J Med Ethics February 2021 Vol 47 No 2 63 Solidarity, sustainability and medical ethics Zoë Fritz In this issue of the Journal of Medical Ethics arguments are cogently made that sustainability and solidarity should be considered as core medical ethical prin- ciples, and that more explicit attention should be given to the complex context in which a decision is made. Munthe et al propose that sustainability should become an established principle for justifying healthcare resource allocation, and should be an explicit factor in procuring drugs and other resources. 1 They argue that the current operational norms which guide decision making (need, prognosis, equal treatment and cost-effectiveness) can lead to what they call ‘negative dynamics’: the gradual depletion of resource available for healthcare. They illustrate this first by examining some well recognised examples of ‘posi- tive dynamics’ which are considered in health policy: immunisation programmes are funded because lead to reduction or absence of disease in the population, thus freeing up resource for other uses; public health measures are offset by future cost reductions or income increases for health- care via reduction of sick leave. ‘Negative dynamics’ however, are not routinely considered in operational deci- sions and they persuasively argue that they should be. Resource depletion (not only fiscal resource, but environmental and human resource) has a negative effect on future cycles of healthcare. As an illus- trative example, they discuss the emis- sion of resistance-driving residue in the production of antibiotics. The accepted principles, particularly of cost effective- ness, drive producers to make antibiotics cheaply, without consideration of gradual contribution to antibiotic resistance. If a principle of sustainability was included when considering procurement, subsidy and prioritisation, this would provide an incentive to change production practices. This argument can be extended to many aspects of the healthcare; system including how we recruit, train and treat our staff; how we invest in infrastructure and how we plan for pandemics. Munthe et al go on to provide a robust definition of their sustainability principle, and to address possible objections. It is an excellent example of reasoned ethical argument which has the potential to change clinical practice. With the roll out of vaccinations for COVID-19 across the globe, Julian Savulescu proposes an algorithm for when mandatory vaccination might be ethically justified. 2 Drawing and expanding upon the 2007 Nuffield Council of Bioethics report he suggests that four criteria are required: 1. There is a grave threat to public health 2. The vaccine is safe and effective 3. Mandatory vaccination has a superior cost/benefit profile compared with other alternatives 4. The level of coer- cion is proportionate. Discussing the value judgement associated with each criterion, he concludes that, at least initially (where uncertainty around safety is greater), mandatory vaccina- tion for COVID-19 would be ethically problematic. He goes on to explore alternative approaches, including non-financial (eg, immunisation passports) and financial incentives. He argues that individuals could essentially be paid for the risk they are undertaking (by being early adopters of a vaccine) for societal benefit, but to do this government would need to be ‘transparent, explicit and comprehen- sive in disclosure of data’, a standard which unfortunately has not always (or even often?) been kept. The danger that payment might signal a lack of confi- dence in safety is real. Clearly payment should only be offered for a vaccine which was considered safe enough to be used in any circumstances; payment for a vaccine which was not consid- ered safe without payment would not be morally acceptable. Payment may also erode the sense of solidarity that people feel when contributing to soci- etal well-being; to ensure that this was maintained he suggests the option of ‘donating back’ the fee to the NHS could be made available. People could be rewarded for taking the vaccine with an increasing sense of civic duty as they not only protect themselves and the vulnerable, but contribute to the (fiscal) sustainability of the health service which treats them. While Savulescu acknowledges the worth of solidarity, Avery Kolers proposes that solidarity plays not just an auxillary part in the interests of acknowledged bioethical values (justice, beneficence etc) but has a freestanding role, which should be independently assessed. 3 He acknowledges that soli- darity per se is not valuable: there is solidarity, he notes, among a firing squad and within a terrorist cell. He develops Prainsack and Buyx metaphor of solidarity as the putty of justice 4 and suggests five individually necessary and sufficient conditions of morally valuable solidarity: it must be (1) norm grounded (2) acknowledged (3) political (4) action and (5) on others’ behalf. He suggests that solidarity (with X) is morally required ‘when it constitutes equitable treatment of X such as to counter- mand or resist inequitable treatment of X’. He notes that moral dilemmas may arise where solidarity with X may lead to inequitable treatment of Y and emphasises that solidarity with the most vulnerable in society will help address inequities in healthcare and in health- care institutions. The complexities and competing moral demands of healthcare institutions, and primary care in particular, are explored by Spicer et al , who question the use of norma- tive moral theories to determine the ‘best’ actions. 5 They argue that the context in which ethical decisions are made is not suffi- ciently acknowledged; if complex contextual factors are not considered, then predictions about outcomes will be flawed, as will the resulting ethical analyses. Examples of contextual factors which might influence decision-making include power relations within the staff and external regulators (including achieving externally determined quality markers and ‘standard’ practice) and the need to maintain both group and individual professional identities. It is often helpful to peel back the layers of complexity in order to reveal a specific ethical question. Before coming to a conclu- sion, however, we must remember to reapply the layers and reconsider the question in the context of its complex environment. Integrating this proposal with others in the journal, this might include considerations of sustainability and solidarity. Funding Zoë Fritz is funded by the Wellcome Trust Grant 208213/Z/17/Z, and is based in The Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge. THIS Institute is supported by the Health Foundation, an independent charity Concise argument doi:10.1136/medethics-2021-107221 on December 8, 2021 by guest. Protected by copyright. http://jme.bmj.com/ J Med Ethics: first published as 10.1136/medethics-2021-107221 on 22 January 2021. Downloaded from