The giant drug company, Pfizer, announced recently that its newly developed vaccine for COVID-19 is more than 90% effective.[i] The news sent human hopes and financial markets soaring. Perhaps this vaccine, or one of its many competitors currently in various stages of testing, could free societies around the world from the threat of the deadly virus. As I write this, COVID-19 has already caused the deaths of about 1.3 million persons worldwide, with nearly a quarter million of those deaths in the U.S.[ii] Instead of diminishing, the troubling numbers are still on the rise.
The hope awakened by the surprising speed of the vaccines’ development is being tempered by many challenges yet to be overcome. Even after a vaccine has been authoritatively declared safe and effective, there will be predictable resistance on the part of many who distrust the evidence. It appears that the COVID-19 has energized a global pandemic of conspiracy theories, including those that fuel anti-vaccination fears.[iii]
For those who do trust the scientific studies and who want to be vaccinated, there are other challenges. There is likely to be a frustratingly long time before supplies will be both sufficient and widely distributed. Thus, there will be pressing questions about who is given priority for the vaccine. What is the fair way to allocate an effective vaccine when there is not enough for all who want and need to be vaccinated?
In a previous blog for this website, I proposed that such triage decisions in a pandemic should not be guided entirely by utilitarian considerations.[iv] Attempts to achieve the “most good,” I argued, need to be informed by an unwavering commitment to fairness, ensuring the equitable treatment of people. Doing good fairly means respectful consideration of the wellbeing of all of society’s members and with special concern for those who are most vulnerable.
Those who share such convictions about social justice in health policies will find much to celebrate in a recent publication from the National Academies of Sciences, Engineering, and Medicine (NASEM), titled Framework for Equitable Allocation of COVID-19 Vaccine.[v] The guidebook opens with a clear espousal of three “ethical principles” deemed to be “foundational.” To quote the report, these principles are as follows:
- Maximum benefit encompasses the obligation to protect and promote the public’s health and its socioeconomic well-being in the short and long term.
- Equal concern requires that every person be considered and treated as having equal dignity, worth, and value.
- Mitigation of health inequities includes the obligation to explicitly address the higher burden of COVID-19 experienced by the populations affected most heavily, given their exposure and compounding health inequities.[vi]
In a webinar introducing this work, Dr. William Foege, co-chair of the committee that produced the publication, acknowledged that it was rare in his experience for a report of this type to begin with a detailed explication of the undergirding ethical principles. Part of the value of this approach is the opportunity it provides for all of us to think more clearly and more deeply about how policy proposals depend on mutually held ethical convictions. Good policies are like ships that float on a sea of shared beliefs about how to structure a society that is both good and just. The policies, when done well, are the formal, visible expressions of society’s ethical values. Like a trustworthy person, a society with integrity is measured by the degree to which it is willing to live by its ethical principles. The wisdom of the NASEM framework for vaccine allocation is that it opens the foundational principles to full view.
The framework attempts to balance the utilitarian requirement to produce “maximum benefit” with a commitment to equitable treatment. Of course, the agreement at the level of principles does not guarantee agreement at the level of their application. The NASEM framework does not shrink from the task of clarifying how the principles should apply to many of the critical questions about resource allocation. In order to make these applications, the framework stratifies levels of risks such as the relative risk of acquiring the infection, the risk of severe morbidity or mortality, and the risk of transmitting the disease to others. The framework also details how the principles should be applied during four distinct phases of a vaccine’s deployment.
Using this elaborate framework, which groups are given priority in the first phase? Perhaps it is not surprising that “high risk health workers” and “first responders” are the two groups listed first. Reasonable people are likely to agree that we all benefit if these essential caregivers are given priority protection.
Next, the framework calls for vaccinating people at high risk because of comorbid conditions and elderly adults living in congregate settings. Statistics regarding the risks of death from COVID-19 indicate a clear pattern of much higher risk for elderly persons, especially those living in an institutional environment. For example, in the county where I live, only about 6% of the cases have been people over 70, but 55% of the deaths have been in this age cohort.[vii]
As the report continues with listing priority groups, one noteworthy element is the attention given to race and ethnicity: “The current moment of ethical reckoning playing out around race in the United States reveals the disproportionate impact of the COVID-19 pandemic on racial and ethnic minorities and other vulnerable and marginalized groups through cultural and political discourse across the country.”[viii]
By now, most Americans should be aware of the disturbing differences in the way COVID-19 has affected various communities. African Americans and Native Americans, for example, have endured much higher rates of infection and death, often two to four times higher.<[ix] Many factors such as poverty, living conditions, access to care, and ability to isolate affect these differences. From the perspective of fairness, it would make sense to give priority to those communities at higher risk. This is one way to achieve a measure of compensatory justice for communities that have so often been unfairly disadvantaged. It is also an example of how egalitarian and utilitarian considerations can sometimes be fully consonant. We can achieve maximum benefit and act in fairness by granting priority to communities that have historically experienced high levels of health disparities. We can do the right thing and the good thing at the same time.
Finally, I will mention the NASEM framework’s praiseworthy commitment to transparency. According to the report, “Transparency includes the obligation to communicate with the public openly, clearly, accurately, and straightforwardly about the allocation framework as it is being developed, deployed, and modified.”[x] Achieving this goal will not be easy in our current cultural environment. The burgeoning conspiracy theories combined with the lack of trust that provides fertile soil for such theories will make this work difficult. But making the norms by which rationing occurs publicly visible is a needed step toward building essential trust. The NASEM consensus report is a model of such openness.
Gerald Winslow, PhD
Dr. Winslow is the Founding Director of the Institute for Health Policy and Leadership and the Director for the Center for Christian Bioethics. He is also a Professor of Religion and Ethics at Loma Linda University School of Religion. His research interests include biomedical ethics and the relationship of social ethics to health policy.
- [i] Katie Thomas, et al, “Pfizer’s Early Data Shows Vaccine Is More Than 90% Effective,” New York Times, Nov. 9, 2020 updated Nov. 12, 2020. https://www.nytimes.com/2020/11/09/health/covid-vaccine-pfizer.html
- [ii] Johns Hopkins University of Medicine, https://coronavirus.jhu.edu/ Accessed Nov. 12, 2020.
- [iii] Emily Rauhala, “The Pandemic Is Amplifying the U.S. Anti-vaccine movement – and Globalizing it,” The Washington Post, Oct. 7, 2020. https://www.washingtonpost.com/world/coronaviurs-antivax-conspiracies/2020/10/06/96ddd2c2-028e-11eb-b92e-029676f9ebec_story.html Accessed Nov. 12, 2020.
- [iv] Gerald R. Winslow, “Fairness in a Pandemic,” posted July 16, 2020. https://ihpl.llu.edu/blog/fairness-pandemic
- [v] Framework for Equitable Allocation of COVID-19 Vaccine, The National Academies Press, Washington, D.C., in press Nov., 2020. Available at https://www.nap.edu/catalog/25917/framework-for-equitable-allocation-of-covid-19-vaccine
- [vi] Ibid, p. 6.
- [vii] San Bernardino County, California. https://www.google.com/search?client=firefox-b-1-d&q=san+bernardino+county+covid+statistics Accessed Nov. 13, 2020.
- [viii] Framework, p. 29.
- [ix] Mary Van Beusekom, “Studies Spotlight COVID Racial Health Disparities, Similarities,” CIDRAP, Sept. 25, 2020. https://www.cidrap.umn.edu/news-perspective/2020/09/studies-spotlight-covid-racial-health-disparities-similarities Accessed Nov. 12, 2020.
- [x] Framework, p. 7.