Nir Eyal

Current fashion supports aligning health policy with the recommendations of deliberative forums, or mini‐publics. These forums' participants are selected randomly from the general public (sometimes with overrepresentation of direct stakeholders or of underrepresented sectors). After being informed and exchanging public reasons with fellow participants under discursive rules that engage all as equals, participants vote on and sometimes rank policy recommendations. According to supporters, a deliberative democratic process that holds such forums and translates their recommendations to policy legitimizes resulting policy. That's thanks to this process's tendencies to strengthen democratic consent, to uncover which policy option is objectively best, to align policy with lay normative outlooks, and to educate the public. I argue that one tri‐partite feature of nearly all instances of democratic deliberation on regional, national, and global health policy under current best practice, which I call the “Scaleup costs, Size, and Statistics” (“3S”) challenge, largely blocks these alleged welcome tendencies. In particular, barring radical changes, true democratic deliberation is expensive to scale, keeping feasible mini‐publics small and irregular. That makes concluding from mini‐public recommendations about the population's hypothetical consent, values, and will statistically unreliable. It also caps low mini‐publics' contribution to public education. In these ways and in others, the long list of alleged welcome tendencies of proper democratic deliberation on health policy, and the related contribution to political legitimacy, is largely a fiction. Public deliberation does have modest true merit, for example, providing relevant qualitative input about the lay public's occasional factual insights and many endemic errors; and making the public feel “listened to,” whether or not it is. But those merits are modest, contingent, and most accentuated under different institutions than envisaged in deliberative democratic literature. Certainly there is room for democratic deliberation, potentially of new breeds, but only as part of the mosaic of health policy design, alongside familiar methods like general elections, public surveys, representative government, and expert decisionmaking. The main question is which method to use when.

Longtermists assign great moral importance to making the long‐term future as good as possible, especially by ensuring the survival of humanity. We argue, to the contrary, that on assumptions that are plausible, conservative, or shared by leading longtermists, human extinction will likely augment total utility among human and non‐human animals on Earth. The reason for this surprising conclusion is that our extinction would increase the number of sentient non‐human animals, which in turn would dramatically increase total utility. Possible responses by longtermists leave them with a difficult quadrilemma. They must either (a) welcome human extinction; or (b) welcome the extinction of most non‐human animals; or (c) tolerate continued human existence and related animal suffering as mere means to ushering in high‐tech transformations of the animal kingdom, space colonization, or digital sentience – relatively esoteric, unpopular, and speculative parts of longtermism; or (d) reject key tenets of longtermism like anti‐speciesism or the equal evaluation of making beings happy and of making happy beings. Embracing any horn of this quadrilemma would cut deep into longtermists' current commitments and/or dash central longtermists' hopes of popular appeal.

In the increasingly likely event of an engineered‐virus outbreak or pandemic of catastrophic potential, managing infectious aerosols to reduce transmission will be crucial. Now is the time to start preparing our buildings, public opinion, and regulatory environments for the infectious aerosol management interventions necessary to protect the public. But which interventions should governments and institutions invest in the most? We review the leading candidate methods for infectious aerosol management and discuss their respective advantages, disadvantages, and suitable settings. There is strong emerging evidence that two recently explored technologies, direct exposure to far‐ultraviolet‐C (UVC) light and triethylene glycol, are particularly efficacious and safe, but there remain open questions about the long‐term safety and efficacy of these interventions. In the meantime, we recommend other interventions—especially upper‐room UVC and in‐room air cleaners—for settings where most occupants regularly spend more than a small fraction of their day. We conclude by listing research questions about these interventions that still need to be researched in social science, product development, medicine, engineering, economics, and ethics.

President Trump’s 2025 decision to remove the United States (US) from the World Health Organization (WHO), echoing his initial 2020 move, raises existential questions about the future of global health governance. This editorial explores the immediate and long-term potential impacts of the withdrawal, noting that it poses a significant threat to the WHO financing. This, in turn, will have adverse consequences for future pandemic preparedness, health inequities, and cross-border collaboration. We also explore the potential role of private philanthropies in bridging the funding gap, against the risk of shifting health priorities away from local needs. For the US, withdrawal means diminished influence on global health policies and weaker alignment with new international regulations. Moving forward, structural reforms within the WHO, equitable contributions from global powers, and renewed US involvement are essential to maintain strong health systems worldwide. Ultimately, a collaborative approach is necessary to uphold collective preparedness against emerging health crises.

Often, a health resource distribution (or, more generally, a health policy) ranks higher than another on one value, say, on promoting total population health; and lower on another, say, on promoting that of the worst off. Then, some opine, there need not be a rational determination as to which of the multiple distributions that partially fulfill both one ought to choose. Sometimes, reason determines only partially, intransitively, or contentiously which of the many “compromises” between these two values is best or most choiceworthy. Norman Daniels, Ruth Chang, Martijn Boot, and Anders Herlitz affirm this opinion, which I shall call “value incommensurability,” “rational underdeterminacy,” or “reasonable disagreement.” To decide between the multiple reasonable compromises on health resource distribution, these philosophers recommend a deliberative democratic process, on two main grounds. First, in such situations, deliberation can produce the determinacy needed for decisionmaking. Second, by treating respectfully and justly even those patients or communities for whom the distributive compromise selected is bad, deliberation shields the legitimacy of that policy. Increasingly, practically-oriented bioethics recommends democratic deliberation even more expansively than these philosophers do—for nearly every decision on health resource distribution and not only when values are incommensurate—on these two grounds and on others. And one could propose a more modest variant on this expansive move as the justification of democratic deliberation. I argue that none of these moves warrants democratic deliberation on health policy.

A scientific trial has individually randomized control when the intervention or control status for each participant is independently chosen at random at the start of the trial. That is in contrast to cluster randomization, where this status is determined for groups of participants, and in contrast to trials without randomization and to non-trial methods of assessing experimental interventions. The individually randomized controlled trial is generally the most effective and thus the most ethical trial design for assessing the safety and efficacy of candidate vaccines against infectious disease. With this trial design, all study participants benefit by receiving protections that other people at similar risk of infection often do not receive. These benefits include close monitoring, enhanced clinician–patient ratios, and the opportunity to be randomized to the preferred arm of the study. Furthermore, individually randomized trials for emergency response usually reach any given level of statistical confidence before alternative designs with group randomization. Individual randomization is also compatible with delayed or active control trial designs, parallel or stepped rollout, a variety of primary endpoint trial population choices, and either environmental or challenge exposure to the pathogen.

U.S. regulation of dual-use research of concern and of research with enhanced pathogens of pandemic potential may alter soon. Much has been written on the best form for that regulation to take. Less was written on a procedural question: whose voices should shape that regulation? This commentary addresses the latter, the procedural question, regarding the appropriate parties to the deliberations and decisions on this matter. It proposes to U.S. virologists that it would be in the interests of their discipline and only appropriate if that regulation were shaped by many voices from outside the discipline and from outside the United States.