Informed consent for anesthesia is an ethical and legal requirement. A patient must have adequate decision-making capacity (DMC) as a prerequisite to informed consent. In determining whether a patient has sufficient DMC, anesthesiologists must draw on their knowledge of DMC. Knowledge gaps regarding DMC may result in incorrect assessments of patients’ capacity. This could translate to an informed consent process that is ethically and legally unsound. This study examined the DMC-related knowledge of anesthesiologists in a group of four university-affiliated hospitals. (...) The findings suggest that anesthesiologists have several areas of knowledge deficiency regarding DMC and DMC assessment. These findings could inform the development of undergraduate and postgraduate curricula. (shrink)

This article explores three ways in which physics may involve counterpossible reasoning. The first way arises when evaluating false theories: to say what the world would be like if the theory were true, we need to evaluate counterfactuals with physically impossible antecedents. The second way relates to the role of counterfactuals in characterizing causal structure: to say what causes what in physics, we need to make reference to physically impossible scenarios. The third way is novel: to model metaphysical dependence in (...) physics, we need to consider counterfactual consequences of metaphysical impossibilities. Physics accordingly bears substantial and surprising counterpossible commitments. (shrink)

Background HIV prevention research has been fraught with ethical concerns since its inception. These concerns were highlighted during HIV vaccine research and have been elaborated in microbicide research. A host of unique ethical concerns pervade the microbicide research process from trial design to post-trial microbicide availability. Given the urgency of research and development in the face of the devastating HIV pandemic, these ethical concerns represent an enormous challenge for investigators, sponsors and Research Ethics Committees (RECs) both locally and internationally. Discussion (...) Ethical concerns relating to safety in microbicide research are a major international concern. However, in the urgency to develop a medically efficacious microbicide, some of these concerns may not have been anticipated. In the risk-benefit assessment of research protocols, both medical and psycho-social risk must be considered. In this paper four main areas that have a potential for medical and/or psycho-social harm are examined. Male partner involvement is controversial in the setting of covert use of microbicides. However, given the long-term exposure of men to experimental products, this may be methodologically, ethically and legally important. Covert use of microbicides may impact negatively on relationship dynamics leading to psychosocial harm to varying extents. The unexpectedly high rates of pregnancy during clinical trials raise important methodological and ethical concerns. Enrollment of adolescents without parental consent generates ethical and legal concerns that must be carefully considered by RECs and trial sites. Finally, paradoxical outcomes in recent trials internationally have advanced the debate on the nature of informed consent and responsibility of researchers to participants who become HIV positive during or after trials. Summary Phase 3 microbicide trials are an undisputed research and ethical priority in developing countries. However, such trials must be conducted with attention to both methodological and ethical detail. It is imperative that guidelines are formulated to ensure that high ethical standards are maintained despite the scientific urgency of microbicide development. Given the controversy raised by emergent ethical issues during the course of microbicide development, it is important that international consensus is reached amongst the various ethics and regulatory agencies in developing and developed countries alike. (shrink)

Background and objectives: There are few insights from sub-Saharan Africa on research participants’ experiences of the informed consent process, particularly in the context of randomised controlled trials, where issues of randomisation and the use of placebos may be confusing concepts for participants. This study investigated the knowledge and perceptions of the informed consent process among individuals participating in influenza vaccine trials in two disadvantaged communities in South Africa.Method: Four to 12 months after completion of the trials, participants were contacted to (...) return to participate in the informed consent study. The semistructured questionnaire administered to assess recall of trial procedures and the informed consent process covered key issues including: purpose of the study; awareness that the study was not part of routine treatment; voluntary nature of participation and freedom to withdraw; randomisation; placebos; and remuneration.Results: A total of 334 participants completed the questionnaire. Only 21% were able to recall that they were allocated randomly to the different treatment arms. Only 19% of those involved in the placebo controlled study had interpreted the concept of placebo as an inactive medication.Conclusion: Although a good general recall of trial concepts was demonstrated, only a small proportion of the participants correctly interpreted and recalled the concepts of randomisation and placebos. Informed consent in this and similarly disadvantaged communities may often be inadequate and new ways to improve understanding of the research process should be explored. (shrink)

Quantum physics is believed to be the fundamental theory underlying our understanding of the physical universe. However, it is based on concepts and principles that have always been difficult to understand and controversial in their interpretation. This book aims to explain these issues using a minimum of technical language and mathematics. After a brief introduction to the ideas of quantum physics, the problems of interpretation are identified and explained. The rest of the book surveys, describes and criticises a range of (...) suggestions that have been made with the aim of resolving these problems; these include the traditional, or 'Copenhagen' interpretation, the possible role of the conscious mind in measurement, and the postulate of parallel universes. This new edition has been revised throughout to take into account developments in this field over the past fifteen years, including the idea of 'consistent histories' to which a completely new chapter is devoted. (shrink)

The use of biological samples in research raises a number of ethical issues in relation to consent, storage, export, benefit sharing and re-use of samples. Participant perspectives have been explored in North America and Europe, with only a few studies reported in Africa. The amount of research being conducted in Africa is growing exponentially with volumes of biological samples being exported from the African continent. In order to investigate the perspectives of African research participants, we conducted a study at research (...) sites in the Western Cape and Gauteng, South Africa. (shrink)

Biobanks are precariously situated at the intersection of science, genetics, genomics, society, ethics, the law and politics. This multi-disciplinarity has given rise to a new discourse in health research involving diverse stakeholders. Each stakeholder is embedded in a unique context and articulates his/her biobanking activities differently. To researchers, biobanks carry enormous transformative potential in terms of advancing scientific discovery and knowledge. However, in the context of power asymmetries in Africa and a distrust in science born out of historical exploitation, researchers (...) must balance the scientific imperative of collecting, storing and sharing high quality biological samples with obligations to donors/participants, communities, international collaborators, regulatory and ethics authorities. To date, researcher perspectives on biobanking in South Africa have not been explored and documented. In-depth qualitative interviews were conducted with a purposive sample of 21 researchers – 8 in the Western Cape, 3 in Gauteng and 10 in Kwa-Zulu Natal. Interviews lasted approximately 40–60 min and were audiotaped with consent. Thematic analysis of the transcribed interviews was conducted by the co-authors. Researchers articulated serious concerns over standardised regulatory approaches that failed to consider the heterogeneity of biobanks. Given that biobanks differ considerably, guidelines and RECs need to stratify risk accordingly and governance processes and structures must be flexible. While RECs were regarded as an important component of the governance structure researchers expressed concern about their expertise in biobanking. Operational management of biobanks was regarded as an ethical imperative and a pre-requisite to building trust during consent processes. While broad general consent was preferred, tiered consent was thought to be more consistent with respect for autonomy and building trust. Material Transfer Agreements were often lacking when biosamples were exported and this was perceived to impact negatively on trust. On the other hand, researchers believed that authentic community engagement would help to build trust. Building trust will best be achieved via a system of governance structures and processes that precede the establishment of a biobank and monitor progress from the point of sample collection through to future use, including export. Such governance structures must be robust and must include comprehensive national legislation, policy and contextualised guidelines. Currently such governance infrastructure appears to be lacking in many African countries including South Africa. Capacity development of all stakeholders including REC members will enhance expeditious and efficient review of biobanking protocols which in turn will reinforce trust in the researcher-donor relationship. Science translation and community engagement in biobanking is integral to the success of biobanking in South Africa. (shrink)

BackgroundThe COVID-19 pandemic presents significant challenges to research ethics committees (RECs) in balancing urgency of review of COVID-19 research with careful consideration of risks and benefits. In the African context, RECs are further challenged by historical mistrust of research and potential impacts on COVID-19 related research participation, as well as the need to facilitate equitable access to effective treatments or vaccines for COVID-19. In South Africa, an absent National Health Research Ethics Council (NHREC) also left RECs without national guidance for (...) a significant duration of the COVID-19 pandemic. We conducted a qualitative descriptive study that explored the perspectives and experiences of RECs regarding the ethical challenges of COVID-19 research in South Africa.MethodsWe conducted in-depth interviews with 21 REC chairpersons or members from seven RECs at large academic health institutions across South Africa that were actively involved in the review of COVID-19 related research from January to April 2021. In-depth interviews were conducted remotely via Zoom. Interviews (60–125 min) were conducted in English using an in-depth interview guide, until data saturation was achieved. Audio-recordings were transcribed verbatim and field notes were converted into data documents. Line-by-line coding of transcripts was performed, and data were organised into themes and sub-themes. An inductive approach to thematic analysis was used to analyse data.ResultsFive main themes were identified, namely: rapidly evolving research ethics landscape, extreme vulnerability of research participants, unique challenges to informed consent, challenges to community engagement during COVID-19, and overlapping research ethics and public health equity issues. Sub-themes were identified for each main theme.ConclusionsNumerous, significant ethical complexities and challenges were identified by South African REC members in the review of COVID-19 related research. While RECs are resilient and adaptable, reviewer and REC member fatigue were major concerns. The numerous ethical issues identified also highlight the need for research ethics teaching and training, especially in informed consent, as well as the urgent requirement for the development of national guidelines for research ethics during public health emergencies. Further, comparative analysis between different countries is needed to develop the discourse around African RECs and COVID-19 research ethics issues. (shrink)

This book defends a radical new theory of contingency as a physical phenomenon. Drawing on the many-worlds approach to quantum theory and cutting-edge metaphysics and philosophy of science, it argues that quantum theories are best understood as telling us about the space of genuine possibilities, rather than as telling us solely about actuality. When quantum physics is taken seriously in the way first proposed by Hugh Everett III, it provides the resources for a new systematic metaphysical framework encompassing possibility, necessity, (...) actuality, chance, counterfactuals, and a host of related modal notions. -/- Rationalist metaphysicians argue that the metaphysics of modality is strictly prior to any scientific investigation; metaphysics establishes which worlds are possible, and physics merely checks which of these worlds is actual. Naturalistic metaphysicians respond that science may discover new possibilities and new impossibilities. This book's quantum theory of contingency takes naturalistic metaphysics one step further, allowing that science may discover what it is to be possible. As electromagnetism revealed the nature of light, as acoustics revealed the nature of sound, as statistical mechanics revealed the nature of heat, so quantum physics reveals the nature of contingency. (shrink)

There is a systematic and suggestive analogy between grounding and causation. In my view, this analogy is no coincidence. Grounding and causation are alike because grounding is a type of causation: metaphysical causation. In this paper I defend the identification of grounding with metaphysical causation, drawing on the causation literature to explore systematic connections between grounding and metaphysical dependence counterfactuals, and I outline a non-reductive counterfactual theory of grounding along interventionist lines.

"This fine collection of essays from a diverse group of authors expounding on a wide variety of subjects presents a generous sampling of the new philosophy of technology." —Choice "... informative, original, and provocative.... Many of the writers are major players in defining the contested political terrain of cultural, science, and technology studies as well as critical theory and Heidegger studies." —Gerald Doppelt.

The apartheid ideology in South Africa had a pervasive influence on all levels of education including medical undergraduate training. The role of the health sector in human rights abuses during the apartheid era was highlighted in 1997 during the Truth and Reconciliation Commission hearings. The Health Professions Council of South Africa subsequently realised the importance of medical ethics education and encouraged the introduction of such teaching in all medical schools in the country. Curricular reform at the University of Stellenbosch in (...) 1999 presented an unparalleled opportunity to formally introduce ethics teaching to undergraduate students. This paper outlines the introduction of a medical ethics programme at the Faculty of Health Sciences from 2003 to 2006, with special emphasis on the challenges encountered. It remains one of the most comprehensive undergraduate medical ethics programmes in South Africa. However, there is scope for expanding the curricular time allocated to medical ethics. Integrating the curriculum both horizontally and vertically is imperative. Implementing a core curriculum for all medical schools in South Africa would significantly enhance the goals of medical education in the country. (shrink)

BackgroundThe use of a Community Advisory Board is one method of ensuring community engagement in community based research. To identify the process used to constitute CABs in Zambia, this paper draws on the perspectives of both research team members and CAB members from research groups who used CABs in Lusaka. Enabling and restricting factors impacting on the functioning of the CAB were identified.MethodsAll studies approved by the University of Zambia Bioethics Research Committee from 2008 – 2012 were reviewed to identify (...) those studies that were likely to include a CAB. Eight teams with studies that included a CAB were identified. For each of these studies, consent was obtained to conduct an informal interview with a research team member and to obtain contact details for one CAB member. In total 14 interviews were conducted with 8 research team members and 6 CAB members from 12–30 August 2013.ResultsIdentification of potential CAB members from the community and their participation in developing the terms of reference for CABs was perceived to have contributed to the success of the CAB. Due to the trust that the community had in members of their community the CABs were then in a stronger position to influence community participation in the research. Training of CAB members was identified as a factor that enhanced the functioning of a CAB. Lack of commitment and low literacy levels of CAB members posed a threat to the role of the CAB. Although compensation in the form of a stipend was not provided, CAB members were provided with transport reimbursements for attending meetings.ConclusionsSelection of CAB members from within the community contributed to community confidence in the CAB, enhancing its ability to act as an effective link between study team and community. This contributed positively to the conduct of the study and enhanced community awareness and acceptance of the research. However, establishment of study specific CABs has the potential to compromise CAB independence due to support provided by the research team in the form of transport reimbursements and other forms of support. Consideration should be given to establishing community wide Community Advisory Boards that could function across a range of studies to increase independent objective decision-making. (shrink)

Consent processes for clinical trials involving HIV prevention research have generated considerable debate globally over the past three decades. HIV cure/eradication research is scientifically more complex and consequently, consent processes for clinical trials in this field are likely to pose a significant challenge. Given that research efforts are now moving toward HIV eradication, stakeholder engagement to inform appropriate ethics oversight of such research is timely. This study sought to establish the perspectives of a wide range of stakeholders in HIV treatment (...) and research to inform consent processes for cure research. In total, 68 South African stakeholders participated in two qualitative research modalities. In-depth interviews were conducted with a purposive sample of 42 individuals - audiotaped with consent. Twenty-six stakeholders participated in three focus group discussions. Thematic analysis of transcribed IDIs and FGDs was conducted. The majority of respondents indicated that there could be unique challenges in HIV cure research requiring special attention. In particular, given the complexity of cure science, translation of concepts into lay language would be critical for potential participants to adequately appreciate risks and benefits in early phase research with experimental interventions. Furthermore, to aid understanding of risks and benefits against a background of desperation for a cure, specially trained facilitators would be required to assist with a psychological assessment prior to consent to avoid curative misconceptions. Long-term participant engagement to assess durability of a cure would mean that the consent process would be prolonged, necessitating annual re-consent. Building trust to maintain such long-term relationships would be critical to retain study participants. Unique consent requirements for cure research in South Africa would include significant efforts to maximise understanding of trial procedures, risks and the need for long-term follow-up. However, the psychological dimension of cure must not be underestimated. Beyond an understanding of cure science, the emotional impact of HIV cure advances the discourse from cure to healing. Consequently, the consent process for cure research would need to be enhanced to include psychological support and counselling. This has several important implications for research ethics review requirements for consent in HIV cure research. (shrink)

Trial participation in the proposed HIV Vaccine Trials in South Africa is discussed in the context of the ethical tension that exists between international ethical research standards and local standards of care and cultural norms in the Third World. The important concepts of informed consent, risk-benefit ratio and fair treatment of trial participants are interpreted differently in traditional, rural African communities, where a moderate form of communitarianism referred to as "Ubuntu" or "communalism" is still prevalent. Research is an altruistic endeavor (...) that benefits communities and societies as a result of risks taken by individuals. Universal ethical guidelines that are highly individualistic and fail to emphasize communalism may represent serious problems for the sort of research needed in Africa today. (shrink)

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. (shrink)

This paper outlines a non-reductive counterfactual account of grounding along interventionist lines, and uses the account to argue that taking grounding seriously requires ascribing non-trivial truth-conditions to a range of counterpossible counterfactuals. This result allows for a diagnosis of a route to scepticism about grounding, as deriving at least in part from scepticism about non-trivial counterpossible truth and falsity.

Alastair Norcross argues that the basic judgments of morality are essentially comparative: alternatives are judged to be better or worse than each other. Notions such as right and wrong are not part of the fundamental subject matter of moral theory, but are constructed in a context-relative fashion out of the basic comparative judgments.

The article offers a critical analysis of the cognitive science of religion (CSR) as applied to new and quasi-religious movements, and uncovers implicit conceptual and theoretical commitments of the approach. A discussion of CSR’s application to new religious movement (NRM) case studies (charismatic leadership, paradise representations, Aḥmadiyya, and the International Society for Krishna Consciousness) identifies concerns about the theorized relationship between CSR and wider socio-cultural factors, and proposals for CSR’s implication in wider processes are discussed. The main discussion analyses three (...) themes in recent work relating CSR to religious and religion-like activities that extend and reframe the model. These include (1) identification of distinctive and accessible cognitive pathways associated with new forms of religious belief and practice (in particular in ‘New Age’ movements), (2) application of CSR to movements and practices outside traditional definitions of religion (near death experiences, conspiracy theories, virtual reality), and (3) engaging CSR in wider cultural processes and negotiations (religion in healthcare settings, and the definition of the study of esoteric religious traditions within academic domains). The conclusion identifies two particular findings: (1) that application of CSR in these areas renders underlying cognitive processes more available to scrutiny and (2) that CSR is employed to identify and enlarge the category of religion. The conclusion suggests that the study of CSR in its application to NRMs and quasi-religion identifies a wide field of common and overlapping themes and interests in which CSR is a more active operand than is commonly assumed. (shrink)

By the 1880s it had become clear that the intellectual tide in Britain was turning against the idea of a minimal state. Under the influence of the New Idealists, the Liberal Party, once the champion of individual liberty, had changed into an organ for interventionist legislation. Challenging this movement was an assortment of anti-collectivists including Old Liberals, Tories, and radical individualists. Spearheading the defence of individualism was the 10th Earl of Wemyss, Francis Wemyss-Charteris-Douglas. Most famous for his role in the (...) formation of the Liberty and Property Defence League, Wemyss worked tirelessly in parliament to obstruct legislation deemed inimical to liberty, as well as to organise a mass educational effort to instruct the public about the errors of collectivist philosophy and policy. This paper examines the role Wemyss played within late Victorian individualism and considers how the melding of traditionalism and individualism provided an intellectual home for libertarianism on the Right. (shrink)

BackgroundBiobanking provides exciting opportunities for research on stored biospecimens. However, these opportunities to advance medical science are fraught with challenges including ethical and legal dilemmas. This study was undertaken to establish perspectives of South African stakeholders on the ethico-legal dimensions of biobanking.MethodsAn in-depth exploratory study was conducted with 25 purposively selected biobankers, clinicians, researchers, postgraduate students in biobanking research, and research ethics committee (REC) members in South Africa. Potential study participants were recruited through known hubs for biobanking in the country, (...) online searches and the snowball sampling technique. A semi-structured face-to-face or Skype interview was arranged. Data was analysed using thematic analysis.ResultsThe emergent themes included: inconsistency in understanding consent models, disconnect between biobank researchers and biosample donors, inadequate processes to support re-consenting minors, inconsistent governance processes for biobanking research; challenges with sample and data sharing, and suboptimal strategies for benefit sharing and return of results. Biobanking practice in general appeared to be inconsistent and fragmented. While the need for consent in research is explicitly outlined in legislative documents, some respondents were unclear on the type of consent model to apply in biosample collection. They also reported inconsistencies in research participants’ understanding of consent. Furthermore, these respondents’ own understanding of consent and consent models were dependent on where they were positioned in biobanking practice (roles occupied). Respondents were unsure about the process to follow to re-consent child participants once the age of majority (≥ 18 years) was reached. It was not surprising that consent was identified as one of the major ethical challenges in biobanking practice. In certain settings, some respondents reported suboptimal governance processes for sample collection. Participants were generally unsure about how to operationalise benefit sharing and how to approach the idea of returning results to research participants and biobank donors.ConclusionThe study findings indicated inconsistencies in stakeholder understanding of ethico-legal considerations related to biobanking in South Africa. A need for ongoing ethics capacity development among stakeholders was identified. Improving understanding of the ethics of biobanking could be facilitated by acknowledging the disconnect created by biosamples in the relationship between biobank researchers and donors. (shrink)

Industrial production imposes geographical, economic and cultural distances between producers and consumers. The concept of constituting 'missing objects' can help shrink these distances by enabling actors to engage in discourses and practices about contexts beyond what is materially present. Since the mid-1990s, food miles have emerged as an example of missing objects, representing the distance that agricultural products travel from the farm to the dining table, and the environmental effects of transportation. I analyse how consumers, farmers, activists, industry and policy-makers (...) in the United States and Europe are building agency in making and using food miles. (shrink)

One of the currently popular dogmata of anti-consequentialism is that consequentialism doesn't respect, recognize, or in some important way account for what is referred to as the The charge is often made, but rarely explained in any detail, much less argued for. In this paper I explain what I take to be the most plausible interpretation of the separateness of persons charge. I argue that the charge itself can be deconstructed into at least two further objections to consequentialist theories. These (...) objections amount to (i) the rejection of axiological aggregation, and (ii) the rejection of deontic aggregation. Of these two objections, I argue that the first one, though often made, is untenable. I also argue that the second objection, in its various forms, relies on distinctions whose moral significance is vigorously denied by almost all consequentialist theorists. I thus argue that the separateness of persons objection poses no special threat to consequentialism. (shrink)

One property of the emulator framework presented by Grush is that imagery operates off-line. Contrary to this viewpoint, we present evidence showing that mental rotation of a simple figure modulates low-level features of drawing articulation. This effect is dependent upon the type of rotation, suggesting a more integrative online role for imagery than proposed by the target article.

First published in 2002. Routledge is an imprint of Taylor & Francis, an informa company.

This article examines an omission in the study of discretionary time that bears on proposals currently being evaluated in this part of political philosophy. Specifically, this is the tendency in many jobs for work time to bleed into what is meant to be protected or discretionary time. I refer to this phenomenon as the relative proximity of labour and capital, which has become more prevalent in the labour market due to increased use of mobile communications technology. Ignored by the literature (...) is the fact that whether a job exhibits a high degree of proximity of labour and capital will influence workers' access to their discretionary time entitlements, including policies such as workplace flexibility and the four-day week. To account for this, I provide a descriptive and normative account of the proximity of labour and capital, in response to which I propose a remedial policy that provides workers with greater autonomy over how and when they take up their discretionary time entitlements. (shrink)

Distinctions in fundamentality between different levels of description are central to the viability of contemporary decoherence-based Everettian quantum mechanics (EQM). This approach to quantum theory characteristically combines a determinate fundamental reality (one universal wave function) with an indeterminate emergent reality (multiple decoherent worlds). In this chapter I explore how the Everettian appeal to fundamentality and emergence can be understood within existing metaphysical frameworks, identify grounding and concept fundamentality as promising theoretical tools, and use them to characterize a system of explanatory (...) levels (with associated laws of nature) for EQM. This Everettian level structure encompasses and extends the ‘classical’ levels structure. The ‘classical’ levels of physics, chemistry, biology, etc. are recovered, but they are emergent in character and potentially variable across Everett worlds. EQM invokes an additional fundamental level, not present in the classical levels picture, and a novel potential role for self-location in interlevel metaphysics. When given a modal realist interpretation, EQM also makes trouble for supervenience-based approaches to levels. (shrink)

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. (shrink)