Personal View The importance of getting the ethics right in a pandemic treaty G Owen Schaefer, Caesar A Atuire, Sharon Kaur, Michael Parker, Govind Persad, Maxwell J Smith, Ross Upshur, Ezekiel Emanuel The COVID-19 pandemic revealed numerous weaknesses in pandemic preparedness and response, including Lancet Infect Dis 2023 underfunding, inadequate surveillance, and inequitable distribution of countermeasures. To overcome these Published Online weaknesses for future pandemics, WHO released a zero draft of a pandemic treaty in February, 2023, and July 5, 2023 subsequently a revised bureau’s text in May, 2023. COVID-19 made clear that pandemic prevention, preparedness, https://doi.org/10.1016/ S1473-3099(23)00364-X and response reflect choices and value judgements. These decisions are therefore not a purely scientific or technical Centre for Biomedical Ethics, exercise, but are fundamentally grounded in ethics. The latest treaty draft reflects these ethical considerations by Yong Loo Lin School of including a section entitled Guiding Principles and Approaches. Most of these principles are ethical—they establish Medicine, National University core values that undergird the treaty. Unfortunately, the treaty draft’s set of principles are numer ous, overlapping, of Singapore, Singapore and show inadequate coherence and consistency. We propose two improvements to this section of the draft pandemic (G O Schaefer DPhil); Nufflield Department of Medicine treaty. First, key guiding ethical principles should be clearer and more precise than they currently are. Second, the (C A Atuire PhD) and The Ethox link between ethical principles and policy implementation should be clearly established and define boundaries on Centre and the Pandemic acceptable interpretation, ensuring that signatories abide by these principles. Sciences Institute (M Parker PhD), University of Background Oxford, Oxford, UK; Pandemic prevention, preparedness, and response Department of Philosophy and Experts estimate a roughly 50% chance of another reflect choices and value judgements. While these Classics, University of Ghana, pandemic in the next 25 years.1 Before the next decisions must take into account scientific, technical, Accra, Ghana (C A Atuire); pandemic, the world must remedy the weaknesses logistical, and other non-normative considerations, they Faculty of Law, Universiti Malaya, Kuala Lumpur, COVID-19 revealed in global preparedness for, and in are fun damentally grounded in ethics.6 To say that the Malaysia (S Kaur PhD); response to, a pandemic. These weaknesses include the global community fell short with previous pandemics is University of Denver Sturm underfunding of pandemic preparedness, inadequate to identify an ethical failure to live up to our obligations College of Law, Denver, CO, disease surveillance, initially slow response to an to protect the interests, wellbeing, and rights of our USA (G Persad PhD); School of Health Studies, Western emerging pandemic, early challenges in procuring fellow human beings.7,8 UN Secretary-General António University, London, ON, personal protective equipment, inequitable distribution Guterres has called COVID-19 vaccine inequity “the Canada (M J Smith PhD); Dalla of counter measures (especially vaccines), and frag- biggest moral failure of our times”.9 Accepting that past Lana School of Public Health, mented global response.2 shortcomings reflect ethical failures, the prospect of University of Toronto, Toronto, ON, Canada (R Upshur MD); To address these problems and fundamentally improving future approaches to pandemics should be Department of Medical Ethics reorganise pandemic prevention, preparedness, and informed by ethics to ensure their success. The bureau’s and Health Policy, Perelman response, the World Health Assembly passed a text reflects this need for an ethical viewpoint by School of Medicine, University resolution in 2021 to begin negotiations for an including Article 3 entitled Guiding Principles And of Pennsylvania, Philadelphia, PA, USA (E Emanuel MD) international pandemic instrument.3 After a series of Approaches that is meant to guide its implementation. Correspondence to: intensive deliberations among member states and other Most of these principles are ethical—they establish core Dr Ezekiel Emanuel, Department stakeholders, WHO released a so-called zero draft of its values that animate the treaty. Moreover, the treaty’s of Medical Ethics and Health pandemic treaty in February, 2023.4 A revised bureau’s main public health provisions, such as equitable access Policy, Perelman School of text was subsequently released in May, 2023, which and sharing of resources and interventions, are shaped Medicine, University of Pennsylvania, Philadelphia, moderated several provisions and provided a series of by ethical considerations such as equity and human PA 19104, USA options for treaty language.5 The treaty is expected to go wellbeing. zemanuel@upenn.edu through further amendments and redrafts before it is Given the political forces that might affect countries’ finalised. willingness to sign a pandemic treaty or faithfully Unless otherwise specified, references in this Personal conduct its provisions, adequate articulation of ethical View to treaty content will be to this latest bureau’s text. principles cannot guarantee the treaty’s success. This treaty sets out specific, legally binding obligations Nevertheless, centring ethics in a pandemic preparedness intended to address the substantial failures the COVID-19 treaty is crucial. Political positions themselves are response revealed. Among various options, the bureau’s grounded in ethical values or views, which includes the text draft of the treaty proposes: a global pandemic supply drive to promote national interests that might sometimes and logistics network chain; intellectual property waivers be in tension with global cooperation. Articulating for pandemic-related products; knowledge-sharing and parties’ responsibilities in a legally binding document research cooperation; centralised pathogen collection provides a source of mutually recognised obligations and and sharing; sharing of a portion of pandemic-related not just rules of conduct.10 Where the treaty leaves room products as they are manufactured; global funding for for discretion and interpretation, parties to the treaty are pandemic preparedness and response; and coordinating bound to take into account the explicitly delineated treaty provisions under WHO. ethical principles in implementing treaty provisions. www.thelancet.com/infection Published online July 5, 2023 https://doi.org/10.1016/S1473-3099(23)00364-X 1 Personal View Public justifications and accountability for said policies Missing key principles can in turn appeal to these principles. And although the Despite the treaty’s stated objectives to prevent pand emics, treaty has inadequate enforcement mechanisms, save lives, reduce disease burden, and protect livelihoods,5 delineation of underlying ethical principles establishes a none of the 12 principles in the bureau’s text (nor the shared, explicit international standard for countries’ 18 principles in the previous zero draft) explicitly captures obligations, which can be leveraged to exert pressure if wellbeing. Although principles such as proportionality or parties do not abide by the treaty. Like the ideal of human respecting human rights might indirectly reflect an rights, over time these principles can become recognised underlying concern for maximising benefits and as canonical. minimising harms, this concern obscures and, as a result, However, the treaty’s set of principles are numerous, downplays the centrality of this concern in motivating and overlapping, and lack coherence and consistency, in a justifying various treaty provisions. Preventing harm and way that could lead to a biased selection of ethical promoting benefits should be underscored as a fun- principles. As such, the treaty principles are unlikely to damental ethical value and commitment, not left implicit be effective. Consequently, we propose two improve- or viewed as a consideration outside ethics. ments to this pandemic treaty. First, key guiding ethical Similarly, an explicit principle of sustainability is principles should be clearer and more precise. Second, absent. Sustainability involves ensuring that short- the link between ethical principles and policy imple- term pandemic preparedness and response builds a mentation should be clearly established and define foundation for enhanced responses to future pandemics, boundaries on acceptable interpretation, ensuring that rather than sacrificing the future to the present (or vice signatories cannot simply do whatever they want. versa).15 Sustainability relates to steady and reliable funding mechanisms to support treaty provisions, Better delineating core principles policies around intellectual property that could affect The precision and clarity of the current draft can be incentives to produce countermeasures, and the improved in three ways: streamlining the number of importance of conducting research during pandemics to principles; adding important, overarching principles; ensure an evidence base for future emergencies, as well and distinguishing substantive from procedural as the long-term viability of new systems of research, principles. development, and production envisaged by the treaty. Streamlining principles Distinguishing substantive and procedural principles The latest bureau’s text reduced the number of principles The treaty should distinguish substantive and procedural from 18 contained in the zero draft to 12 in the current principles. Substantive principles relate to questions version that, taken together, should guide parties to asking what is the right decision or optimal outcome. achieve the treaty’s objectives and implement its Procedural principles relate to processes and how should provisions. This streamlining is a step in the right signatories make decisions. Procedural principles direction, but could be taken further. Not all enumerated determine the mechanisms for applying and enforcing principles are ethical in nature, which might cause substantive principles. Although some principles might confusion in terms of how to consistently apply the address both substantive and procedural matters, principles. Other WHO documents better exemplify identifying principles’ primary category can help clarify parsimony, including the WHO Guidance For their function in decision making. Managing Ethical Issues in Infectious Disease Outbreaks For example, equity is primarily a substantive principle, (seven principles),11 the Ethical Framework For WHO’S as are its dimensions, such as non-discrimination and Work in the Act-Accelerator (seven principles),12 and the not compounding unfair disparities. Engagement and WHO SAGE Values Framework for the Allocation and accountability are procedural principles. Determining Prioritization Of COVID-19 Vaccination (six principles).13,14 what is ethically appropriate in pandemic response—for To further streamline the principles for ease of instance, identifying the goals vaccine prioritisation application, some principles could be removed and should aim to achieve—should make reference to overlapping principles could be merged. For instance, substantive principles. But an answer to the question of the central role of WHO is a concrete treaty provision how the international community should balance the that can be ethically justified based on accountability importance of relevant substantive principles, and then and other principles, rather than being an ethical disseminate and implement their implications should be principle in itself. Similarly, the option in the bureau’s guided by and make reference to procedural principles. text of removing the principle of One Health should be exercised given the principle’s narrow scope, and that The grounding role of human rights and the ethical thrust of accounting for empirical facts sovereignty about zoonotic pathogen origins can be captured by Human rights and sovereignty should be understood as appeal to the separate, broader principle of science and foundational values that underpin the treaty rather than evidence. guiding ethical principles. 2 www.thelancet.com/infection Published online July 5, 2023 https://doi.org/10.1016/S1473-3099(23)00364-X Personal View Definition Illustrative treaty provision reflecting the principle Substantive principles Maximise benefits and Protect and promote human wellbeing, including physical and mental health, social and Article 13 (supply chain and logistics), with an option to establish a minimise harms economic security, human rights, and child development, while minimising the harmful global supply chain network to improve efficiency of pandemic response effects of policies (whether direct or indirect, health-related or not) Equity Ensure fair deployment of pandemic prevention, preparedness, and response globally and Article 12 (access and benefit sharing), with an option for a scheme for within countries, prioritising those disadvantaged due to biological, social, or other factors; global sharing of countermeasures during a pandemic honouring obligations while avoiding unjust discrimination, compounding disadvantage, or exploitation of vulnerable parties Global solidarity Act in a manner that acknowledges countries’ international responsibility and Article 15 (international collaboration and cooperation), supports joint interdependence, and that countries’ interests are dependent on effective coordination of and unified global efforts for pandemic preparedness, prevention, pandemic prevention, preparedness, and response and response Sustainability Ensure that emergency responses that are appealing for the immediate problem do not Article 19 (financing), delineates funding expectations to sustain treaty imperil future responses, preparation for the next pandemic, or responding with research, provisions development, and manufacturing to subsequent pandemics Procedural principles Accountability Make decisions with clearly defined objectives, targets, processes, roles, and Article 20 (conference of the parties), assigns and details governance and responsibilities, supported by enforcement mechanisms to enable decision makers to be responsibility for treaty implementation to a new entity housed under held to account and mitigate conflicts of interest the World Health Assembly Transparency Publicly communicate the underlying rationale (including relevant risks and benefits), Article 9 (research and development), promotes open global sharing of decision-making processes, and decisions related to pandemic prevention, preparedness, knowledge and expertise from pandemic research and development and response in an honest, straightforward manner, made available for public review Engagement Make decisions with the opportunity for input from relevant stakeholders such as civil Article 22 (implementation and compliance committee), delineates the society and community organisations, to the extent practicable and appropriate for a given role of signatories as well as other parties for inputs into treaty context implementation Science and evidence- Ensure decisions and policies are informed by the best available science and that they Article 18 (pandemic prevention and public health surveillance), informed decisions evolve in response to changing information delineates importance of information gathering via surveillance in pandemic prevention Table: Substantive and procedural ethical principles and the illustrative treaty provisions that discuss them Human rights is needed. The treaty’s obligations flow from signatories’ States have already signed human rights treaties and so sovereign decision to sign and ratify the treaty. the obligations they entail do not need to be included as a There might be some pragmatic value in going beyond guiding principle. Instead, the pandemic treaty should be the requirements of sovereignty and signalling to interpreted and implemented in light of existing human potential signatories that the treaty will not unduly rights obligations. That being said, the breadth and interfere with individual countries’ decision making.19 universal applicability of human rights treaties means However, this value should be weighed against the fact they cannot definitively resolve more crucial and nuanced that signatories might not treat the mandatory provisions pandemic policy questions. Indeed, the bureau’s text as genuinely mandatory. This risk is compounded by makes scant, explicit reference to human rights after inadequate enforcement mechanisms for treaty introducing them as a purportedly guiding principle. violations, a source of ongoing concern among obser- Rather than a policy objective or a framework for vers,20 as well as the bureau’s text weakening the interpreting specific treaty provisions, human rights are prescriptiveness of various provisions compared with the better seen as a set of commitments that might inform the previous zero draft.4,5 content and formulation of key principles,16 and motivate A principle of sovereignty also risks conflation with the the importance of their implementation within the treaty.17 related but distinct notions of nationalism and countries For instance, human rights to health and wellbeing can prioritising the interests of their own people. We will ground the principle of maximising benefits and separately discuss the implications of national priority in minimising harms, and various human rights to fair and the context of the treaty’s countermeasure allocation equal treatment support the principle of equity. model, which might be seen as a constraint or limitation on the realisation of the treaty’s ethical principles rather Sovereignty than a principle itself. Like human rights, national sovereignty is an established political and legal norm that already binds countries, Refining the principles irrespective of any provisions of the treaty.18 Furthermore, To help refine the principles, we propose four substantive the inclusion of sovereignty as a guiding principle seems and four procedural principles as a consistent and tautologous. The signatories are states, hence the treaty coherent framework to implement to form a global recognises the sovereignty of states. No separate principle pandemic treaty (table). The proposed list encompasses www.thelancet.com/infection Published online July 5, 2023 https://doi.org/10.1016/S1473-3099(23)00364-X 3 Personal View widely shared values that are generally acceptable both Only afterwards would allocation consider countries’ internationally and cross-culturally.12,13,21 Several of our disparate COVID-19 health burden.22 proposed definitions draw on existing WHO guidance, In Article 12 option 6(c).X, the bureau’s text indicates particularly the Ethical Framework for WHO’s Work in the that a new WHO network should allocate vaccines and ACT-Accelerator.12 The careful review and revision of the other countermeasures equitably according to public Ethical Framework document by WHO supports these health risk and need. This provision (justifiably) rejects definitions within this international treaty, especially distribution purely based on population.23,24 However, an given WHO’s prominent role in treaty governance. alternative option 6(c).Z implies distribution should simply be to low-income and middle-income countries, Applying the principles to develop specific while option 6(c).Y makes no mention of distributive policies standards. Ethical principles should be applied to the treaty’s Both the principle of maximising benefits and provisions in two ways. First, the principles could outline minimising harms, as well as the principle of equity, the justifications for different treaty provisions and support allocating scarce medical resources on the basis options. The treaty will legally bind signatories who will of health risks (found in option 6(c).X, as well as in in turn adopt policies that apply to their citizens and Article 13’s discussion of distribution of pandemic-related residents. As such, some justification for the treaty’s products). In the context of a pandemic, countries facing provisions is necessary. Articulating the principles that the greatest health risk likely stand to benefit the most underlie any given article clearly, transparently, and from receiving a given countermeasure, such as vaccines.25 accessibly conveys that justification, and facilitates Such allocation also promotes equity by allocating based ethically informed deliberation over which options to on the ethically relevant criteria of health risk as opposed retain during negotiations. Such articulation would to ethically irrelevant criteria such as purchasing power or mean not merely listing principles relevant to a given population, allowing those who would otherwise be worst treaty provision, but explaining how those principles off to benefit.24 Furthermore, maximising benefits and motivate or justify the provision. minimising harms means that the allocation should Second, the principles provide an ethical framework for consider relevant benefits and risks broadly, reflecting not the application of treaty provisions. Although some just risks from the circulating pathogen but also other, provisions are highly directive, such as Article 26 on the indirect health risks caused by the pandemic or health role of WHO Secretariat, others allow considerable emergency, such as postponement of other immunisations discretion (eg, Article 9 on research and development or reduced health system capacity. capacity). The proposed principles might identify relevant value trade-offs required when interpreting and applying Contributing to a common pool of funds and increasing the treaty’s provisions. Additionally, revealing how global manufacturing capacity principles were evaluated and which ones were decisive The international response to COVID-19 was plagued by in determining a given policy facilitates accountability. inequitable distribution of effective countermeasures, Such value adjudication is commonplace for all policy particularly the initial distribution of vaccines. making. A universal list of principles provides a common According to various estimates, well over a million set of standards that everyone shares, which can be deaths from COVID-19 by the end of 2021 could have appealed to for justification of particular decisions. been prevented by more widespread vaccine distribution For illustrative purposes, we elucidate how the revised and administration.26,27 principles inform the deliberations around four crucial The treaty strives to mitigate this inequity by ensuring policies in the draft treaty and might favour imple- that those who receive pathogen samples and genomic menting certain options found in the bureau’s text over sequences share their pandemic countermeasures. others. This elucidation is not meant to be model text Article 12 option 12.B proposes the WHO pathogen for direct inclusion in the treaty, but indicative of the access and benefit-sharing system (PABS), a network of ways in which principles can be integrated into the WHO-coordinated laboratories to which signatories treaty’s text. must send pandemic-potential pathogen samples. PABS then facilitates sharing of those samples with the global The allocation of scarce vaccines and other medical community. Furthermore, option 6(c).X proposes that countermeasures any manufacturer whose products relied on accessing During the COVID-19 pandemic, the COVID-19 Vaccines PABS samples or sequences must sign a standard Global Access initiative proposed allocating scarce material transfer agreement (MTA) that requires “real- vaccines primarily based on country population.22 Each time access by WHO to 20% of the production of safe, country would first receive sufficient vaccines for 3% of efficacious, and effective pandemic-related products”, its population, intended primarily for health-care workers such as tests and vaccines. Because this MTA must be and other front-line workers. Subsequently, each country signed by any recipient regardless of whether they are (or would receive sufficient vaccine for 20% of its population. reside in) a treaty signatory, PABS facilitates the 4 www.thelancet.com/infection Published online July 5, 2023 https://doi.org/10.1016/S1473-3099(23)00364-X Personal View enforcement of pandemic countermeasures even against principles of equity and maximising benefits and non-signatories. minimising harms. PABS can best be understood as a pragmatic The ethical principles also illuminate a gap in the mechanism to advance key ethical principles of equity, PABS arrangement. Sharing obligations should go global solidarity, and maximising benefits and beyond samples, sequences, and pandemic counter- minimising harms. These principles often align during measures. The principle of maximising benefits and pandemic response. For example, more widespread minimising harms supports sharing any information distribution of COVID-19 vaccines would have or products that can reduce harms from pandemics, minimised harms by saving a million or more lives such as data related to surveillance or vaccine around the world.26 Negotiating parties should consider effectiveness.31,32 to what extent this mechanism requires more fine- tuning, as loopholes could undermine the ability of the Intellectual property and a sustainable pandemic mechanism to realise the key ethical principles. For response instance, the treaty could prohibit countries concurrently In Article 7 option 11.A paragraph 5(a), the bureau’s text sending samples or sequences to a non-PABS repository calls for suspension of intellectual property during an that would not require recipients to sign the PABS MTA. emergency: the parties will “support time-bound waivers PABS thus permits countries receiving samples to of intellectual property rights that can accelerate or scale retain no more than 80% of domestic production of a up manufacturing of pandemic related products during a countermeasure. Some might see PABS as excessively pandemic, to the extent necessary to increase the restrictive of legitimate national priority. For instance, availability and adequacy of affordable” products. An India completely stopped COVID-19 vaccine exports alternative option put forward is to make no mention of when its own cases spiked in 2021.28 PABS would have time-bound waivers. required India to share 20% of its vaccine production Whether suspending intellectual property rights would regardless. This option’s approach balances equity, global promote scaled-up manufacturing of affordable vaccines solidarity, and maximising benefits and minimising and other countermeasures is an empirical question that harms and legitimate national priority. Undoubtedly, can be expected to have different answers in different countries have sound ethical reasons to give some pandemics.33,34 But if intellectual property suspension priority to their own residents in pandemic response.23,29 would improve short-term response to a particular Citizens must rely on their own government to ensure pandemic, policy makers would then face a tension their wellbeing. Consequently, governments have an between short-term human wellbeing, equity, and obligation to prioritise meeting the needs of their solidarity, and the long-term sustainability of incentives citizens. to respond to future pandemics. But this national priority is neither absolute nor Current laws do not require pharmaceutical unlimited.30 The interests of individuals beyond one’s companies to invest in preparing for and combating a borders are ethically relevant, and give rise to obligations future pandemic. Indeed, during COVID-19, some to those individuals in virtue of their humanity. Finding a pharma ceutical companies did not rush to develop balance between obligations to one’s own citizens and vaccines and other countermeasures.35 Absent public obligations to the world is a difficult task. But it is investment in countermeasures required financially possible to rule out extremes. Countries might not incentivising companies to devote their intellectual, simply prioritise all their citizens, including those at low financial, and manufacturing resources to preparing risk, before helping any people in other countries. Such for and conducting research, as well as developing and an approach would undermine the principles of producing counterm easures. Intellectual property is solidarity, maximising global benefit, and equity. one such incentive, and is currently the most common; A commitment to set aside a proportion of products for however, other options such as prize systems are being international distribution as they are produced sets a proposed for the development of new antibiotics.36 The reasonable limit on national priority, and so options 12.B principles require a careful balancing of the immediate and 6(c).X should be exercised. These options still allow response to maintain sustainability versus a long-term the vast majority of supply to be dedicated domestically, response to inevitable future pandemics. On balance, it reflecting countries’ legitimate prioritisation of their own is by no means clear if suspending intellectual property people’s interests, while at the same time providing a rights will sustainably maximise benefits and minimise meaningful and steady supply of products to the global harms. Any decision to uphold waiver language community. The precise 20% level itself, however, cannot found in option 11.A needs to be publicly justified and be directly derived from the ethical principles, nor from shared. foundational values such as sovereignty or human rights. Additionally, efforts to regulate firms’ conduct should It remains to be seen whether the precise 20% number not focus solely on intellectual property. Although there is survives international negotiation, but some meaningful little evidence that intellectual property formed a distri bution across borders is essential to fulfil the meaningful barrier to COVID-19 response,37 advance www.thelancet.com/infection Published online July 5, 2023 https://doi.org/10.1016/S1473-3099(23)00364-X 5 Personal View purchase agreements clearly did, by directing most initial Conclusion supply to wealthy countries.38 An international treaty can These suggestions do not exhaust the ways that ethical and should regulate advance purchase agreements to principles inform and justify various treaty provisions ensure that at least some supply is distributed on the basis and their interpretation. Procedural principles of of equity and maximising benefits and minimising harms. transparency, accountability, and engagement underlie Solidarity as well as equity would also counsel in favour of the treaty’s move to centre WHO in coordinating and self-restraint and moderation by countries able to pre- carrying out various treaty provisions, and as an entity purchase all supplies, when pre-purchase will preclude with a clear governance structure that can be held access for low-income countries who lack financial muscle accountable for decisions made at the global level. to engage in advance purchasing agreements. WHO itself is ultimately answerable to the global community, since it is a UN agency and can thereby be Funding mechanisms subject to reformation through action by member In Article 19, the bureau’s text seeks to ensure states. Furthermore, maximising benefits and mini- sustainable financing for pandemic prevention, mising harms requires embedding learning, research, preparedness, and response. These provisions are and evaluation into pandemic preparedness and arguably essential to ensure that PABS and other treaty response as reflected in the latest draft’s Article 9. Such initiatives are successful. As the COVID-19 pandemic embedded learning does not only involve formal showed, equity and maximising benefits and mini- clinical trials. Learning should recognise and value the mising harms require more than just supplies of agency of low-income countries in generating real- countermeasures. Logistics, transportation, and admini- world solutions to pandemic challenges that go beyond stration also involve substantial costs. merely transferring knowledge from high-income The bureau’s text removed concrete, static commit- countries to low-income ones.39 ments for both domestic funding (as a percentage of Deliberation and discussion of all provisions as the budgets) and international funding (as a percentage of treaty is amended and refined can be informed by gross domestic product [GDP]) found in the zero draft. keeping those ethical principles firmly in view. The In some ways, this amendment was ethically principles can also help illuminate gaps within the treaty. justifiable. The so-called flat nature of the zero draft’s For example, preventing pandemics from emerging in percentages raises concerns about equity and the first place would be the most effective ways to maximising benefits and minimising harms. Specific promote equity and maximising benefits and minimising targets for domestic spending will only make a harms. Yet the treaty overlooks ethical questions around difference if they alter practices in at least some outbreak suppression and early warning mechanisms countries. Binding decision makers to alter domestic such as surveillance. Such questions implicate values of spending allocations based on an arbitrary cutoff found privacy, liberty, and tensions between the data sharing in the zero draft risks directing health resources away needs of global health security and the economic and from where they are needed most. other interests of states.40 Similarly, the zero draft provisions on international Effective pandemic preparedness, prevention, and funding could operate as a global tax for pandemic response requires identifying and addressing ethical funding. Such a flat tax would be inequitable because issues both in advance and in real time, as well as redirecting, for example, 1% of GDP to WHO is a acknowledging that the availability of even high quality, substantially greater burden for low-income countries timely, and accurate information and data to policy than high-income countries. To promote equity, this makers does not always answer the question of what to provision would need to be revised to become a progressive do. Value judgements are central to all decision making tax that is sensitive to a country’s ability to pay, rather than and they need to be made in ways that are reflected in a flat tax that will disproportionately burden the worst-off. widely shared principles, engage seriously with relevant However, the bureau’s text did not replace the flat diversity of values and commitments, and are carefully funding mechanism with a more progressive, equitable considered and justified. model. Instead, the bureau’s text provides no concrete Contributors funding threshold or target at all, referring vaguely to All authors contributed equally to the writing of this Personal View. annual contributions by parties, within their respective Declaration of interests means and resources. This amount of discretion risks The views expressed in this Personal View are solely those of the authors substantially underfunding the pandemic treaty, in turn and do not reflect the positions of WHO or any other entities with which endangering its financial sustainability and ability to the authors are affiliated. GOS is a rapporteur for the COVID-19 Ethics and Governance Working Group and was a special rapporteur for the Act maximise benefits and minimise harms. To realise the Accelerator Ethics & Governance Working Group. CAA is a member of treaty’s principles, future iterations of the treaty should the Access to COVID-19 Tools Accelerator Working Group. CAA has also revisit concrete financing targets with an eye towards received a grant from Wellcome Trust Discovery Award to conduct equity by setting different targets depending on a research on solidarity in global health and received honoraria for a webinar on cultural competence and psychiatric diagnosis in low-income country’s resource levels. and middle-income settings. SK serves on the WHO Ethics and 6 www.thelancet.com/infection Published online July 5, 2023 https://doi.org/10.1016/S1473-3099(23)00364-X Personal View Governance Working Group. MP was a member of the Ethics Working 5 WHO. Bureau’s text of the WHO convention, agreement or other Group on 2019-nCoV (coronavirus) and is a member of the COVID-19 international instrument on pandemic prevention, preparedness Ethics & Governance Working Group. GP was a consultant for WHO and response (WHO CA+). Geneva: World Health Organization, during early 2020 on a project on pandemic influenza. 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