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The COVID-19 pandemic has been a defining defining event of the 21st century. Global estimates of excess mortality indicate that it has taken fifteen fifteen million lives over 2020-21 (Knutson et al. 2022). It has closed national borders, put whole populations into quarantine and devastated economies. Almost half of workers in low or middle income countries lost a job or business due to the pandemic (Anonymous 2021). The International Monetary Fund has estimated a global loss to the world economy of US$12trillion by the end of 2021 (Bill and Melinda Gates Foundation 2020). It led to a rise in rates of extreme poverty for the first firstfirst time in 25 years, with 37 million additional people experiencing this in 2020. The pandemic toll and the cost of measures taken to combat it—both effective effectiveeffectiveeffectiveeffectiveeffective and ineffective—has ineffective—has ineffective—hasineffective—hasineffective—hasineffective—hasineffective—has ineffective—has been paid in human lives, mental and physical suffering,suffering, suffering, suffering,suffering, and economic hardship. The costs will continue to be paid by individuals and societies for decades to come. While the COVID-19 pandemic has been catastrophic, it is not unique. It is not as severe as Spanish influenza, estimated to have killed between 50-100 million people. Recent MERS and SARS epidemics were more deadly to those infected, but less contagious. Future influenza pandemics, perhaps like the hypothetical example above, undoubtedly lie ahead. We await ‘Disease X’, the World Health Organisation’s placeholder name for “a serious international epidemic … caused by a pathogen currently unknown to cause human disease.” In some ways, the COVID-19 pandemic has been a wake up-call. Children who have been home-schooled during the COVID pandemic will almost certainly face another pandemic in their lifetime – one at least as bad—and potentially much worse—than this one.

In the response to this pandemic, two vital, but controversial ethical questions are we should allocate ventilators to patients with severe respiratory failure, and how we should distribute vaccines to people at risk of contracting coronavirus. There There are opposing ethical views about how to prioritise, and countries have taken different different differentdifferentapproaches. There There is a strong ethical argument that policies should take a pluralistic approach to allocation that reflectsreflects reflectsreflectsreflectsmultiple ethical values - both because of the diversity of viewpoints within communities and the recognition that there are competing relevant ethical values. In this chapter, I look at the epistemic and normative problems raised by pluralistic allocation in this pandemic and suggest implications for future pandemics. I summarise some of the relevant evidence about the public’s views and values relating to prioritisation. I also explore some practical approaches to prioritisation of scarce resources in the face of contrasting and competing ethical values

There are two broad schools of ethical theory: consequentialism and non-consequentialism. According to consequentialism, the right act is that act which has the best consequences. According to non-consequentialism, the rightness of an action is not solely determined by its consequences. (Though, most versions of non-consequentialism allow some ethical relevance of consequences). The most famous version of non-consequentialism is deontology, which holds that one has an absolute duty to obey certain rules. “Never kill an innocent person” or “never lie” are examples of such rules. Christianity is one form of deontology and the Ten Commandments represent one set of rules. Medical law exists at the intersection between consequentialism and deontology. Much of medical law is consequentialist in nature. However, having evolved from a set of Christian values and principles, it retains certain deontological characteristics. In particular, it retains a commitment in many jurisdictions to the Sanctity of Life Doctrine, though this is being shed or modified as assisted dying becomes legalised. In this chapter, we will begin by defining consequentialism, and contrasting it with deontology. We will describe some examples of the influence of consequentialism over current medical law. We will close by outlining the areas where consequentialism is at odds with current medical law and how medical law should evolve according to consequentialism.

The case of Charlie Gard raises a number of serious ethical questions, including how a child’s best interests should be assessed, the role of parents in decision-making for a child, the appropriateness of trying untested experimental treatment in a serious ill child, and the allocation of limited healthcare resources. Elsewhere, I have reviewed these questions in some detail and explored the implications for future disputes over medical treatment for children.1 In this chapter, I will focus on one of the questions that arose in the Gard case and was also raised in the subsequent case of Alfie Evans. If there is disagreement between parents and health professionals about treatment for a child, should courts overrule parents on the basis of an assessment of what would be best for the child, or only if what the parents propose would be harmful for the child? I will largely focus on the ethical question (and leave the more specific legal questions to other commentators in this volume).2 I outline the ethical case for using a harm threshold test rather than a best interests test, identifying a set of cases where these tests may yield different decisions. I respond to a series of counterarguments against the use of harm thresholds. In the last part of the chapter, I propose a compromise, a conditional harm threshold test that would apply only if there is a question of preventing parents from pursuing treatment that other health professionals are offering to provide. I explore the implications of this test for a set of challenging cases similar to the Gard/Evans cases, setting out two different alternatives for evaluating the harm of prolonging life in children with absent consciousness.

What should happen when doctors and parents disagree about what would be best for a child? When should courts become involved? Should life support be stopped against parents' wishes? The case of Charlie Gard, reached global attention in 2017. It led to widespread debate about the ethics of disagreements between doctors and parents, about the place of the law in such disputes, and about the variation in approach between different parts of the world. In this book, medical ethicists Dominic Wilkinson and Julian Savulescu critically examine the ethical questions at the heart of disputes about medical treatment for children. They use the Gard case as a springboard to a wider discussion about the rights of parents, the harms of treatment, and the vital issue of limited resources. They discuss other prominent UK and international cases of disagreement and conflict. From opposite sides of the debate Wilkinson and Savulescu provocatively outline the strongest arguments in favour of and against treatment. They analyse some of the distinctive and challenging features of treatment disputes in the 21st century and argue that disagreement about controversial ethical questions is both inevitable and desirable. They outline a series of lessons from the Gard case and propose a radical new “dissensus” framework for future cases of disagreement.

This chapter distinguishes between essential features of the zone of parental discretion and the longstanding concept of a grey zone in neonatal treatment decision-making. The grey zone has traditionally described a gestational age range where the outcomes of medical treatment for newborn infants are uncertain, and therefore parents have discretion to choose between resuscitation or palliative care options. In contrast, the ZPD refers to a space where parents may make decisions for their child (not restricted to newborns) even if their decisions conflict with the decisions a clinician would make. A key difference between the two zones is that the boundaries of the grey zone are defined on the basis of published evidence about medical outcomes, whereas the boundaries of the ZPD are based on the broader but arguably vaguer notion of harm to the particular child. The grey zone has usually been defined in terms of gestational age. Wilkinson argues instead for a prognosis-based grey zone in neonatal treatment decision-making, which incorporates a range of prognostic factors rather than focusing solely on gestational age.