Ethics and Inequities in the Context of Urgency : A Qualitative Study With Stakeholders on COVID-19 Decision-Making in Germany and Israel.

Urgent decision-making during the early COVID-19 pandemic raised complex ethical challenges, in particular concerning how to reach and include marginalized populations. To examine these issues, we conducted a qualitative study based on twenty-three semi-structured interviews with pandemic decision-makers and representatives of marginalized populations in Germany and Israel, focusing on decisions made in 2020 before vaccines were available. Key ethical themes emerged, including decision-making with ethical relevance under intense time pressure, the dominance of biomedical framings often at the expense of social considerations, inadequate attention to populations in bio-psycho-socially vulnerable positions, and the exclusion of stakeholders from decision-making processes. These findings have critical normative significance, highlighting issues of justice in the distribution of burdens and benefits, underscoring the importance of epistemic humility in acknowledging uncertainty and diverse forms of expertise, and affirming the moral obligation to integrate considerations of psycho-social vulnerabilities into public health. To inform future policy, we recommend establishing equitable governance structures to ensure broader stakeholder representation, implementing inclusive communication strategies to reach marginalized groups, and strengthening ethically informed crisis preparedness. Such measures can better align urgent public health decision-making with principles of justice, protection from harm, inclusion, and moral responsibility.