Pandemic prioritarianism: what can we learn from Covid-19?

By Lasse Nielsen.

Medical ethics have to learn from actual ethical experiences from the medical practice. The relevant interpretation and application of ethical theories must adhere to issues and questions that arise in clinical practice, and oftentimes we find that our intuitions about practical matters do not fit our theories and principles. In these cases, we will have to decide whether to stick with our favourite theories and thus set aside our intuition in the particular case, or alternatively revise our theories according to our practical experience. More often than not, I think the right decision is the latter. In this paper, I ask what we learn from the pandemic experience of Covid-19 about health care priority setting theory. More specifically, I investigate how the distributive theory of prioritarianism should be interpreted in light of the pandemic experience.

Generically, prioritarianism is the view that it matters more to benefit people, the worse off they are. But more particularly, prioritarianism has taken a number of different applications to health care priority setting. I identify and distinguish between three specific expressions of prioritarian thought. First, social justice prioritarianism identifies the worst off on a wide social dimension, which implies a special moral duty to protect the wellbeing of the socially disadvantaged. Second, severity prioritarianism focuses on giving priority according to severity of illness and implies that we have special moral duties to help the most severely ill. Third and finally, age-weighted prioritarianism holds young people to be relevantly worse off than older people, because they have had less life years, and that it matters more, for this reason, to help people the younger they are.

All three applications of prioritarianism have relevant implications in the case of pandemic health care priority setting. First, in light of the Covid-19 outbreak, it became indubitably apparent that health risks concentrate unevenly upon the socially vulnerably and disadvantaged. Second, the pandemic also caused a state of emergency resulting in almost triage-like rationing decision-making which invoked the concern of priority for the most severely ill. Finally, the Covid-19 outbreak raised questions about the role of age in the rationing of intensive care resources; questions to which age-weighted prioritarianism provides answers.

The paper arrives at the following conclusions: (i) that the social effects of the pandemic raise special prioritarian concerns for the socially disadvantaged; (ii) that severity of illness is an important factor in deciding who is worse off but that this should not be taken to override the importance of social disadvantage; (iii) and finally that age-weighted prioritarianism, when applied to the Covid-19 case, runs counter to the strong fundamental social commitment of prioritarianism in a way that has so far been neglected in the way the view has been put forward, and that, for this reason, we should not consider the age-weighted view a proper prioritarian response to the pandemic.

This result has both theoretical and practical implications. Theoretically, it implies that social disadvantage should be a primary concern for prioritarianism even when narrowly applied to health care priority setting. As a practical implication, the argument suggests that welfare state health systems take special interest in the protection of the socially disadvantaged, and that they initiate health policies to mitigate the unfair social harms caused by the pandemic.


Paper title: Pandemic Prioritarianism

Author: Lasse Nielsen

Affiliations: University of Southern Denmark

Competing interests: None to declare

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