Who is vulnerable and why? Uncovering mechanisms of vulnerabilization in healthcare

In healthcare ethics, the concept of vulnerability is often used to refer to the susceptibility and fragility of individuals who, due to age, illness, disability, social circumstances, or other characteristics, are at particular risk of harm or neglect in the context of clinical care and research and have specific needs which require protection and above-average professional commitment. 1 The concept has also been repeatedly criticized for being too unspecific, as all humans, together with other beings, are "ontologically" vulnerable and circumstantial vulnerability is a primal human experience. 2 In the eyes of its critics, this ubiquity of vulnerability in the realm of healthcare questions both the added value and specificity of the concept. 3 However, during the Coronavirus pandemic, the term has been copiously used by public health authorities, epidemiologists, ethicists, and politicians to refer to individuals or groups who may suffer disproportionately from the sequelae of the Coronavirus disease. 4 Yet, recalling vulnerability was never meant to remind the fragility of human existence alone and the differentialimpact of the pandemic for specific populations. It also provided a rationale for policies that aimed at addressing vulnerability and averting perceived harm through appropriate protective measures. 4 These not only included prioritizations for vaccines, testing options or the access to essential medicine and care but also-as in the case of nursing homes-restrictions on freedom of movement and visiting (including visiting bans) as ways of reacting to this vulnerability. Many countries are now trying to learn from their response to the pandemic and reflect on how to improve their preparedness for future public health crises caused by novel pathogens, armed conflicts, or natural disasters. This also includes the examination of the processes by which individuals and populations are identified as vulnerable and subsequently subjected to policy interventions. Again, the example of nursing homes illustrates this point: The evaluation of policy interventions seen as responses to vulnerability must also include considerations regarding excess mortality reported in many nursing homes worldwide, and the increasing evidence of suffering and harm inherent to many interventions. 4-7 The situation in Switzerland can serve as an example: In a postulate report on the effects of the COVID-19 pandemic on nursing home residents, 8 the Federal Council states "… that it has not always been possible to ensure the proportionality of protective measures for nursing home residents and respect individual freedom