Received: 19 October 2021 | Revised: 1 December 2021 | Accepted: 16 December 2021

DOI: 10.1111/dewb.12342

ORIGINAL ARTICLE

Global sharing of COVID‐19 vaccines: A duty of justice,

not charity

Nancy S. Jecker

Correspondence
Nancy S. Jecker, PhD, Department of Abstract
Bioethics and Humanities, School of Medicine,
Global scarcity of COVID‐19 vaccines raises ethical questions about their fair allo-
University of Washington, Seattle,
Washington, USA. cation between nations. Section I introduces the question and proposes that wealthy
Email: nsjecker@uw.edu
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 in-
justices that systematically advantaged wealthy countries and disadvantaged poorer
countries, contributing to global disparities of COVID‐19 vaccines. Section IV ex-
amines 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 na-
tions and to restore relationships damaged by injustice. All nations should take steps
to transform unjust structures.

KEYWORDS
Africa, bioethics, ethics, international justice, justice, resource allocation

1 | INTRODUCTION
After witnessing highly effective vaccines against the SARS‐CoV‐2
virus develop at break‐neck speed, the world is now witnessing the
sluggish pace at which globally scarce vaccines are being shared
around the world. As of December 23, 2021, just 8.1% of people in
low‐income countries had received at least one dose of vaccine.1 By
contrast, many wealthy countries have accumulated doses to vacci-
nate their citizens many times over. Canada, for example, pre‐ordered
enough vaccines to inoculate its citizens six times over; the UK and
US enough to do so four times over; in the European Union and
2
Australia, pre‐orders are sufficient to protect each citizen twice.
Many high‐income countries are offering booster shots to healthy
1 4
Our World in Data. (2021, December 22). Coronavirus (COVID‐19) Vaccinations. Retrieved
December 23, 2021, from https://ourworldindata.org/covid-vaccinations
2
Allison, S. (2021, January 30). Bill Gates, Big Pharma and Entrenching the Vaccine
Apartheid. Mail and Guardian.
young citizens, while healthcare workers and other high risk groups in
poorer countries are unprotected,3 ignoring an appeal by the
Director‐General of the World Health Organization (WHO) to delay
booster shots until 10% of people in every nation receive first shots.4
From a humanitarian standpoint this lopsided state of affairs is
clearly a disaster. It prolongs the pandemic and increases the human
toll of disease, death, and suffering. Yet this paper argues that lack of
access to COVID‐19 vaccines in poorer countries is not only a hu-
manitarian failure, but deeply unjust. The argument I give in support
of this claim shows that the present‐day allocation comes about
through structural injustices that placed wealthy nations at an
3
Jecker, N.S., & Lederman, Z. (2021). Three for Me and None for You? An Ethical Argument
for Delaying COVID‐19 Boosters. Journal of Medical Ethics, 1‐4. https://doi.org/10.1136/
medethics-2021-107824
World Health Organization. (2021). WHO Director‐General's Opening Remarks at the
Media Briefing on COVID‐19. Retrieved December 1, 2021, from https://www.who.int/
director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-
briefing-on-covid-4-august-2021

Developing World Bioethics. 2022;1–10. wileyonlinelibrary.com/journal/dewb © 2022 John Wiley & Sons Ltd | 1
2 |
advantage and poorer nations at a disadvantage. As beneficiaries of
these unjust systems, wealthy nations incur a duty to relinquish
holdings, in this case vaccines, and restitute poorer nations. All na-
tions have a duty to help create fairer structures. Section II distin-
guishes duties of justice from duties of charity and argues that those
who benefit from structural injustices incur duties of justice to those
made worse off. Section III gives a case‐based argument describing
three upstream examples of injustices that contributed to global
vaccine inequalities: concessionary lending in sub‐Saharan Africa by
the World Bank and International Monetary Fund (IMF); the agree-
ment on Trade‐Related Aspects of Intellectual Property Rights
(TRIPS) enacted by the World Trade Organization (WTO); and
COVAX, the WHO co‐led effort to equitably distribute COVID‐19
vaccines. Section IV examines more closely the duties of justice
owed, including a duty to relinquish holdings, restitute victims, and
restore relationships damaged by injustice. Section V concludes that
wealthier nations have a duty of justice to share COVID‐19 vaccines
and to repair relationships damaged by injustices. All nations should
take steps to transform unjust structures.
2 | D U T I E S O F J U S T I C E AN D C H A R I T Y
Duties of justice are usually marked off from duties of charity by
virtue of four distinguishing features.5 First, they are grounded in
what others are due and can legitimately claim, as opposed to what
would be benevolent but not mandatory to deliver. For this reason,
failing to do what justice requires is generally considered blame-
worthy or a violation of what one owes. Second, duties of justice are
usually regarded as enforceable and non‐elective. In this sense, “we
6
demand justice, but we beg for charity.” Third, duties of justice re-
flect an impartial requirement of morality in which 'like cases are to
be treated alike'. Thus, we do not except ourselves or those we
personally favor from justice standards unless we can show that
there are morally relevant differences that justify this. Lastly, duties
of justice are ordinarily thought to relate to agency and what is within
our power to do or refrain from doing. In the case of structural in-
justices, agency is involved indirectly because we could have avoided
a bad outcome by establishing institutional structures to avert it.
While there are variations in how the justice‐charity distinction is
rendered,7 and some reject the distinction altogether,8 I bracket
these debates and use the fourfold analysis described here as a
working definition.
In the case of COVID‐19 vaccines, to say that making reasonable
efforts to share with people in low‐income countries is a duty of
justice entails (1) that people in low‐income countries can advance a
right or claim to access these vaccines which holds against
5 14
Miller, D. (2021). Justice. In E. N. Zalta (Ed.), Stanford Encyclopedia of Philosophy. Retrieved
December 1, 2021, from https://plato.stanford.edu/archives/fall2021/entries/justice/
6
Ibid.
7
Goodin, R. (2017). Duties of Charity, Duties of Justice. Political Studies, 65(2), 268‐283;
8
Buchanan, A. (1987). Justice and Charity. Ethics, 97(3), 558‐575.
JECKER
governments in other countries; (2) the duty is enforceable and those
who owe it are morally required to meet it; (3) the duty holds irre-
spective of factors considered morally arbitrary, such as ability to pay;
and (4) there is a responsibility to help establish the institutional
structures to realize this duty. Practically speaking, it matters then,
whether making COVID‐19 vaccines available to people in low‐
income countries counts as a duty of justice or not. If it is a duty of
justice, this would show that the charitable giving of governments or
the voluntary offerings of philanthropic groups are not enough to
meet ethical duties to people in low‐income countries. To the extent
that charitable acts postpone or impede attempts to strengthen just
systems, they may in fact do great harm in the long run, even if they
help in the short‐term.
Duties of justice are often thought to arise from people's choices
as free and rational agents. Consent‐based accounts, such as those
associated with Rawls,9 reflect the Kantian tradition, and the general
view that legitimate moral principles are those we choose to impose
upon ourselves as free and rational agents. When obstacles to free
rational choice are pervasive and embedded in background condi-
tions affecting many people and groups systematically, they may
point to injustices that are structural. Kant himself recognized the
problem. Even while Kant emphasized a normative framework fo-
cused on rational choice as a source of moral duty, he suggested in
various writings that people in positions of wealth and privilege are
often ignorant about and may misjudge the many ways in which they
benefit from, and owe recompense for, what he called, “general in-
justices.”10 In Lectures on Ethics Kant states, when people “take pity
on another” they “render back the benefits they have previously
snatched away, though they are not aware of any injustice; the
reason being that they do not rightly examine the matter.”11 On
examination, Kant contends, do‐gooders would frequently find that
they previously partook of a “general injustice” that renders their
present acts of kindness to an unfortunate person, not a “free gift,”
but repayment for what they previously appropriated through a
general injustice.12 Kant judges that in these cases, what appears as
kindness is in truth, “duty and indebtedness, arising from the rights of
others.”13 Elsewhere, Kant comments, “One need only reflect a little
and he will always find a debt that he has by some means incurred
towards the human race.”14 Finally, Kant argues that possessing
ample resources to afford beneficence itself often depends on “cer-
tain human beings being favored through the injustice of the gov-
ernment;” and concludes rhetorically, “Under such circumstances,
does a rich man's help to the needy, on which he so readily prides
9
Rawls, J. (1971). A Theory of Justice. Cambridge, MA: Harvard University Belknap Press.
10
Kant, I. (1997/1784‐1785). Of Duties Towards Other People. In P. Heath & J. B.
Schneewind (Eds.), P. Heath (Transl.), Immanuel Kant, Lectures on Ethics (pp. 177‐182). New
York, NY: Cambridge University Press, p. 179.
11
Ibid: 179.
12
Ibid: 179.
13
Ibid: 179.
Kant, I. (2015/1788). The Critique of Practical Reason. In T. K. Abbott & W. Hastie (Transl.),
The Ethics of Immanuel Kant: Metaphysics of Morals ‐ Philosophy of Law & The Doctrine
of Virtue + The Critique of Practical Reason: Theory of Moral Reasoning + Perpetual
Peace (Kindle locations 5378‐7943). Prague, Czech Republic: e‐artnow ebooks: Kindle
location 7900).
JECKER
himself as something meritorious, really deserve to be called bene-
ficence at all?”15 Kant goes so far as to consider that a tendency
toward benevolence might be implanted in us to rectify a common
epistemic deficiency, namely our failure to know the multitude of
injustices in which we unwittingly partake. While we call such acts
‘beneficence,’ they are not truly acts of beneficence, but payment of
debts owed.
Contemporary scholars also appeal to epistemic deficiency to
support the general claim that wealthy nations have duties to make
amends to poorer nations. For example, Pogge argues wealthy na-
tions owe recompense for harms they inflicted upon the global poor
during the colonial era.16 Waldron refers to the “contagion of in-
justice” to explain interdependencies between domestic and inter-
national parties that make it plausible to say that wealthy nations owe
recompense to poorer ones.17 Others, including Shklar,18 Young,19
and Sangiovanni20 also comment on the more general tendency to
mistake restitution for charity.
A difficulty all such suggestions encounter is that it is challenging
to say exactly what a duty of justice arising in this way requires,
because people may not know who they owe recompense to or even
what exactly they owe recompense for. Waldron sees the difficulty
as wide‐ranging, arguing that it is always possible when attempting to
address a particular injustice to raise the question “why stop there?”
and inquire about other injustices in the vicinity.21 One solution,
which Kant suggests, is treating debts that arise from general in-
justice as if they were duties of beneficence to give back to the least
advantaged members of a group. According to this proposal, even
though duties of recompense are in truth of a more stringent class,
i.e., duties of justice, not charity, we make good on them by bene-
fitting the least well off. Moran characterizes Kant's suggestion
this way:
facts about structural injustice should figure into a
privileged agent's assessment of her various obliga-
tions… Unlike other acts of beneficence…these acts
warrant neither merit nor gratitude…agents should
avoid any hint of self‐congratulations for performing
acts of beneficence in these circumstances. Rather
they should humble themselves in recognition of the
debt they owe…simply to acknowledge the diffuse,
systematic, and entrenched nature of past injustice.22
15
Kant, I. (1996/1797). Metaphysics of Morals. In McGregor, M. (Transl). The Metaphysics of
Morals, Cambridge Texts in the History of Philosophy, (2nd ed.), New York, NY: Cambridge
University Press, p. 454.
16
Pogge, T. W. (2002). World Poverty and Human Rights. New York, NY: Cambridge
University Press.
17
Waldron, J. (1992). Superseding Historic Injustice. Ethics, 103(1), 4‐28.
18
Shklar, N. J. (1992). The Faces of Injustice. New Haven, CT: Yale University Press.
19
Young, I. M. (2011). Responsibility for Justice. New York, NY: Oxford University Press.
20
Sangiovanni, A. (2018). Structural Injustice and Individual Responsibility. Journal of Social
Philosophy, 49(3), 461‐483.
21
Waldron, op. cit. note 17.
22
Moran, K. A. (2016). Neither Justice Nor Charity? Canadian Journal of Philosophy, 47(4),
477‐498.
| 3
What light can these suggestions shed on the unequal access to
COVID‐19 vaccines between rich and poor nations? It suggests that
the duty to share COVID‐19 vaccines qualifies as a duty of justice if
the benefits wealthier nations enjoy are the outcome of general in-
justices. One way this may have occurred is if the upstream processes
and structures that led to unequal distribution were themselves un-
just. The argument can be specified in skeletal form as follows.
The Bare Bones Argument for Vaccine Sharing as a Duty of Justice
1. The Kantian Principle: beneficiaries of general injustices incur
duties of justice toward those disadvantaged by them.
2. The privileged access to vaccines wealthy nations enjoy resulted
from structural injustices that benefitted them while disadvanta-
ging low‐income nations.
3. Then wealthy nations incur a general duty of justice to share
vaccines with people in low‐income nations.
The remainder of the paper will explore this argument in greater
detail. Aside from what has been suggested already, I will not further
examine the Kantian principle (premise 1), but instead assume it is a
plausible principle to hold and focus attention on premises 2 and 3.
Section III will make the case that upstream structures that con-
tributed to COVID‐19 vaccine distribution were unjust in ways that
gave rich nations privileged access to vaccines while giving poor
nations reduced access. Section IV will identify the duty of justice
that follows and what is required to discharge it.
3 | UPSTREAM STRUCTURAL INJUSTICES
Structural injustice exists “when social processes put large groups of
persons under systematic threat of domination or deprivation of
the means to develop and exercise their capacities and, at the same
time … these processes enable others to dominate or to have a wide
range of opportunities for developing and exercising capacities
available to them.”23 This section will argue that the structures that
underlie the global distribution of COVID‐19 vaccines have put
people in low‐income countries under systemic threat of domination
or deprivation in this way. The structures in question can be thought
of in terms of what Buchanan terms, a ‘global basic structure.’24
A global basic structure refers to “a set of economic and political
institutions that has profound and enduring effects on the distribu-
tion of burdens and benefits among peoples and individuals around
the world.”25 It includes, for example, international economic agree-
ments, such as the WTO and North American Free Trade Alliance;
international financial regimes, such as the IMF and World Bank; and
the global system of private property rights, including intellectual
property rights. In the examples below, I pay particular attention to
23
Young, I. M. (2011). Responsibility for Justice. New York, NY: Oxford University
Press, p. 51.
24
Buchanan, A. (2004). Justice, Legitimacy, and Self‐Determination. New York, NY: Oxford
University Press.
25
Ibid: 213.
4 |
Africa, because the continent lags far behind any other region in
vaccination: as of December 22, 2021, Africa had fully vaccinated just
8.6% of its 1.3 billion people. By comparison, rates of vaccination in
Europe were 60%, North America 58%, Asia 55%, and South
America 63%.26
Pre‐pandemic, myriad upstream factors fed present‐day global
vaccine disparities. Three examples serve to illustrate: concessionary
lending programs offered to African nations during the 1980s and
1990s; the 1995 WTO agreement on Trade‐Related Aspects of In-
tellectual Property Rights (TRIPS) that governs patent rights for
COVID‐19 vaccines; and the 2020 formation of COVAX, which
aimed to accelerate development and equitable global distribution of
vaccines.
3.1 | Concessionary lending in sub‐Saharan Africa
The health and social structures prevalent across much of Africa today
trace to the twentieth century, when newly independent African na-
tions were making substantial public sector investments in education,
healthcare, infrastructure and industrialization. During the 1980s and
1990s, these domestic investments were sharply curtailed when the
World Bank and IMF began offering African governments conces-
sionary loans that reshaped their domestic policies. In exchange for
credit, they required governments to implement a package of domestic
reforms prescribed by the IMF and World Bank aimed at promoting
free‐market trade and foreign investment and integrating African na-
tions within dominant structures of global trade, finance and produc-
tion.27 Loans were conditioned on liberalizing trade by eliminating
tariffs, lowering wages and reducing government spending on do-
mestic programs, such as education and healthcare, to ensure African
governments could meet loan repayment schedules. By 1982, 19
African countries had taken IMF loans involving conditionality and 19
had accepted conditional World Bank loans.
While African governments accepted the terms of concessionary
loans, they were disadvantaged in negotiating these terms. As Hodd
notes, control of the IMF and World Bank at the time was in the
hands of wealthy industrialized nations who held the majority of
voting rights. For example, in 1984, 18 wealthy industrial nations held
67.5% of IMF votes, compared with 5.2% of votes held by 43 African
countries.28 In this respect, the terms of loans were not freely chosen
by African nations but instead driven by institutional decisions that
subjected African nations to domination, exploitation, and exclusion.
These historical patterns are reproduced in contemporary social
structures and relations, creating what Lu calls “unpaid debts,”29
26
Our World in Data. (2021). People Fully Vaccinated Per 100 hundred percent. Retrieved
December 23, 2021, from https://ourworldindata.org/grapher/share-people-fully-
vaccinated-covid?tab=table&country=OWID_WRL~Europe~South+America~Asia~North
+America
27
Hodd, M. (1987). Africa, the IMF and the World Bank. African Affairs, 86(344), 331‐342.
28
Ibid.
29
Lu, C. (2017). Justice and Reconciliation in World Politics. New York, NY: Cambridge
University Press, p. 148.
JECKER
referring not to the pecuniary debts of African nations, but the moral
debts incurred by wealthy nations who benefitted. During the
COVID‐19 pandemic, the legacy of concessionary lending policies is
evident. Prior cutbacks in health, education, and infrastructure added
to the region's pandemic challenges related to developing, manu-
facturing, transporting and administering vaccines. The continent not
only has a large unmet need for COVID‐19 vaccines, it also manu-
factures less than 1% of all the vaccines it uses.30 According to Ri-
chardson, an advisor to the African Centres for Disease Control and
Prevention, concessionary lending policies “eviscerated safety nets and
public health infrastructures across the Global South. They privatised
public assets, cut spending on healthcare, food and farm subsidies, and
deregulated trade rules, such that illicit financial flows to the Global
North currently dwarf what is sent to the Global South in ‘aid’.”31
What implications do these concessionary lending practices have
for how we think about the duties of high‐income countries toward
people in low‐income countries in Africa during the COVID‐19
pandemic? At a minimum, we can say that they raise the bar on what
wealthy nations owe and make their obligation to share vaccines
stronger. Do the duties of wealthy nations rise to the level of justice?
One way of bolstering a claim that they do is to appeal to the
Rawlsian view that that a just distribution must be the result of fair
terms of negotiation.32 To the extent that the IMF and World Bank
methods for arriving at concessionary lending agreements fell short
of fair negotiations, they implicate the subsequent distribution of
benefits and burdens resulting from them. Furthermore, they suggest
that wealthy nations who were beneficiaries of these practices incur
a duty of justice to set things right, not only by sharing vaccines and
assisting with getting shots in arms but by supporting efforts to build
Africa's vaccine manufacturing capacity for COVID‐19 and future
pandemics. Africa is currently taking the initiative in ramping up its
vaccine manufacturing capacities; for example, the African Union has
unveiled plans to accelerate local vaccine production sufficient to
meet 60% of Africa's routine immunization needs by 2040.33
It might be objected that the duty to share vaccines and build
vaccine manufacturing capacity falls narrowly on wealthy nations
who participated in IMF and World Bank decisions during the 1980s
and 1990s, rather than on every wealthy nation. Yet, the Kantian
analysis from Section II suggests otherwise. It nudges privileged
people to acknowledge their own ‘epistemic deficiency’ or limited
capacity to know the myriad ways in which their privilege accrues
from unjust structures. Accepting a general duty to help the least well
off is for Kant, a way out of this morass.
30
Editorial staff. (2021). Africa's Vaccines Revolution Must Have Research at its Core. Nature,
592, 487‐488.
31
Ritchie, H. (2021, May 13). Western Countries Prevented African Nations From Having
Their Own Vaccine. Vice World News. Retrieved December 1, 2021, from https://www.vice.
com/en/article/epnxd7/africa-covid-vaccine-blocked-by-western-countries
32
Rawls, op. cit note 9.
33
African Union. (2021). African Union and African CDC Launch Partnerships for African
Vaccine Manufacturing (PAVM), Framework to Achieve it and Signs 2 MoUs. Retrieved
December 1, 2021, from https://africacdc.org/news-item/african-union-and-africa-cdc-
launches-partnerships-for-african-vaccine-manufacturing-pavm-framework-to-achieve-it-
and-signs-2-mous/
JECKER
3.2 | The TRIPS agreement
Consider next the patent protections enjoyed by for‐profit pharma-
ceutical companies that sell and set prices for COVID‐19 vaccines.
These protections are governed by the WTO's 1995 TRIPS agreement,
which made compulsory the enforcement of intellectual property
rights by WTO member states. In the process, it limited access to
pharmaceutical products for low‐income nations whose governments
cannot afford to pay the prices for‐profit pharmaceutical companies
set for patent‐protected products. Prior to TRIPS, countries enjoyed
wide latitude in enforcing patents in developing nations and could
exclude whole sectors from patent protections; pharmaceuticals
were frequently excluded from patentability in developing countries.
TRIPS represented a major shift that benefitted the pharmaceutical
industry because it increased patent protection for their products;
simultaneously, it represented a major loss for low‐income countries.
According to Correa, the overall effect for poorer nations was to limit
their ability to “discharge their obligations in public health rights in-
cluding those subsumed under the right to health.”34 The reason this
occurred was that the vast majority of economically developing
countries consume rather than produce intellectual property and im-
port rather than export intellectual property.35 TRIPS thus favored
industrialized countries that “built economic prowess by appropriating
others' intellectual property” because it foreclosed such an option for
later industrializers.”36
According to Sell et al., when developing countries initially signed
onto TRIPS, they did not fully realize the future impact of TRIPS and
they were strong‐armed into agreeing: “they were subjected to
pronounced economic coercion leading up to and during the nego-
tiations. Furthermore, they assented to an IP agreement in exchange
for Organization of Economic Cooperation and Development (OECD)
commitments to expand market access for developing countries'
agricultural and textile exports.”37
It could be countered that TRIPS is a fair system for allocating
patent rights because pharmaceutical companies own the products of
their labor. Shouldn't they be free to set whatever prices they wish?
In response, critics challenge this claim, noting that public tax dollars
contributed substantially to the development of COVID‐19 and other
38
vaccines and to the basic science on which vaccines are based.
Yet, it could also be claimed that the protection of intellectual
property that TRIPS afforded was necessary to encourage innovation.
According to the original TRIPS Agreement,
protections and enforcement of IP rights should con-
tribute to the promotion of technological innovation
34
Correa, C. M. (2009). Intellectual Property Rights and Inequalities in Health Outcomes. In
R. Labonte & T. Schrecker (Eds.), Globalization and Health: Pathways, Evidence and Policy.
(pp. 263‐288). New York, NY: Routledge.
35
Sell, S. K., Ikenberry, G. J., & Smith, S., et al. (2003). Private Power, Public Law: The
Globalization of Intellectual Property Rights. New York, NY: Cambridge University Press.
36
Ibid: 9.
37
Ibid: 9.
38
Jecker, N. S. & Atuire, C. A. (2021). What Yours is Ours: Waiving Intellectual Property
Protections for COVID‐19 Vaccines. Journal of Medical Ethics, 47, 595‐598.
| 5
and to the transfer and dissemination of technology to
the mutual advantage of producers and users of
technological knowledge and in a manner conducive
to social and economic welfare, and to a balance of
rights and obligations.39
However, even if profit is essential to incentivize innovation,
unlimited profits are not.40 Pharmaceutical companies that developed
COVID‐19 vaccines have already enjoyed substantial profits:, in 2021,
Pfizer/BioNTech is forecast to make between 15 and 30 billion US
dollars in COVID‐19 vaccine sales, while Moderna is expected to make
18 to 20 billion US dollars and Johnson & Johnson 10 billion US dollars.41
Arguably, this is sufficient to keep intact the incentive to innovate.
Finally, while the public good is served by innovation, it is also
served by the diffusion of products, such as essential medicines.
Thus, the merits of granting exclusive rights to intellectual property
owners must be balanced against the prospect of excluding from the
market “competitors who may be able to imitate or adapt the in-
vention in such a way that its social value is increased.”42 Vaccine
dissemination stands out from dissemination of other essential
medicines in this regard because vaccines benefit public health to a
much greater extent. While other essential medicines enhance in-
dividual health, vaccines also protect population health by preventing
infectious diseases from spreading.
Setting aside the debate over TRIPS, it is widely agreed that
during a pandemic, ‘business as usual’ is not ethically supported.
Emanuel et al. observe that many pharmaceutical companies and
governments recognize the need to suspend business as usual, as
evidenced by their willingness to donate vaccines and waive patent
protections.43 The problem has been coordinating their efforts to
achieve a fair global distribution of COVID‐19 vaccines, defined as a
distribution based on need, not wealth:
Fairness requires that vaccine allocation should appro-
priately prioritise countries in great need, not those with
great wealth; fairness also requires not leaving people
who are in need at the back of the queue, and instead
ensuring that they receive the vaccine in a timely man-
ner; no segment of the world's population should be left
behind because of inability to afford vaccines.44
The TRIPS agreement has in fact met resistance during the
pandemic on grounds of fairness. Two petitions currently before the
39
World Trade Organization. (1994). Agreement on Trade‐Related Aspects of Intellectual
Property Rights (TRIPS), Article 7. Retrieved December 1, 2021, from https://www.wto.org/
english/docs_e/legal_e/27-trips_01_
40
Sell, Ikenberry, & Smith, op. cit. note 35.
41
Kollewe, J. (2021, March 6). From Pfizer to Moderna: Who's Making Billions from
COVID‐19 Vaccines? The Guardian.
42
Trebilcock, M., & Howse, R. (1995). The Regulation of International Trade. New York, NY:
Routledge, p. 250.
43
Emanuel, E. J., Buchanan, A., Chan, S. Y., et al. (2021). What are the Obligations of
Pharmaceutical Companies in a Global Health Emergency? Lancet, 398(10304), P1015‐1020.
44
Ibid: 2.
6 |
WTO seek to temporarily waive patent rights,45 and seek to require
pharmaceutical companies to share licenses to manufacture COVID‐
46
19 vaccines. While these petitions have are not received sufficient
backing to pass, there are other steps countries can undertake.
Emanuel et al. propose tiered pricing and limiting the proportion of
vaccines sold through bilateral deals to offset market influences.47
Such efforts are critical to prevent gaps between rich and poor na-
tions from widening and becoming even more entrenched. The IMF's
2021 World Economic Outlook offers a longer‐run perspective on the
impact of slower vaccine rollouts in developing economies, fore-
casting that they will deepen global economic inequalities absent
multilateral efforts to accelerate vaccine access and provide debt
relief.48
3.3 | COVAX
A third example of an upstream structural injustice relates to the
design and execution of COVAX. COVAX is the co‐led partnership
between two international philanthropic organizations, CEPI and
Gavi, and the WHO. Its initial goal was delivering two billion doses of
vaccines by the end of 2021, with each participating country re-
ceiving sufficient doses to vaccinate its highest priority populations
and 20% of its general population. COVAX initially functioned like an
insurance plan, enticing wealthier countries to invest in its efforts in
exchange for priority access to a portfolio of vaccine candidates it
was purchasing by pooling resources from many countries. While
COVID‐19 vaccine candidates were still being studied, wealthy
countries had no idea if the vaccine candidates they had paid for
would wind up being effective; overall, just 20% of clinical trials of
pharmaceutical products result in a marketable product.49 Against
this backdrop, many high‐income nations were persuaded to join
COVAX. Simultaneously, they were completing their own bilateral
advance purchase deals directly with pharmaceutical companies.
COVAX fell short of is aspirations in ways that reveal structural
injustices in its design and execution. First, during the critical period
when COVAX was signing participants, raising funds, and pooling
demand to advance purchases vaccines, its efforts were stymied by
wealthy nations buying up most of the initial global vaccine supply.
According to Christos Christou, President of Médecins Sans Fron-
tières, “by pre‐booking billions of doses of COVID‐19 vaccines out-
side of COVAX, the EU and other high‐income countries have side‐
lined the mechanism. As a result, COVAX has been left without
45
World Trade Organization. (2020, October 2). Waiver from Certain Provisions of the TRIPS
Agreement for the Prevention, Containment and Treatment of COVID‐19, Communication
from India and South Africa. Retrieved December 1, 2021, from https://docs.wto.org/
dol2fe/Pages/SS/directdoc.aspx?filename=q:/IP/C/W669.pdf&Open=True
46
Josephs, J. (2021, February 16). New WTO Boss Warns Against Vaccine Nationalism. BBC
News. Retrieved December 1, 2021, from https://www.bbc.com/news/business-56079088
47
Trebilcock, & Howse, op. cit. note 42.
48
International Monetary Fund. (2021, October). World Economic Outlook: Recovery During a
Pandemic. Washington, D.C.: International Monetary Fund.
49
Wong, C. H., Siah, K. W., & Lo, A. W. (2019). Estimation of Clinical Trial Success Rates and
Related Parameters. Biostatistics, 20(2), 273‐286.
JECKER
purchase options and highly reliant on ad‐hoc charitable donations of
doses.”50
Second, COVAX lacks independent powers of enforcement. This
not only made participation purely voluntary but meant that promises
could be routinely broken with impunity. Pharmaceutical companies
were incentivized to prioritize delivering vaccines to the most profit-
able markets. As of October 9, 2021, Moderna had not shipped any of
the 34 million doses it promised COVAX.51 In tandem, many wealthy
countries broke promises to COVAX and prioritized their own citizens.
According to Dr. Christian Happi, a professor at Redeemer University
in Nigeria and Harvard School of Public Health, “donations from
wealthy countries are completely unreliable, as they have already
hoarded the global supply and are now moving on to inoculating
children and planning booster shots.”52 In September 2021, the UN
reported COVAX had secured legally binding commitments for 4.5
billion doses but expected to secure just 1.4 billion doses in 2021.53
While multiple factors contribute to supply shortfalls, the failure of
wealthy countries is a significant part of the supply problem.
Third, while COVAX produced the social good of making vaccines
available to poorer countries, it simultaneously thwarted an historic
opportunity. Early in the pandemic, governments, pharmaceutical
companies, the National Institutes of Health, and the WHO were at-
tempting to put in place a just system for distributing vaccines that
would curb the profits of pharmaceutical companies and reign in the
power of wealthy purchasers by establishing a pooled resource of
COVID‐19 products that would “override a global drug system based
on proprietary science and market monopolies.”54 The effect of forming
COVAX was that these efforts lost steam and never materialized.
Finally, baked into COVAX's model is a form of philanthropy that
has been termed, philanthrocapitalism, because it emulates the way
business is done in the capitalist world.55 Through COVAX, rich na-
tions essentially became “rivals” with COVAX in “a vaccine‐buying
race,” bidding up vaccine prices and creating supply shortages.56
Meanwhile, poorer countries were left to rely on loans to finance
debt in order to pay pharmaceutical companies for lifesaving vac-
cines. Philanthrocapitalism concentrates power in the hands of a
small group of wealthy philanthropreneurs. Both CEPI and Gavi were
founded by the Bill and Melinda Gates Foundation, which is also the
50
Christou, C. (2021, September 15). More Empty Promises about Global Vaccine Equity.
Quoted in Médecins Sans Frontières & European Union. Retrieved December 1, 2021, from
https://www.msf.org/european-union-more-empty-promises-about-global-covid-19-
vaccine-equity
51
Robbins, R. (2021, October 9, Updated November 9). Moderna, Racing for Profits, Keeps
Covid Vaccine Out of Reach of Poor. New York Times.
52
Cheng, M. & Hinnant, L. (2021, August 14). Back of the Line: Charity Only Goes So Far. AP
News. Retrieved December 1, 2021, from https://apnews.com/article/joe-biden-middle-
east-canada-health-coronavirus-pandemic-4581a4ac07631e66f9db8fd0dd02942a
53
United Nations. (2021, September 8). COVID‐19: ‘Unacceptable’ Deals and Delays,
Hampering Lifesaving COVAX Deliveries. Retrieved December 1, 2021, from https://news.
un.org/en/story/2021/09/1099422
54
Zaitchik, I. (2021, April 12). How Bill Gates Impeded Global Access to Covid Vaccines. New
Republic. Retrieved December 1, 2021.
55
Bishop, M., & Green, M. (2010). Philanthrocapitalism: How Giving Can Save the World.
Bloomsbury Publishing USA.
56
Mueller, B. & Robbins, R. (2021, August 2). Where a Vast Global Vaccination Program
Went Wrong. New York Times.
JECKER
largest funder of the WHO. CEPI and Gavi are accountable only to
their shareholders; to the extent that the WHO becomes reliant on
private donors, this conflicts with its duty to member states.
Stepping back from the analysis of this section, the examples of
concessionary lending, TRIPS, and COVAX illustrate injustices that are
structural in the sense that the social structural positions that poorer
states occupy put them at a disadvantage relative to others. In the first
case, concessionary lending demonstrated structural injustice because
it deprived poorer nations of the means to develop their own capacities
through domestic programs and infrastructures. In the second example,
TRIPS strengthened the hand of for‐profit pharmaceutical companies
by enabling them to protect profits in sales of pharmaceuticals to low‐
and middle‐income nations; it simultaneously excluded these nations
from timely access to lifesaving vaccines and thwarted their ability to
meet their citizens' basic health needs. Finally, COVAX kept in place
market structures and vaccine monopolies, reinforcing a business
model and putting down initial efforts to reform these structures.
Taken together, these examples of upstream structural injustices
show that wealthy countries benefitted from injustices and incurred a
duty of recompense. The Kantian analysis (from section II) suggests
that as a consequence of benefitting from such injustice, wealthy
nations incur a duty of recompense to people in poorer nations that
lost out. Kant thought the best way to repay in such case was often
helping the least well off. If that is right, rather than regarding nations
that share vaccines as altruistic do‐gooders, they are more aptly seen
as setting things right. Thinking of vaccine sharing as an act of charity
wrongly positions poorer nations as akin to beggars, pleading for
favors. Kant adamantly opposed begging, regarding it as “depreciat-
ing” and “abasing,”57 because it forces some citizens to become de-
pendent on the choices and will of others.
An objection to the case‐based argument is that duties arising
out of individuals' acts at a particular historical moment do not
transfer from individuals to nations. In response, nations routinely
incur responsibilities for actions performed by individuals when those
individuals act in official capacities on behalf of their governments. In
the cases discussed, when government officials negotiated and voted
on international financial regimes, such as concessionary lending
programs and TRIPS, or when government leaders joined COVAX,
they were acting in official roles. Their actions embedded injustices in
the global basic structure, for which governments bear responsibility.
Another possible concern is that the cases selected are drawn
from the recent past; perhaps, considering the more distant past
would weaken the argument. In reply, considering the more distant
past is apt to strengthen, not weaken, the argument, since it would
include the long history of colonialism, in which European‐led colonial
and imperial expansion was marked by “conquest, dispossession, legal
exclusion and unequal treaties, not to mention enslavement, political
subjugation, forced labor, violence, and even genocide.”58
57
Kant, I. (1997/1793). Notes on the Lectures of Mr. Kant on the Metaphysics of Morals. In
P. Heath, & J. B. Schneewind (Eds.), P. Heath (Transl.), Immanuel Kant, Lectures on Ethics.
(pp. 249‐452). New York, NY: Cambridge University Press, pp. 421, 351.
58
Lu, op. cit. note 29, p. 143.
| 7
4 | PRACTICAL I MPLICA TIONS
Building on the analysis throughout the paper, I turn next to examine
more closely the practical duties of justice wealthy nations owe as
beneficiaries of structural injustices. As noted previously (Section II),
the debts incurred by benefitting from general injustice are diffuse,
i.e., it is unclear how much is owed and to whom. The Kantian
principle stated that a duty of recompense might be paid as a general
duty to the least well off. Yet one worry with this strategy is that it
places victims of injustice at a disadvantage twice over: first, from the
original injustice and second, because the duty can be discharged at
the timing and manner of the benefactors' choosing.59 Is there more
that we can say? This section explores practical ways of spelling out
the duty beneficiaries of injustice owe.
4.1 | Relinquishing holdings and restituting victims
One alternative is to emphasize the objects of gain and loss. It holds
that parties benefitting from unjust structures should relinquish the
benefits/advantages gained and restitute the harms/disadvantages
lost. Notably, advantages and disadvantages often accrue to people
other than (or in addition to) the original perpetrators and victims. For
example, TRIPS benefitted future generations of stockholders at
Pfizer, Moderna, and Johnson & Johnson during the COVID‐19
pandemic, as well as citizens of wealthy nations who accessed
globally scarce vaccines before poorer nations. On this interpretation,
the requirement to relinquish ill‐gotten gains applies irrespective of
whether the beneficiary took part in the original wrongdoing or did
anything to solicit the benefit.60 The idea is simply that those hold-
ings are illegitimate. Goodin puts the point this way: “People
wrongfully in possession of goods should acknowledge that they
have no legitimate claim to them and should be prepared to give
them up.”61
Unlike relinquishing holdings, which focuses on perpetrators,
restitution foregrounds victims. Restitution claims that people who
have lost something that was rightfully theirs deserve something
back. With restitution, the point is not a particular victim's welfare,
but more generally putting objects in the hands of a group of people
who rightfully hold them. This involves attending to the overall pat-
tern of exchange that injustice disrupts and making amends through
social schemes that restore objects to persons or groups.
A pragmatic advantage of a restitution strategy is that in order to
establish a duty, it is sufficient to know that holdings are substantially
tainted; it is not necessary to know more, e.g., the identities of par-
ticular perpetrators that merit punishment, or the identities of par-
ticular victims that merit compensation. In the case of COVID‐19
59
Moran, op. cit. note 22.
60
Pasternak, A. (2016). In K Lippert‐Rasmussen, K. Brownlee, & D. Coady (Eds.), Companion
to Applied Philosophy (pp. 411‐423). New York, NY: Oxford University Press.
61
Goodin, R. (2013). Disgorging the Fruits of Historical Wrongdoing. American Political
Science Review, 107(3), 478‐491.
8 |
vaccines, this approach gives ground for saying that if the vaccines
possessed by wealthy nations are tainted by structural injustices,
wealthy nations have a duty to give them up. The underlying ethical
reason is that there is something wrong about enjoying the fruits of
wrongdoing. More precisely stated,
Wrongful benefits principle: if one benefits from
wrongdoing one incurs a moral duty to address the
wrongdoing and/or disgorge the wrongful benefit.62
Yet a difficulty the wrongful benefits principle faces is that there
are cases where benefits accrue from wrongdoing that are purely
happenstance. Barry gives the example of a terrorist bomb that leads
to a chance meeting between two individuals who subsequently form
a lucrative partnership.63 Participants in the lucrative partnership
benefitted from the bombing in the sense that if it had not occurred,
they may never have met; yet, they did nothing wrong and do not
incur a duty to the bombing's victims. Thus, even if benefitting from
wrongdoing is necessary, it seems not to be sufficient to incur a duty
of justice. Analogously, the mere fact that wealthy countries bene-
fitted from ill‐gotten access to vaccines is not sufficient to say they
have a duty of justice to relinquish vaccines or share them with
victims. Whether a duty to share arises depends on other con-
siderations. One additional consideration that seems salient is whe-
ther the benefits people in wealthy nations gained enabled or
reproduced injustices. Since the chance meeting that led to the lu-
crative partnership did not perpetuate terrorist bombings, it does not
yield any duties on the part of those who formed the partnership.
This leads Barry and Wiens to endorse a variation of the wrongful
benefits principle:
Sustaining harms principle: beneficiaries
benefitting‐related duties to the victims of wrong-
doings…if and only if receiving and retaining the
benefits sustains wrongful harm.64
In the cases explored in Section III, wealthy countries incurred
duties not just because they received ill‐gotten gains, but also be-
cause they used their privileged status to perpetuate injustices. To
take but one example, wealthy nations struck bilateral advance
market deals to hoard vaccines, which drove down global vaccine
supply and bid up prices. These deals were made possible by the
patent protections TRIPS established for pharmaceutical companies.
In addition, wealthy nations perpetuated wrongful harms by offering
booster doses to their own citizens before ensuring people in
low‐income nations could access first shots.65
62
Goodin, R. & Pasternak, A. (2016). Intending to Benefit from Wrongdoing. Politics,
Philosophy and Economics, 15(3), 280‐297.
63
Barry, C., & Wiens, D. (2016). Benefitting from Wrongdoing and Sustaining Wrongful
Harm. Journal of Moral Philosophy, 13(5), 530‐552, p. 532.
64
Ibid: 533.
65
Jecker, & Lederman, op. cit. note 3.
JECKER
4.2 | Restoring relationships
To understand more clearly how the sustaining harms principle
applies during the COVID‐19 crisis we need to say more about what
it means to ‘sustain harms.’ One way of spelling this out identifies
the kind of harm at stake as relational. On this rendering, the
wrongfulness of retaining ill‐gotten gains is not just that the dis-
tribution that results from unfair negotiations is unjust, but also that
ill‐gotten gains damage relationships between nations. Building on
Barry and Wiens' analysis, a principle of right relations holds that
beneficiaries incur a debt just in case their actions sustain harms and
disrupt right relations.
Principle of right relations: beneficiaries of wrongdoing
incur a duty to victims of wrongdoing just in case they
(1) receive and retain benefits and (2) doing so sustains
a wrongful harm and (3) this includes disrupting right
relations.
Walker captures the crux of a relational account a duty to “repair
relations damaged by injustice,” distinguishing this from corrective
justice, which aims to return victims to a pre‐harm baseline.66 Walker
notes that corrective justice, which stresses relinquishing holdings or
restituting victims, does not always do enough, because it does not
assess the pre‐harm baseline or recognize that it might be tainted. By
contrast, the aim of right relations is normative. It aspires to relations
in which
people are confident that they share… basic standards
for the treatment of each other. are able to trust each
other to abide by those standards or at least to ac-
incur knowledge fault if they (or others) do not.… [and] are
entitled to be hopeful that unacceptable treatment
will not prevail, that unacceptable behavior will not be
defended or ignored where it occurs, and that victims
will not be abandoned.67
On this analysis, relinquishing holdings and restituting victims is
necessary, not sufficient. Repairing relationships damaged by in-
justice is also necessary. Combining corrective and relational
approaches affords the better strategy, because it both gives up
ill‐gotten gains and examines the normative baseline.
4.3 | Next Steps
Taking steps to remedy structural injustices is a duty that befalls all
nations who participated in them, but especially beneficiaries. In the
three cases discussed above (concessionary lending, TRIPS, and
66
Walker, M. U. (2006). Restorative Justice and Reparations. Journal of Social Philosophy,
37(3), 377‐395, p. 377.
67
Ibid: 384.
JECKER
TABLE 1 Structural Injustices in Global Vaccine Allocation and Steps to Rectify Them
Structural injustices
Concessionary lending • Undercuts domestic self‐determination
• Exploits economic inequalities
• Adversely affects health systems in poorer nations
TRIPS • Reduces capacities of poorer nations to meet duties to
citizens
• Exploits political inequalities at WTO
• Adversely affects health access in poorer nations by
limiting diffusion of innovations
COVAX • Lacks funding & enforcement
• Thwarts efforts to establish alternative frameworks
• Undermines democratic values & concentrates power
in the hands of private philanthropists
COVAX), the wealthiest nations incurred special duties by virtue of
the privileged vaccine access they gained through unjust systems.
While there is not a single way to go about righting relations, a pri-
mary goal should be transformative reparations.
An example that illustrates transformative reparations is re-
quiring World Bank and IMF lending to contribute to health systems
development in economically developing nations in ways that avoid
creating financial hardship for those countries. Examples are lending
that supports domestic capacities for universal healthcare, health
research, and manufacturing of pharmaceutical products. Ethically,
the rationale for imposing such a requirement on the World Bank
and IMF is that a country's health care system is the first line of
defense during a pandemic emergency. Financing aimed to support
universal healthcare systems and build health system resilience is
transformative in the sense that it builds “the capacity of health
actors, institutions, and populations to prepare for and effectively
respond to crises, maintain core functions when a crisis hits; and,
informed by lessons learned during the crisis, reorganize if condi-
tions require it.”68 Promising developments in this area include the
WHO's establishment of mRNA vaccine technology transfer hub,69
and the WTO's expression of interest in creating regional vaccine
70
manufacturing hubs in South Africa, Senegal, Rwanda, or Nigeria.
Yet more is needed. The African Union has set a continent‐wide
goal of raising vaccine capacity from 1% to 60% by 2040 and
expanding the fill and finish vaccine manufacturing capacities cur-
rently being established to encompass more stages up and down the
chain of vaccine development.
68
Kruk, M., Myers, E. M., Varpilah, S. T., Dahn, B. T. (2015). What is a Resilient Health
System? Lessons from Ebola. Lancet, 385(9980), 1910‐1912.
69
World Health Organization. (2021, April 16). Establishment of a COVID‐19 mRNA Vaccine
Technology Transfer Hub to Scale Up Global Manufacturing. Retrieved December 1, 2021,
from https://www.who.int/news-room/articles-detail/establishment-of-a-covid-19-mrna-
vaccine-technology-transfer-hub-to-scale-up-global-manufacturing
70
Miller, J. (2021, June 21). WTO Head Says South Africa, Senegal, Rwanda and Nigeria
Considered as Vaccine Production Hubs. Reuters. Retrieved December 1, 2021, from
https://www.reuters.com/world/wto-head-says-south-africa-senegal-rwanda-nigeria-
considered-vaccine-production-2021-06-21/
| 9
Steps to rectify injustices
Set standards for World Bank & IMF lending to support self‐
determination & build health systems capacity
Waive intellectual property during pandemic emergencies
Empower global institutions to fund and enforce pandemic
response
Another example of a transformative reparation is waiving in-
tellectual property protections for vaccines and other pharmaceuticals
and taking other steps to build drug manufacturing capacities, such as
sharing knowhow, technology, and resources to expand drug manu-
facturing capacities. A concrete step toward realizing this during the
COVID‐19 pandemic would be passing India and South Africa's peti-
tion to the WTO to temporarily waive intellectual property rights for
medical products pertaining to preventing, containing, or treating
COVID‐19.71 Rather than viewing this as an act of charity given to
poorer nations, the arguments throughout the paper suggest that it is
more properly understood as a duty of justice.
Finally, empowering the WHO and/or other global institutions with
funding and enforcement authorities needed to address global health
emergencies would enact transformative reparations. Many of the
structures that govern relations between nations date to 1945 and the
aftermath of the Second World War, when the UN was created to
provide a forum for discussions and agreements between states. The UN
and the organizations under its sponsorship (such as the WHO, WTO,
IMF and World Bank) have no independent powers of enforcement or
sources of funding and serve at the behest of member states. Funding
for these global institutions could be established by creating an Inter-
national Pandemic Financing Facility capable of rapidly scaling up funding
for pandemic response and require contributions based on countries'
ability to pay.72 Powers of enforcement for global institutions could be
established by harnessing the power of law to promote global health and
sustainable development, as the Lancet Commission recommends.73
Strengthening global institutions will be essential to overcoming barriers
to transformative change, such as short‐termism, nationalism, costs, and
‘capture’ by private for‐profit industries.74
71
Sell, Ikenberry, & Smith, op. cit. note 35.
72
Gostin, L. O. (2021). 9 Steps to End COVID‐19 and Prevent the Next Pandemic. JAMA
Health Forum, 2(6), e211852.
73
Gostin, L. O., Monahan, J. T., Kaldor, J., et al. (2019). The Legal Determinants of Health:
Harnessing the Power of Law for Global Health and Sustainable Development. Lancet,
393(10183), 1857‐1910.
74
Goldin, I. (2020, September 1). Rethinking Global Resilience. IMF Finance and
Development Magazine. Retrieved December 1, 2021, from https://www.imf.org/external/
pubs/ft/fandd/2020/09/pdf/rethinking-global-resilience-ian-goldin.pdf
10 | JECKER

Table 1 displays the sources of structural injustice discussed in AUTHOR BIOGRAPHY

Section III and the possible steps to rectify them.
Nancy S. Jecker, PhD, is a Fulbright Scholar (2021‐22); Visiting
Professor, University of Johannesburg, Department of Philoso-
5 | C ONC LUS I ON phy; and Professor, University of Washington School of
Medicine. Dr. Jecker's research explores justice, human dignity
In conclusion, this paper argued that that the duty of wealthier na- and global bioethics, particularly in sub‐Saharan Africa and East
tions to share vaccines is a duty of justice, not charity. A case‐based Asia. Her most recent book is Ending Midlife Bias: New Values for
argument established that privileged access to COVID‐19 vaccines Old Age (Oxford University Press, 2020).
reflects upstream structural injustices. By benefitting from and sus-
taining structural injustices, wealthier nations incur a duty to restitute
victims and restore right relations. All nations have a duty to enact
How to cite this article: Jecker, N. S. (2022). Global sharing of
transformative change to create fairer structures.
COVID‐19 vaccines: A duty of justice, not charity. Developing
World Bioethics, 1–10. https://doi.org/10.1111/dewb.12342
ORCID
Nancy S. Jecker http://orcid.org/0000-0002-5642-748X