developing a new view of personhood that we call, Emergent Personhood. Section 1 introduces diverse approaches to personhood within African thought. Section 2 compares African and Western approaches. Section 3 evaluates advantages and disadvantages of each and identifies conditions that any account of personhood must meet to leverage the advantages and avoid the disadvantages identified. Section 4 introduces Emergent Personhood, which meets these conditions. Section 5 concludes that expanding the conversation about personhood across cultures enriches an ongoing conversation about what it means to be a person.

Academic freedom under siege.

This paper describes a global pattern of declining academic freedom, often driven by powerful political interference with core functions of academic communities. It argues that countering threats to academic freedom requires doubling down on ethics, specifically standards of justice and fairness in pursuing knowledge and assigning warrant to beliefs. Using the example of the selection of a Qatari university to host the 2024 World Congress of Bioethics, the authors urge fairness towards diverse groups over time and efforts to counter injustices that conferences generate.

Towards a new model of global health justice: the case of COVID-19 vaccines.

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.

The ethics of bioethics conferencing in Qatar.

In 2022, the International Association of Bioethics (IAB) announced that the 17th World Congress of Bioethics would be held in Doha, Qatar. In response to ethical concerns expressed about the Qatar selection, the IAB Board of Directors developed and posted to the IAB website a response using a Q&A format. In this Letter, we (the IAB President and Vice President) address concerns about the ethics of bioethics conferencing raised in a 2023 Letter to the Editor of Bioethics by Van der Graaf et al. We do not represent the Board of Directors, and this Letter expresses solely our own views.

Global sharing of COVID-19 vaccines: A duty of justice, not 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.

What the 'greater good' excludes: Patients left behind by pre-operative COVID-19 screening in an Ethiopian town.

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.

Vaccine passports and health disparities: a perilous journey.

This paper raises health equity concerns about the use of passports for domestic and international travel to certify COVID-19 vaccination. Part I argues that for international travel, health equity objections undercut arguments defending vaccine passports, which are based on tholding people responsible, protecting global health, safeguarding individual liberty and continuing current practice. Part II entertains a proposal for a scaled down vaccine passport for domestic use in countries where vaccines are widely and equitably available. It raises health equity concerns related to racial profiling and fairness to people who are vaccine cautious. Part III sets forth a proposal for a flexible pass that certifies people who have been vaccinated, tested, previously infected or granted a conscientious objection. It sets ethical guidelines for the timing and use of flexible passes that promote equity, public health education, antidiscrimination, privacy and flexibility.

What money can't buy: an argument against paying people to get vaccinated.

This paper considers the proposal to pay people to get vaccinated against the SARS-CoV-2 virus. The first section introduces arguments against the proposal, including less intrusive alternatives, unequal effects on populations and economic conditions that render payment more difficult to refuse. The second section considers arguments favouring payment, including arguments appealing to health equity, consistency, being worth the cost, respect for autonomy, good citizenship, the ends justifying the means and the threat of mutant strains. The third section spotlights long-term and short-term best practices that can build trust and reduce 'vaccine hesitancy' better than payment. The paper concludes that people who, for a variety of reasons, are reluctant to vaccinate should be treated like adults, not children. Despite the urgency of getting shots into arms, we should set our sights on the long-term goals of strong relationships and healthy communities.

Does Zero-COVID neglect health disparities?

Since the World Health Organization (WHO) 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.

A world away and here at home: a prioritisation framework for US international patient programmes.

Programmes serving international patients are increasingly common throughout the USA. These programmes aim to expand access to resources and clinical expertise not readily available in the requesting patients' home country. However, they exist within the US healthcare system where domestic healthcare needs are unmet for many children. Focusing our analysis on US children's hospitals that have a societal mandate to provide medical care to a defined geographic population while simultaneously offering highly specialised healthcare services for the general population, we assume that, given their mandate, priority will be given to patients within their catchment area over other patients. We argue that beyond prioritising patients within their region and addressing inequities within US healthcare, US institutions should also provide care to children from countries where access to vital medical services is unavailable or deficient. In the paper, we raise and attempt to answer the following: (1) Do paediatric healthcare institutions have a duty to care for all children in need irrespective of their place of residence, including international patients? (2) If there is such a duty, how should this general duty be balanced against the special duty to serve children within a defined geographical area to which an institution is committed, when resources are strained? (3) Finally, how are institutional obligations manifest in paradigm cases involving international patients? We start with cases, evaluating clinical and contextual features as they inform the strength of ethical claim and priority for access. We then proceed to develop a general prioritisation framework based on them.

Too old to save? COVID-19 and age-based allocation of lifesaving medical care.

Adults aged 65 and over are disproportionately impacted by the coronavirus disease 2019 (COVID-19) pandemic and represent by far the largest share of severe disease and death. This paper critically examines ethical arguments for using implicit and explicit age criteria as a standard for allocating scarce lifesaving resources during the pandemic. Section 1 introduces the topic. Section 2 distinguishes standard from pandemic triage. Section 3 assesses ethical arguments for criteria that are implicitly age-based, including quality-adjusted life years, disability adjusted-life years, and total number of future life years. Section 4 examines ethical arguments for criteria that are more directly age-based, including fair innings, equality between old and young, and priority to the worse off. The paper concludes that neither implicit nor explicit age-based allocation withstands careful scrutiny.

Global sharing of COVID-19 therapies during a "New Normal".

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.

Intergenerational ethics in Africa: Duties to older adults in skipped generation households.

This paper examines individual and societal duties to older adults in sub-Saharan Africa who reside in skipped generation households, which are households in which a young and old generation live together with the middle generation absent. As they age, older adults in skipped generation households may lack the prospect of social and economic support from offspring, making their situation precarious. If ill health results in an older adult's inability to work, who will support them? If they need assistance with basic activities of daily living, who will provide it? This paper addresses these questions through the lens of African ethics. Section I appeals to the African ethic of ubuntu ('humanness') to identify normative conceptions of persons and moral character relevant to skipped generation ethics. Section II elaborates this focus by means of the virtues of gratitude and reciprocity, discussing their conditions, requirements, and limits and comparing surrogate parent-child to parent-child cases. Section III explores the application of an ubuntu ethic to society as a whole and defines societal duties toward older adults by appealing to African conceptions of dignity and justice.

Bioethics in Africa: A contextually enlightened analysis of three cases.

Across sub-Saharan Africa, bioethics is an emerging field of scholarly inquiry, informed by contextual features distinct to the region. A cultural mix comprised of Euro-American influences, indigenous traditions, Christian faiths and Muslim communities, a bioethics for the sub-Saharan region must be responsive to this milieu. This paper asks, what values and methods can best promote the practice of bioethics in Africa? We set forth a strategy that leans one way or another in response to contextual features of a particular setting. Since our aim is to be responsive to context, we begin with a series of cases and develop values and methods in response to each case as we work through its ethical analysis. Section I introduces a case involving setting priorities for public funding of services that produce large benefits for a small group of people, using the example of dialysis in Ghana. Section II presents a situation involving determining the permissibility of a double standard of quality for healthcare devices in rich and poor nations, using the example of explanting pacemakers from deceased people in wealthy nations for use by people in low- and middle-income nations. Section III describes a scenario where international groups clash with religious and spiritual healers over the chaining of people with severe mental illness at prayer camps and healing centers in Ghana. Section IV articulates a three-pronged strategy for engaging in bioethics brought to light by the case analyses and defends it against objections. Throughout the paper, we tag certain views 'African' and others 'Western' to indicate ethical beliefs commonly found in these regions and less commonly found elsewhere. We do not mean to imply that all Africans hold a certain ethical stance or that all Westerners do; nor do we mean to suggest that people outside these regions do not hold the views in question.

Achieving Global Vaccine Equity: The Case for an International Pandemic Treaty.

This paper presents an ethical argument in support of an international Pandemic Treaty. It argues that an international Pandemic Treaty is the best way to mark progress on global vaccine equity and broader issues of global pandemic preparedness and response which came to light during the coronavirus disease 2019 (COVID-19) pandemic. Section I evaluates principles of multilateral charity, national security, and international diplomacy standardly invoked in debates about global vaccine allocation and argues that these approaches fall short. Section II explicates notions of solidarity, duties to the least well-off, and mutual aid as ethical values more fitting for an era of emerging infectious diseases. Section III relates the discussion to an international Pandemic Treaty and presents legal, pragmatic, and ethical reasons to support it. The paper concludes that in an interconnected world, fair sharing of vaccines between nations is morally mandatory.

Nothing to be ashamed of: sex robots for older adults with disabilities.

This paper spotlights ways in which sexual capacities relate to central human capabilities, such as the ability to generate a personally meaningful story of one's life; be physically, mentally and emotionally healthy; experience bodily integrity; affiliate and bond with others; feel and express a range of human emotions; and choose a plan of life. It sets forth a dignity-based argument for affording older people access to sex robots as part of reasonable efforts to support their central human capabilities at a floor level. The argument develops stepwise: (1) first, I dispel ageism and negative stereotypes about later-life sexuality, showing their deep historical roots in medicine and science; (2) second, I set forth a positive argument, grounded in capability accounts of justice, for deploying sex robots for older people with disabilities; (3) finally, after responding to objections, I conclude that sex robots are a reasonable way to support later-life sexuality for persons with disabilities. While often depicted as a product for younger, able-bodied people, this paper is a bid for reimagining sex robots as a product for older, disabled people.

Three for me and none for you? An ethical argument for delaying COVID-19 boosters.

This paper argues in support of the WHO's proposal to forego COVID-19 booster shots until 10% of people in every country are fully vaccinated. The Ethical Argument section shows that we save the most lives and ensure the least amount of suffering by allocating doses first to unvaccinated people. It also argues that there is a duty to support decent lives and to promote health equity, which establish that refraining from boosters is a requirement of justice, not charity. The Replies to Objections section answers objections that appeal to pragmatism, nationalism, ownership, scientific advancement, self-interest, semantics and futility. The Conclusion section emphasizes that for now, wealthy nations should not boost vaccinated people's immunity and should instead send doses to poorer nations where they are most urgently needed.