In a recent article in this journal, Saunders has criticized my proposed nonconsequentialist policy regarding the use of a lottery for the distribution of scarce vaccine by the state in the face of an influenza pandemic (Saunders, 2018). I argued that, in some circumstances, on the grounds of justice, the state should distribute the scarce vaccine it holds to citizens randomly and equally on the principle of a lottery (McLachlan, 2012, 2015). Saunders writes:

The proposal to give “equal chances” to everyone is not as simple or as appealing as it first appears. Any policy will have to be sensitive to differences, in need and productive capacity, between people….Thus, while I believe that policymakers should show equal concern for all citizens, I suggest that this may permit, or even require, departures from equality in the distribution of (chances of getting) vaccine.

Saunders, 2018, p. 80

As we shall see, Saunders’s claim about the need to be sensitive to differences in need and productive capacity is not as simple or as appealing as it might first appear.

I shall answer the specific questions that he addresses to me and thereby restate, amplify, and develop my position. Saunders’s criticism contains some very strong points about the ethical allocation of scarce vaccine in general. Recognition and accommodation of them serves to strengthen and develop rather than discredit my initial policy proposal.

My argument was, at root, a response to the tacit consequentialist rationale of the official UK governmental policy on vaccinations in influenza pandemics as expressed in the UK Contingency Pandemic Plan of 2005. It stated: “The priority in an influenza pandemic is to reduce the impact on public health (i.e. reduce illness and save lives). Interventions will therefore be applied where they will achieve maximum health benefit.”[1] The recommended policy involved dividing the population into priority groups including groups of high medical risk and age groups, as well as certain healthcare workers and providers of essential services. I argued that, in certain assumed conditions, if there were an influenza pandemic or an impending one and the state held a scarce supply of vaccine, it should, in fulfilment of its duty of care towards its employees, distribute it firstly to the front-line care providers who might be at risk of catching influenza in their work at the state’s behest of providing healthcare. Thereafter,

if there is not sufficient vaccine to give all other citizens equally an effective dose, the state should give them all an equal chance of receiving an effective dose….This would be the just thing to do because the state has a duty to treat each and all of its citizens impartially and they have a corresponding right to such impartial treatment.

McLachlan, 2012, p. 318

In my view, it matters ethically not only what consequences ensue from our actions, but also how and why we do what we do (Emanuel and Wertheimer, 2006; Jansen and Wall, 2021; Williams and Dawson, 2020; Colgrove, 2019). It matters, too, who does what is done and in what roles they perform their actions. If particular envisaged circumstances—such as, for instance, the outcome of the effects of the taking of doses of vaccine by particular groups of people—happen to be particularly morally good, it does not follow that, by a sort of imaginative reverse engineering, we can deduce that all or any of us must have a moral duty to bring or to try to bring these circumstances about. What distribution of vaccine would produce the morally best outcome? This is a different question from, How ought we to distribute it? This latter question will have different correct answers depending upon whether “we” are, for instance, rich philanthropic private citizens or, for instance, officials or agents of the state.

When people perform particular roles, they are morally constrained as well as morally authorized by rights and duties that are intrinsic to these roles and by the nature of these (McLachlan and Swales, 1999). They do not have the moral freedom of action that they have as normal private citizens. For instance, it is not the business of the members of a jury to decide what, overall, would be the morally best outcome of declaring particular defendants to be innocent or guilty when they produce their verdicts. It is not the business of lecturers to allow a consideration of the moral desirability or undesirability of the overall consequences of passing or failing particular students to influence the marks they choose to give to the particular essays of these students that they are responsible for marking. Similarly, those who perform roles in the government and other such agencies of the state are constrained as well as legitimated by their occupancy of such roles. The primary end of their action is not the morally best outcome, and even when what they do does happen to produce the morally best outcome, that in itself is no automatic vindication of their policy making.

For instance, incumbents of such roles have a moral duty to act justly. Members of governments, like other public officials, agents, and other members of agencies, have a moral duty to treat citizens impartially as individuals in the distribution of benefits and burdens that are individually experienced. Citizens have a corresponding moral right to be treated impartially by them. Each citizen should be treated the same unless there is a morally relevant difference pertaining to them that justifies the different treatment of them. This is the nature of distributive justice.

Justice demands impartial treatment of individual people as individual people. It pertains to differences in their treatment that are related to and proportionate to morally relevant differences in their personal features, conditions, and circumstances. This is different from discriminating among particular people on the basis of average differences among features and factors that pertain to the different categories or groups that the particular individuals belong to. Hence, I consider the priority given to age categories in the distribution of vaccine that is proposed in the UK Contingency plan for influenza pandemics and that is practiced currently in the UK in the distribution of vaccine against COVID-19 to be unjust (Savulescu and Cameron, 2020; Hughes, 2020; Peterson, 2008).

Consider, for instance, the role of lecturers with regard to the treatment of their students in, say, the marking of their essays. As a matter of justice, they are required to treat them the same and to give them the same mark unless there are morally relevant reasons for treating them differently, in which case discrimination is not only justifiable, but morally obligatory. Acting justly does not merely mean treating one’s students the same unless there is a moral justification of some sort for treating them differently. There must be a morally relevant justification. That means treating them differently only when the difference in treatment is morally justified by a corresponding and proportionate difference pertaining to the merits of the essays that are submitted by them. Notice that the allocation of different treatment, of, say, benefits and burdens, is just or unjust regardless of the consequences of that particular allocation. The virtue of distributive justice does not lie in the consequences of any particular distribution of burdens and benefits, but in its appropriateness. With regard to distributive justice, one might say that the proof of the pudding is in the recipe rather than in the eating.

Among the assumptions I made were that anyone might die from the influenza and that all might want to live. The chance of a vaccine that might prevent them dying from the influenza was of value to each and every one of them. That people who are, for instance, older or who belong to a particular sex or racial or ethnic origin might be, on average, more prone to infection or more likely to die if infected is an irrelevance. The presumptions that the state should make are that all people need to live in order to do what they want to do and to enjoy what they want to enjoy, and that they all want to live. A dose of the scarce vaccine might prevent influenza from killing any particular one of them, as far as any one of them can know. They each have valid claims to receive one, between which it is not proper for the state to discriminate.

If we knew in advance what particular people would die or suffer from serious illness if they were to catch, say, influenza or COVID-19, there might be a good case for saying that, on the grounds of justice, they, regardless of their age, should be given priority in the allocation of an appropriate vaccine. However, we do not have and cannot have that information. Most of those who have died from COVID-19 so far or who have suffered serious illness have been old, but, with regard to justice, this is irrelevant. Not all old people who caught it have died or suffered serious illness. Not all who have died or suffered from serious illness have been old. Moreover, the pattern of the pandemic might change from what it has been in the past. The virus might change. Available effective remedial treatment might change. Any of us might catch COVID-19. If we do, for all that we know, we might die or have serious long-term or short-term consequences to our health or our life expectancy. Whether or not any of us needs a vaccine, we might all want to have one and equally have a legitimate interest in getting one or, at least, the chance of getting one. Younger people who catch COVID-19 might show slight symptoms now, but, for all we know, might die in years to come much younger than they would have done had they not caught it. They might suffer later in life from appalling illnesses and disabilities. We do not have the sort of knowledge available to us that would morally justify discrimination between the younger and the older in the distribution of vaccine.

To give priority in a pandemic in the allocation of vaccine against influenza or COVID-19 on the basis of membership of age groups is unjust. It might be expedient to allocate vaccines in such a way. It might even, in some circumstances, have consequences that morally permit or even morally compel the adoption of such a policy, but it would remain, nonetheless, an unjust one. It is like giving awards to particular school children on the basis of the school they attended or the socioeconomic class of their parents. If one age group has, per capita, a higher rate of deaths or serious illness among those who catch COVID-19 or influenza than a younger age group, it does not mean that all those who are in each group share the same chances of dying or of becoming seriously ill if they catch the disease as their fellow age-group members. Within each age group, there might well be much variation in the chances of the particular members dying or suffering from a serious illness if they catch the disease. Some or many people in the younger group might well have a far greater chance of dying or suffering from a serious illness if they catch it than some or many people in the older group.

What counts as impartiality in the distribution of publicly financed and provided goods or services such as, say, medical surgery, higher education, or vaccines and what counts as morally relevant reasons for discrimination are contentious issues. It depends partly on what we consider to be the proper function of the goods or services in question, to whom the benefit should be bestowed, and for what purpose (Wardrope, 2012). For instance, the need of the recipient is sometimes but not always thought to be a morally relevant reason for discrimination in, say, the distribution of medical surgery, but not in, say, the distribution of places in higher education. Some people—very many, perhaps—think that places in universities should be allocated to those people who can benefit society most from taking them up and that higher education is not primarily for the benefit of students but for the expansion of the economy. Most people, I am sure, would say that medical treatment should be allocated primarily for the benefit of the recipients. We would typically give, say, a heart transplant to someone who needed a new heart and who was certain or very likely to die or be seriously ill without such treatment rather than to someone who did not. However, we would hardly consider it to be just to give heart transplants to, say, everyone in a particular age group before giving one to any to those people in a younger group on the grounds that, in the past, a higher proportion of older people than younger ones needed a heart transplant or, to say a different thing, that a higher proportion of those who needed a heart transplant in the past were in the older age group. Similarly, we do not and would not give heart transplants to all smokers before giving one to any nonsmoker on the grounds that, on average, smokers are more likely than nonsmokers to need one. To act justly, we should give, for instance, heart transplants to those particular people who need one rather than to those who do not, whatever age they are and whether or not they are nonsmokers. We should allocate, when need is the relevant factor, on the basis of the needs of individual potential recipients regardless of the social or natural categories to which they belong.

When vaccines are allocated primarily as a prophylactic, to people who are not in ill, in order to try to ensure that they do not become ill, primarily for their benefit, the notion of “need” is not readily applicable. Healthy people do not need a vaccine against, say, COVID-19, in the way in which some people who currently suffer from a particular illness need, for instance, a heart transplant and those who do not suffer from it do not. However, anyone might catch and die from or suffer severely in the long or short term from catching COVID-19. All of us might want a vaccination as soon as possible against catching it. We each have a legitimate interest in receiving the vaccine. Any request we might explicitly or implicitly put forward deserves consideration. Not all such requests can be immediately acceded to but the grounds for their rejection or the deferral of compliance to them should be providable by any government that wants to act justly and to be seen to do so.

With some vaccines, in some sorts of pandemics, we might all have a very strong interest in the provision of vaccines to each and every person. My argument was, like the official policy to which I was responding, based on the assumption that the vaccine against influenza would be distributed as a prophylactic, for the benefit of its recipients. Where the benefits of particular treatments and services are not intended to be enjoyed solely or primarily by those who receive them, the question of whether and how they can be distributed impartially is more complex (Wardrope, 2012; McLachlan, 2015). Some vaccines can protect those who receive them from becoming ill from catching a particular viral infection without preventing them from becoming asymptomatically infected and infectious. Some vaccines can prevent the recipient from becoming infected and being infectious. Thus, we might benefit significantly from the vaccination of other people if and when their lack of infectiousness can reduce our chances of becoming ill or dying from catching a particular infection.

We might all equally have a very strong interest in the vaccination of all people with whom we might directly or indirectly socially interact. To try to give everyone, citizen and noncitizen alike, who is living within the geographical boundaries of the state an efficacious dose of vaccine as promptly as possible—regardless of the ordering of the distribution to particular people or to particular categories of them—might in some circumstances be a very good policy. It might be a policy that could be considered sufficiently impartial in the circumstances. It might be the morally optimal vaccination policy for a government to adopt at least with some sorts of vaccines in some or other stages of some sorts of pandemics. It might form part of an optimal package of policies that a government could try to implement.

The state is morally obliged to refrain from wantonly killing each and every one of us but is not similarly morally obliged to do all that is required to try to postpone the deaths of each and every one of us (McLachlan, 2010). To let us die is, normally, morally permissible for the state whether or not there is a pandemic. Whether or not there is a pandemic, particular deaths can be delayed, and particular lives lengthened, very often, only at the expense or risk of hastening other deaths and shortening other lives. Hence, the notion that, in a pandemic or in any other times, the government has a paramount duty to save lives or, indeed, that it has any sort of paramount duty is not plausible. To protect the National Health Service (NHS), for instance, is not inherently ethically more important than, say, to protect the education system or, say, the systems of civil or criminal justice. The postponement of particular deaths does not matter more than or less than, say, the education of children or the livelihoods of adults or the freedom of adults to, for instance, hug, kiss, and enjoy other forms of intimate contact with other consenting adults. Such things matter ethically but they matter differently. They are different morally good things. There is a host of things that are morally permissible for governments to do, a host of things that are morally desirable for them to do, a host of things that are obligatory for them to do, and a host of things that are obligatory for them to refrain from doing. Hence, it is appropriate for governments to try to produce an optimal blend of policies rather than to try to maximize the specified output of any particular prioritized policy or policies, whether or not they are in a pandemic.

Notice that, in some instances, unjust actions and policies might be morally justifiable on grounds other than justice.[2] For instance, governments might be confronted by a severe emergency to which they do not have, say, the time or imagination to devise a policy that is both a just and an effective solution. Perhaps, in some such cases, there is none. However, they should acknowledge the injustice of such actions and policies. The state, its agents, and its agencies should not lightly violate the moral right to justice, even when the benefits that are unjustly denied or the burdens that are unjustly bestowed are comparatively slight. We, as citizens, should often be prepared to waive our moral right to just treatment in particular circumstances. We should, however, beware that governments do not get into the habit of overriding it.

Saunders asks us to consider a particular situation where a benefit to one person can result, indirectly, in a benefit to other people (Wardrope, 2012; McLachlan, 2015). It is an assumption of the supposed scenario he depicts that the chances of survival from the pandemic are the same as the chances of receiving a dose of the distributed vaccine. He writes:

Suppose we have ten individuals, labelled Alpha through Kappa, and two doses of vaccine. With no relevant differences between individuals, it would seem reasonable to allocate the vaccine randomly, giving an equal chance (20 percent) to each individual. But what if Alpha works in the manufacture of vaccine? Let us suppose that if she receives one of the two initial doses, whether as a result of a lottery or not, then she can produce two further doses, which can be randomly allocated among the remaining individuals. Should this alter our distribution and, if so, how?

Saunders, 2018, p. 75

To allocate the vaccines among all ten people on the basis of two random draws is Option 10. Saunders shows that if we weight the draw in favour of Alpha, increasing the probability that she will survive and produce the additional doses, we can increase everyone’s chances of survival, which become equal at 25 percent. This is Option 11. However, Saunders shows that we can increase the chances of survival of everyone even more by the following policy, Option 12:

Give the first dose to Alpha, without a lottery. Allocate the other of the initial doses, and the two extra doses produced by Alpha, by lottery, giving each of the other nine individuals an equal chance. Allocating three doses between nine people means that each has a one in three (33.33 percent) chance of receiving a dose of vaccine.

Saunders, 2018, p. 77

Saunders favours Option 12. He writes:

Alpha enjoys a larger share of the benefit than the other nine. The result is that we depart from the equality of Option 11. In this case, Alpha receives the vaccine for certain, which makes her much more likely to benefit than anyone else. The fact that Alpha’s survival is instrumentally useful does not give her any greater claim to the vaccine though. Thus, while it may be rational for all involved to consent to Alpha receiving one of the initial doses, it is nonetheless unfair….It is an unfairness that we should almost certainly tolerate, since it increases everyone’s chances of receiving vaccine….If we are prepared to compromise equality for the sake of efficiency by allocating the vaccine by lottery in the first place, rather than giving it to no one, then we ought also to prioritize efficiency here.

Saunders, 2018, p. 77

Saunders suggests that his preference for Option 12 is not merely a subjective, personal one. He seems to think too that, specifically, both the distributors and potential recipients of the vaccine should prefer Option 12. He writes:

I would suggest that, if we find ourselves in these circumstances, we ought to favour Option 12. If we take the perspective of those involved, then what they care about is maximizing their own chances of survival. They ought not to care what chances others have, except insofar as those chances affect their own chances….To reduce everyone’s chances for the sake of equality would be to make a fetish of equality, neglecting the fact that the only reason to care about equality is that we are distributing a good and hence that people should prefer inequality if it means more of that good for all.

Saunders, 2018, p. 78

According to Saunders, my attitude to this policy is hard to predict. He writes:

On the one hand, McLachlan is clearly committed to the value of equality, even when it results in more deaths (McLachlan, 2015, p. 193). On the other hand, his case for giving everyone equal chances is that the state ought to treat its citizens “the same in relevant respects unless there are relevant reasons for treating them differently” (McLachlan, 2012, p. 317, emphasis added). When he introduces priority for frontline healthcare workers, he refers to there being “at least one relevant reason for treating some citizens differently” (McLachlan, 2012, p. 318), viz. the fact that their occupation puts them in danger. This reason does not extend to those whose work involves production of vaccine who, I assume, are at no greater risk of infection than anyone else. (Saunders, 2018, p. 78)

I am not “committed to the value of equality” (McLachlan, 2000). Apart from anything else, treatment that is equal in some respects will be unequal in other respects. We cannot use the notion of equality to tell us what respects should matter. Moreover, equal treatment can produce outcomes that are unequal. In order to produce equal circumstances for particular people, we would often have to treat them unequally. I consider equality and inequality to be in themselves morally neutral terms.

Notice that I did not suggest that frontline healthcare workers should be given priority because of the danger of being infected pertaining to the nature of their work. I suggested that the state and its agencies have a particular duty of care towards those people that they employ as healthcare workers to do that which puts them in danger of being infected, a duty that it does not have towards other people—including, for instance, other frontline healthcare workers whom it does not employ and, for instance, sex workers and those who work in shops—who might be equally or even more at risk of infection (Symons, Matthews, and Tobin, 2021).

Saunders also writes:

Showing impartial (or equal) concern for everyone does not necessarily require giving them equal chances of anything. It may be that equal concern leads to unequal outcomes. We might read McLachlan’s proposal to prioritize healthcare workers as a tacit admission of this point, though it is not clear to me whether he takes this to be compatible with impartial treatment or a justifiable departure from impartiality.

Saunders, 2018, p. 74

Prioritization of healthcare workers in the distribution of the vaccine as a prophylactic is, in my view, compatible with impartiality. The state has a duty of impartiality towards citizens as citizens among its various other duties, one of which is a duty of care towards those whom it employs to do particular jobs. Where the job of the provision of particular sorts of health care involves a particular risk of catching influenza, to give its employees preferential treatment in the allocation of scare influenza vaccine is an appropriate way of trying to discharge that duty of care as an employer. It is compatible with fulfilling its duty to act impartially towards citizens since there is a morally relevant difference between citizens as citizens and these particular providers of healthcare, some but not all of whom will also be citizens.

If Alpha works in the manufacture of vaccine and her being vaccinated would result in the availability of more vaccines than if she would not, “should this alter our distribution and, if so, how?” As usual, I would say that whether and how this should alter our distribution depends, among other possible things, on who “we” are, in what capacity “we” act, to whom the vaccine will be distributed, and for what intended purpose or purposes. If “we” are agents or an agency of the state, it might well be an appropriate and properly impartial policy to treat those who are indispensable to the production of the vaccine and who are not readily replaceable differently from other people and to give them priority in the distribution of scarce vaccine that is presently available. This is vaguely similar to the appropriate and properly impartial policies of treating patients differently in some respects from people who are merely at present potential patients and of treating university students differently from applicants and potential applicants to university. The state can treat citizens impartially as citizens, students impartially as students, and patients impartially as patients while treating students and patients differently from other citizens in some respects. Indeed, impartiality requires such different treatment in some respects. The state should treat, for instance, applicants to join the army impartially. It should treat also soldiers impartially but should not, generally, treat applicants as it treats soldiers. Similarly, the state might treat all citizens impartially as citizens and all essential workers in the production of vaccine impartially as essential workers in the production of vaccine while treating those workers differently from citizens who are not essential workers in the production of vaccine.

Hence, I have no reluctance to support the adoption of Option 12. Such support does not clash with my proposal to distribute vaccine to citizens on the basis of a blind lottery in other ones. With Saunders’s assertion that “equal consideration of everyone does not necessarily mean giving everyone equal chances” I agree completely. Only in some circumstances would an equiprobable lottery or a lottery of any sort be an appropriate way to distribute goods or services by the state, its agents, and agencies.

Saunders writes:

While…McLachlan may be right to reject a policy seeking to maximize the number of lives saved, on the grounds that this will be unfair to some, it does not follow that we should give everyone equal chances. Impartial consideration is compatible with taking efficiency into account, even if the results are contrary to strict equality.

Saunders, 2018, p. 67

Notice that I did not mention fairness or unfairness in my discussion of this topic. I talked, rather, of justice and injustice (McLachlan, 2002; McLachlan, 2005; McLachlan, 2021; Rawls, 1985). However, I agree entirely that impartial treatment does not imply equal treatment.

One might, as I am, be favourably disposed towards Option 12 and its adoption by the state without accepting the Rawlsian basis that Saunders puts forward to support it (Rawls, 1999). Apart from anything else, there is a difference between thinking that, morally, the world would be a better place if Option 12 were to come about and thinking that any particular agent or agency is morally permitted, far less morally obliged, to try to promulgate or implement any policy that would bring that outcome about. Our moral duties might even lead us in a contrary direction.

Saunders writes:

This situation is similar to Rawls’s famous original position….Here, Rawls assumes that parties are concerned only with their absolute position and not how they stand relative to others. Thus, he proposes that they would reject strict egalitarianism in favour of the difference principle, which permits inequalities that benefit all….My proposal is an application of similar reasoning to the problem at hand. That is, I suggest that vaccine ought to be distributed equally unless an unequal distribution benefits everyone. This policy satisfies the requirement to treat everyone impartially. It explains why we should prefer allocating effective doses of vaccine by lottery to giving everyone an equal but ineffective share of the vaccine. And it also tells us that, if prioritizing Alpha improves everyone’s chances of survival, this is what we should do.

Saunders, 2018, p. 78

It is not clear how, in practice, Saunders’s principle “that vaccine ought to be distributed equally unless an unequal distribution benefits everyone” could apply or is meant to apply. We can, as an exercise of philosophy, suppose that Alpha and other hypothetical people will need such-and-such medication to survive and will react in particular specified ways to particular doses of vaccine when we formulate our abstract examples. However, actual distributors of vaccine can never have such knowledge. For instance, in practice, no matter how thoroughly a vaccine is tested before it is used, some people might have unfortunate, even fatal, reactions to it. It can never be known for certain that this will not happen. It is reasonable to suspect that with any vaccine against, for instance, COVID-19, if we give enough people a dose, at least someone or other will not only significantly fail to benefit from it but will, to some or other extent, suffer.[3] How, if at all, should this consideration influence our distribution policy? Should we always distribute such vaccine equally? If the suggested justification of policies regarding such things as the distribution of vaccine is a sort of consequence that could not be known prior to the implementation of the policies, it is not clear that the suggested justification is of practical usefulness to agents and agencies who have the responsibility of distributing vaccine.

Notice, too, the complication of a time gap in the implementation of Option 12. If we give a dose of vaccine to Alpha and allocate the remaining one by lottery rather than allocating two by lottery initially, there is a potential loser—someone who might have won the dose that was given to Alpha might catch the disease and die before Alpha gets round to producing the replacement and the additional dose. Furthermore, there is a risk that she will not actually produce the two doses. She might die in a road accident. She might resign from her job as, for instance, a consequence of the unexpected inheritance of a fortune. It cannot be known in advance that Saunders’s principle will be satisfied by any particular application of Option 12.

Furthermore, when distributions are just and unequal, their justice is not dependent on whether or not they conform to Saunders’s suggested principle. For instance, it is, I suggest, just that motor-car drivers are not all treated the same with regard to the possibility of parking without legal penalty in public places and that special treatment is given to those who have particular disabilities and impairments. They have a particular need which other drivers lack for available and convenient parking spots. This is a morally relevant difference. It is proportionate to the unequal treatment. Whether or not all people or all car drivers benefit from this arrangement as compared to one of strict equality is irrelevant to the justice or injustice of this particular arrangement.

Saunders writes: “My position is that the state owes citizens something like equal consideration or treatment as equals, but this need not require giving them equal amounts of anything, be it vaccine, chances of vaccine, etc.” (Saunders, 2018, p. 81, note 5). He concludes his paper by, similarly, saying: “Thus, while I believe that policymakers should show equal concern for all citizens, I suggest that this may permit, or even require, departures from equality in the distribution of (chances of getting) vaccine” (Saunders, 2018, p. 80). With all this I totally agree. My proposed nonconsequentialist policy for the ethical distribution of scarce vaccine in the face of an influenza pandemic reflects this agreement and withstands Saunders’s criticism of it.

I do not regard lotteries as such as moral ends in themselves but, in some circumstances, for some ends, as appropriate means. It is not my view, that, in the general run of things, medical treatment should be distributed by the NHS on the basis of a lottery system. For instance, I do not suggest that at the reception of accident and emergency departments, prospective patients should be given what functions as a lottery ticket on arrival. The combination of the rule of first come, first served and a triage system that takes account of the extent and urgency of the medical needs of the relevant particular individuals serve to give, in the circumstances, a practical expression of the principle of impartiality.

At the start of this paper was highlighted Saunders’s claim that “the proposal to give ‘equal chances’ to everyone is not as simple or as appealing as it first appears. Any policy will have to be sensitive to differences, in need and productive capacity, between people” (Saunders, 2018, p. 80). As I have shown, we cannot say what people must be sensitive to or what sort of principles must guide their distribution of scarce goods or services without considering the nature and context of the particular roles in which these particular people act and the nature and function of that which they distribute. When people act not as private individual citizens but, rather, in the role of officials or agents of the state, they act within particular spheres of authority and acquire particular moral and legal rights and duties along with their occupancy of such roles. In order to fulfil their moral duty to treat citizens impartially, agents and agencies of the state are sometimes morally required to treat particular citizens differently from others. This can be—but will not necessarily be—on the grounds of differences pertaining to their particular needs or abilities. This is not the same as treating some citizens differently from others on the grounds of differences in the needs or abilities, on average, of the members of the particular categories they belong to. Additionally, the notion of “need” does not fit comfortably with the distribution of vaccine to healthy people as a prophylactic.