Bioethical parameters for judicial decision-making in public health emergencies: a normative framework derived from COVID-19 health judicialization in Brazil

Abstract Background Health judicialization intensified during the COVID-19 pandemic in Brazil, placing courts at the centre of disputes over resource allocation, access to treatment, vaccination mandates, and intergovernmental health governance. Although bioethical frameworks for pandemic decision-making are abundant, they are primarily directed at administrators and clinicians. Guidance tailored to judges’ institutional role and to the specific conditions of a declared public health emergency remains underdeveloped. This study addresses that gap. Methods This empirical bioethics study was conducted in two integrated stages. Stage 1 comprised a qualitative documentary analysis of Brazilian judicial decisions concerning COVID-19 health litigation, retrieved from the AASP/JUIT case-law database. The decisions are primary public sources, identified by case number and reproduced in full in Additional file 1. The search identified 17,537 cases from 2019 to 2025. Systematic probabilistic sampling (k = 18) yielded 1,002 decisions, of which 417 were excluded during eligibility screening, leaving a final corpus of 585 decisions distributed across four mutually exclusive thematic axes. Stage 2 used wide reflective equilibrium to integrate the empirical patterns with three theoretical traditions: principlist bioethics, Latin American social bioethics, and public health ethics benchmarks. An audit trail linked each empirical finding to the bioethical tension identified, the candidate parameters generated by each tradition, the points of divergence, and the final adjudicated parameter. Results The corpus comprised 223 decisions on ICU access and resource scarcity (38.1%), 171 on compulsory vaccination and individual autonomy (29.2%), 122 on medication provision (20.9%), and 69 on federative conflicts and SUS governance (11.8%). We propose the Bioethical Matrix for Judicial Orientation in Sanitary Emergencies (BMJOSE), which comprises four sets of axis-specific parameters and five cross-cutting principles: proportionality, equity of access, evidence-based reasoning, institutional transparency, and protection of the minimum existential core. The derivation is presented in full for Axis I. The framework is then applied to three decisions from the corpus: one in which it confirms and enriches the reasoning, one in which an existing binding precedent already embodies the relevant parameter, and one in which it would have required different reasoning. Conclusions BMJOSE is offered as a reasoning scaffold, not as a source of authority that supersedes law, precedent, or judicial ethics. It operates within duties already imposed on judges by Brazilian law, particularly articles 20 and 21 of the Law of Introduction to the Norms of Brazilian Law, as amended in 2018, and gives those duties emergency-specific, axis-based content. Its contribution lies in structuring judicial reasoning and making it auditable, rather than in creating new principles.