Vaccine Priority Decisions: Ethical Considerations and Concerns

The Issue

As COVID-19 vaccine pharmaceutical developers race toward safe and effective candidates to stem the tide of the pandemic, health officials and policy makers as well as citizens are grappling with a number of significant philosophical, operational and ethical or social justice challenges.

This blog addresses three questions:

  1. How best can we allocate limited vaccine doses to the world’s and a specific country’s population?
  2. How best do we prioritize values and ethics to determine who gets the vaccine first?
  3. Why is it likely that the vaccine will not signal the end of COVID?

Vaccine Allocation Globally and Nationally

Which countries should get a vaccine first? To reach herd immunity, about two-thirds of the world population – four billion to five billion people – need to be vaccinated. Most global citizens, at least for the Pfizer, Moderna and AstraZenica vaccines, will have two doses – that is 10 billion doses of the vaccine. This immense challenge of global distribution reflects a number of realities:

  • Demand for vaccines far outstrips the available supply, and is expected to do so for at least several more months.
  • Many of the world’s wealthier countries have already pre-purchased the available vaccines. Canada for example has pre-purchased enough for more than five times its population.
  • We don’t have enough vaccines for richer countries, so poorer countries that are next in line will have to wait longer.
  • According to the WHO, 75% of all current doses have been deployed in only 10 countries.
  • It is unlikely that countries with excess vaccines would start sharing vaccines until they have completed their own vaccination campaigns.
  • Countries like Russia and China are engaging in “vaccine diplomacy”—that is, linking their allocation of vaccine production to strategic attempts to influence the economies and foreign policies of developing nations.

The Economist Intelligence Unit, part of The Economist Group, recently explained that whereas the rollout of vaccines against coronavirus has started in developed countries, mass vaccination will take time. The unit predicts that the bulk of the adult population in advanced economies will have been vaccinated by mid-2022. Middle-income countries will take until late 2022 or early 2023. For poorer economies, mass immunization will take until 2024, if it happens at all.

Prioritizing Whose Shoulders Get Injected

Ethical and moral-value immunization priorities:  What ethical principles should policy makers employ? Should they distribute vaccines to citizens to minimize premature death, save the most lives, combat poverty, forestall economic devastation, or something else? To what degree should inoculating essential workers, the poor, minorities and the young (or old) affect vaccine distribution within a country? Is it better to prioritize the quantity of lives saved by a vaccine or rather the quantity of life-years saved? Or should the criteria be doing the most good while doing the least harm?

Here are some of the contending ethical and moral vaccine considerations at play:

Ethical or Moral Value Application Complications
Maximize good (benefits) versus minimizing harm   Reduce overall illness and death related to COVID-19, protect those at greatest risk of serious illness and death, protect critical infrastructure, and promote social and economic well-being Bias toward the elderly since they are most at risk in wave one and two. Try to target most vulnerable populations (nursing homes, prisons, aboriginal communities, warehouses)
Fairness Equal opportunity of health outcome. Ensure that every individual within equally prioritized groups has the same opportunity to be vaccinated         Recognize that younger cohorts more at risk with wave three. Ensure inclusive consistent processes that are tailored to unique needs of varied communities
Equity Equal opportunity of access. Distribute vaccines without bias or discrimination, to reduce disparities in illness and death related to COVID-19 Changes as supply of vaccine changes. Ensure benefits for groups experiencing greater burdens from the COVID-19 pandemic
Reciprocity Recognize heroic effort to everyone’s well-being from front-line workers Which front-line workers are prioritized?
Transparency Ensure that decision-making processes and plans are clear, understandable and communicated to the public Translation in multiple languages, and use of translators/ facilitators where necessary
Public trust   Ensure decisions advance confidence and trust in immunization program Different locations may have different needs, demographics and priorities
Legitimacy   Make decisions based on the best available scientific evidence, shared values, and input from affected parties including those historically underrepresented Ensure decisions have the intended impact, as well as include participation of affected parties in the creation and review of decisions and decision-making processes

 Source: EthicScan Knowledgebase, including adaptation from COVID-19 Vaccination Task Force and from PHAC, The Public Health Ethics Framework: A Guide for Use in Response to the COVID-19 Pandemic in Canada

Operational or Logistical Issues:  Some countries (such as Canada) are giving the two-injection vaccine in prolonged intervals whereas others (such the United States) are inoculating within supplier’s recommended four to six week intervals.  Global experts including those working with the WHO say that current vaccines will not be fully distributed until 2024.

Vaccine Hesitancy: In such countries as France, Japan and Argentina – vaccine hesitancy abounds– around half of their populations have said they do not want to get the jab for various reasons.

Social Determinants of Health:  If we focus vaccine prioritization on the goal of alleviating poverty, how should we measure poverty and combine that with health? To measure poverty, some propose taking the total shortfall between each poor person and the poverty line and dividing by the level of the poverty line. How much does preventing some poverty on this measure matter compared to a life? Are we willing to prioritize vaccine distribution to sacrifice lives to help the poor? How many lives should we be willing to sacrifice exactly? And who exactly participates in such vital decision-making?

Applying Ethics To Specific Immunization Priority Decisions:  Should school teachers receive vaccine priority as part of the initial vaccine rollout? What about child care workers, hospital technicians, or Indigenous peoples? Should health-care providers come before or after residents of long-term care facilities? These are tough choice decisions.

How we prioritize access to the COVID-19 vaccine is not an exclusively political or medical decision, but an ethical decision. It must be informed by good science, but science cannot tell us who should get the vaccine first. We have to decide upon and between a mix of interesting criteria like these:

Criteria Analysis Assessment
Numbers and Age Risk groups for death from COVID include those over 85 years of age, those who are health compromised, including recipients of an organ transplant, haematological cancers, chronic kidney disease, immunosuppression, dementia, stroke, diabetes, obesity, malignancy, and liver disease. The risk is higher among the elderly who reside in care homes, where the risk of infection is higher than in the case of elderly living in isolation or with few contacts. Prioritizing this criterion will likely maximize the number of lives saved. Other values, apart from saving lives, should be included, or at least considered. Implicit in the idea of prioritizing care-home residents and workers, as well as health-care workers is that this will significantly reduce infections among those at the highest risk. This principle could be extended to anyone who has contact with vulnerable people, such as carers.
Years of Life Saved   What matters is not only whether a person’s life is saved, but how long it is saved for. It is morally different to save a person for 50 years than it is to save them for one year. Those who have most life years to gain are usually those who have so far lived the least. However, the young deserve to have their life saved because they have had less life. The greatest benefit might be achieved by targeting the vaccine to the elderly. This is essential in a situation of limited availability of resources. Current estimates suggest that vaccination is most cost-effective in terms of QALYs gained if targeted at groups with higher risk of hospitalization and death.
Vaccine effectiveness  A vaccine may have different levels of effectiveness in different groups. Flu vaccination, for instance, is much less effective in the elderly. If a future vaccine turns out to be similar to the flu vaccine in this respect, this will be a factor. Recent UK vaccine prioritization modelling suggests that as long as a vaccine is more than 20% effective (i.e. only working 1 in 5) it would still save the most lives and life years if older age groups were targeted. Targeting the young might better protect the vulnerable via indirect protection.
Quality of Life It is standard in health economics and the allocation of limited health resources to take into account not only probability of beneficial effect and length of effect, but also the expected quality of the expected life. This is combined in the concept of a Quality Adjusted Life Year (QALY). (1) In the UK, treatments will only be funded (with a few exceptions) if they cost less than £30 000 per QALY. Unconsciousness, dementia, or other forms of severe cognitive disability would affect the number of QALYs a person could gain by surviving COVID-19, and therefore the level of priority such a person would be given in accessing the vaccine. This would clearly be relevant to a policy of prioritizing patients in nursing homes.
Number of Dependents   Those who have dependents might be given extra priority, and those who have dependents who are in COVID-19 vulnerable groups might be given even higher priority. The health of dependents should be factored into the health costs of COVID-19, as a sick carer might (at least temporarily) undermine the health of their dependents, too.
Societal value or worth Taking into account the contribution a person makes to society—for example, as a writer, poet, performer, or business executive, or alternatively in an essential  service role as a garbage collector, grocery store clerk, or truck driver. Although the idea might appear controversial, the public does give moral weight to “social worth”

Source: adapted from By Alberto Giubilini, Julian Savulescu and Dominic Wilkinson, British Medical Journal  

(1) A QALY is given by multiplying a year of life x its quality (on a scale of 0-1).

Is the End of COVID in Sight?

Too many of us may be guilty of wishful thinking that two shots in the arm means we will be able to go back to life pre-pandemic. Epidemiologists and public health experts have various reasons for saying this thinking is a gross fallacy:

  • (a) the evolution of deadlier variants in the virus may mean that protection coverage is suspect over the course of a year or two. Vaccines may have to start over on a seasonal basis;
  • (b) if large parts of the world’s less-developed countries are delayed in receiving the vaccine, travel (notably air and cruise ship) as we knew it pre-pandemic is not possible; and
  • (c) even if the problem of vaccine hesitancy is overcome, there is uncertainty and disagreement about whether herd immunity will give protection to most or all of us.

EthicScan Blogs  Mandatory Vaccination If and When, You or Me (October 7, 2020) and Boredom, Vaccine Fatigue, Mental Health and COVID-Enhancing Morale Finding Meaning (March 24, 2021) raised questions about when, and if, the coronavirus will end. While the world recovers from COVID-19, it will be plagued by economic and health challenges and uncertainties that will impact everyone. According to some thought leaders, the cautionary implications are as follows

  • a national vaccination campaign is not the “light at the end of the tunnel” even if the entire population is immunized
  • global travel is unlikely to resume until 2024
  • emergence of new vaccines may mean going back to square one in fighting the pandemic
  • according to the most optimistic predictions, the skies will only really begin to open, and travel and tourism will resume, sometime between 2023 and 2024
  • some forecasters think  the virus will never go away—that we will learn to live with it, like the flu.

Conclusion

There are many complex ethical and operational considerations governing the allocation of the COVID-19 vaccine. While it is too early to tell, we may be in error in thinking the pandemic will be conquered by currently available vaccines.

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Further Readings

NPR – The Ethics Of Who Gets The COVID-19 Vaccine And When:
https://www.npr.org/2020/12/20/948614855/the-ethics-of-who-gets-the-covid-19-vaccine-and-when

EthicScan Blog – The Ethics Of Who Gets The COVID-19 Vaccine And When:
https://ethicscan.ca/blog/2020/10/07/mandatory-vaccination-if-and-when-you-or-me/

Scientific American – How to Distribute a COVID-19 Vaccine Ethically:
https://www.scientificamerican.com/article/how-to-distribute-a-covid-19-vaccine-ethically/

Toronto Star Podcasts – The ethics of a COVID-19 vaccine and who gets it first:
https://www.thestar.com/podcasts/thismatters/2020/07/30/the-ethics-of-a-covid-19-vaccine-and-who-gets-it-first.html  LISTEN ONLY

EthicScan Blog – Boredom, Vaccine Fatigue, Mental Health and COVID: Enhancing Morale/Finding Meaning:
https://ethicscan.ca/blog/2021/03/24/boredom-vaccine-fatigue-mental-health-and-covid-enhancing-morale-finding-meaning/

Government of Ontario – Ontario Releases Ethical Framework for COVID-19 Vaccine Distribution:
https://news.ontario.ca/en/release/59850/ontario-releases-ethical-framework-for-covid-19-vaccine-distribution

Journal of Medical Ethics – Vaccine distribution ethics: monotheism or polytheism?:
https://blogs.bmj.com/medical-ethics/2020/11/11/vaccine-distribution-ethics-monotheism-or-polytheism/

Dalhousie University – Novel Tech Ethics – Priority groups for COVID-19 vaccination: Ethics, policy and practice in select jurisdictions:
https://www.dal.ca/sites/noveltechethics/news-events/PastEvents/2021/02/11/priority_groups_for_covid_19_vaccinations.html   NOT TEXT ARTICLE

Government of Canada – Public health ethics framework: A guide for use in response to the COVID-19 pandemic in Canada:
https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/canadas-reponse/ethics-framework-guide-use-response-covid-19-pandemic.html

Jerusalem Post – COVID-19: Here’s why global travel is unlikely to resume ‘till 2024:
https://www.jpost.com/health-science/coronavirus-in-israel-vaccination-doesnt-equal-liberation-657898

David Nitkin
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