I was waiting for this one.
Back when ventilators were the rage (before we found out that once you were on a ventilator, you were pretty much toast anyway–Science!), I had filed an article about the likelihood that Down Syndrome sufferers would be deemed unworthy of high priority when scarce equipment was being rationed. I never got around to writing about it, but I knew, like the giant swan in “Lohengrin,” the issue would be sailing by again. Sure enough, as the prospect of a Wuhan virus vaccine seems within view, the same basic question is being raised: if there aren’t enough vaccines for everyone, who gets the first shot (pun intended)?
Well, there is no right answer to this one, unfortunately. All debates on the topic will become that popular game show, “Pick Your Favorite Ethical System!” or its successful spin-off, “What’s Fair Anyway?” That’s fun and all, but the debates are completely predictable.
The issue is essentially the same as the “meteor or asteroid about to hit the Earth” dilemma in movie like “Deep Impact,” where only a limited number of citizens can be sheltered as a potential extinction event looms. If you follow the Golden Rule or the John Rawls variation, you end up with survivors being chosen by lot, or pure chance. Kantian ethics also tends to reject any system that sacrifices one life for a “more valuable” one. Competent and rational public policy, however, has to take into consideration more factors than these over-simplified (and this appealing) ethical systems can.
Like it or not, a decision in the rationing of a vital resource problem has to come down to utilitarianism, or balancing. That means winners and losers, and the losers in such decisions always feel that the winners being favored is unfair. From their perspective, they are right. Policymakers, however, have a duty to society as a whole, and the long-term best interests of the whole population. Being human, they also have biases, and how they weigh the various factors involved in balancing interests inevitably is affected by their own agendas.
If the job of determining who got the vaccine first was delegated to Black Lives Matters, how do you think it would approach the problem?
This article by the American Council on Science and Health (Full Disclosure: I acquired funding for an ACSH study when I ran the National Chamber Foundation) discusses the vaccine problem and proposals that so-called “superspreaders”—young people who are not at the greatest risk of fatality from the pandemic but are the ones most likely to spread it—should get the vaccine before the elderly. You can make up your own mind about the logic. My own approach to “balancing” would begin with leaving anyone 80 or above (what my father called “the Red Zone”) last on the the priority list, since they might drop dead any minute anyway. The real battle is bound to be over “essential” people, whoever they are. Again, there are no right answers (though there are wrong ones), because priorities and relative values are not reducible to certainly. Should parents have priority over single adults? Are teachers essential or only good teachers? Elected officials? Citizens over illegal residents? Artists over athletes? Lawyers over truck drivers? Clergy over sex workers?
Yes, I was waiting for this one.
That doesn’t mean I am looking forward to it.
Pointer: Arthur in Maine
32 thoughts on “On Distributing The Wuhan Vaccine: An Old Ethics Dilemma With No Solution”
Real talk: I managed buying decisions for our retail’s pharmacies for the first year, and part of that was sourcing seasonal flu vaccines. Unless you make it mandatory to get the vaccine, or predicate a vaccination as part of an opening program, I would be absolutely dumbfounded if uptake on the vaccine reached 30% of any population. The average flu shot only reaches 10-15% of a population, and the market produces vaccines with that assumption baked in…. As much as flu clinics push for everyone to get a shot, if everyone actually tried, the system would fail.
I think the administration of a COVID19 vaccine should be given based on previous flu vaccination history. It’s a perfect revealed preference story, if you really believe you are ‘essential’ or high risk you would have been getting the flu vaccine as well.
I think you’re right. Had the vaccine come out at the peak of the panic, there would have been a huge rush to try to get it. The fear has dwindled considerably, and many people in low-risk groups might make the calculation that getting the virus carries fewer unknowns at this point than taking a vaccine with no long-term clinical record.
I suspect, unless the vaccine is mandated in some way, or an incentive system is devised (exemption from mask mandates for those who have been vaccinated, for example – though that is probably unworkable), there will be an initial shortage and rationing, but a surplus of doses will be available fairly quickly.
There are currently at least four vaccines in late-stage testing, so there is going to be a mad dash to capture the market initially. Once herd immunity is reached and the case numbers fall off a cliff (and recent studies suggest that may happen with as low as a 25% vaccination rate) the demand will dry up overnight, so production will be going around the clock to manufacture and distribute while the demand is high. It seems to me like we’re setting up for a huge case of oversupply.
Rush or not, I doubt very much whether there will be an oversupply. The group known as ‘antivaxers’ is already growing, with more ungrownups than ever ignoring the Get Yer Flu Shot signs. So says a pharmacist I know. Added to that are those who were never in close proximity to the coronavirus in the first place, or those who were (as with other family members) but who never acquired the disease even if they brushed up against it. They believe, or want to believe, that they are immune or that …. wait for it! … there was never any Wuhan virus around in the first place. Sooner or later it will pop up again – due to idiots like the above – and there will be a second rush – or mandatory public health regulations as they have for tb . . . Quarantine in hospital. Okay, the last is not likely; just my suggestion. Make that a prison hospital.
I think that people who get the flu shot aren’t doing so because they’re afraid of the flu, remember: we aren’t talking about pox or polio here, we’re talking about the normal, seasonal flu. Perhaps, people get it to feel better about themselves, having Done Their Part, as a private, feel-good personal virtue signal. Perhaps, they do it as a ward against the inconvenience of illness, at least so long as the inconvenience of getting the shot doesn’t outweigh that risk. Perhaps, they see it as a smart thing to do because all the information regarding booster shots led them to that conclusion, which is a completely legitimate idea.
But that is largely irrelevant, because regardless of why people are getting the flu shot, what’s more important is why people aren’t: Inconvenience. “I didn’t know about the flu clinic” “The lines were too long” “I don’t like needles” “I didn’t have a chance to visit my pharmacy during clinic hours” Whatever justification you need: People don’t go out of their way to get flu shots. Again 10-15%. I assume that to an extent, fear will drive some usage. But only some. America might actually have the highest uptake; Depending on whether the Democrats decide that either that the vaccine is a moral imperative or Hitler Juice, something approaching 50% of America will probably get the vaccine just to spite the other half of America on purely partisan lines. .
I think a more pressing moral dilemma is over making the vaccine mandatory for participation in society. As for distribution, I would only distribute it to populations at high risk of developing serious symptoms from this Coronavirus. New vaccines, especially ones rushed into service, can have unexpected side effects. Take the swine flu vaccine developed by GlaxoBuroughsWellcomeSmithClineBeecham which caused (probably lifelong) narcolepsy in hundreds of children as an example. Covid-19 is not a serious health risk for most people, I wouldn’t take it voluntarily and wouldn’t allow my family to take it until it has several years of proven use. Like the flu and chicken-pox vaccine, this vaccine will be a life-saving vaccine for some, but it will only be an inconvenience-saving vaccine for most. New vaccines are riskier than proven vaccines, so it only makes sense to distribute it to groups when the benefits outweigh the risks the most.
Glad you found this article worth an EA post, Jack.
To me, the prioritization actually appears fairly straightforward. It works as follows, in descending order of priority:
1) First responders (EMS, Police, Fire, etc.) and retail pharmacy employees – These are individuals who have a high likelihood of encountering contagious individuals in an uncontrolled setting.
2) Frontline acute care medical personnel – starting with Doc-In-The-Box and hospitals (from docs to nurses to housekeeping and dietary). These individuals are at high risk of exposure but in somewhat more controlled settings than first responders.
3) Non-acute-care medical personnel (general practitioners, orthopedic surgeons, oncologists, chemotherapy, nursing homes, etc. – and their office and facilities staffs
4) Persons with known risk factors regardless of age (except maybe “red zone – see below) – e.g., hypertension, COPD, etc, and those who are otherwise healthy but above 60 years of age. I think the so-called “red zone” should be included here, but if you keep the caregivers protected and control visitation, that can help.
5) Retail sales personnel working in areas of essential commerce (grocery, hardware, etc.)
6) Transportation personnel – airlines, trains, ground transportation, etc.
7) Scholastic and Academic education staffs
8) General population, sorted by vulnerability as vaccines become available
The prioritization rationale that makes sense to me is to first protect those who offer vital services that can help manage public health, then move into essential services to help the economy recover.
Given the fact that maybe a third of the population wants to be first in line and nearly half doesn’t want a vaccine at all, the point may be moot. All of the pharma outfits who have stuff in phase three trials right now are already betting on the come and producing millions of doses in hopes that their vax will prove safe and effective. So it may ultimately not be much of an issue.
I would put the all doctors ahead of the police and fire, then at number 2, I’d add prison guards/staff with the police and fire. Prisoners moving into a prison can be quarentined so any new infection vector would come from staff.
Prison guards are an excellent call, Valk, but I reiterate my rationale for putting frontline medical personnel behind first responders. They work in MUCH cleaner environments and have access to much better PPE. I speak from first-hand experience on this.
A family member has been working the COVID wing of a large nursing home for several months now. They have about 20 admits/day to the COVID wing. He has been pulling about 2, 12 hour and 1, 48-hour shift each week. He is tested weekly and has not contracted COVID yet. I know a lot of health-care professionals who deal with COVID patients daily. None have contracted COVID from work and neither have their co-workers. One co-worker of a family member contracted COVID from a family member but not from patients. So, healthcare workers seem to not be THAT high risk of contracting it, much less dying from it.
Lottery. Let randomness decide. It’s the easiet and fairest route.
maybe a third of the population wants to be first in line and nearly half doesn’t want a vaccine at all,
Agreed. i don’t want to be pushy, so I’ll opt for second in line.
Vaccines work by initiating a managed immune response. If young people get covid and show no symptoms they are effectively innoculated. That is how herd immunity forms. So it makes little sense to give them a vaccine first. Using a killed vurus vaccine on the most vulnerable would make far more sense.
I for one will not rush out to get vaccinated against a virus that kills people in my age group but I might recommend others do so. I have not really altered my day to day activities since this began. Moreover, I will not spend my remaining years worrying that I could drop dead any minute. I choose to live like the 20 something rock climber or base jumper. When my number is up it’s up. Far too many go about life in a state of dread. The only thing I fear is my loss of personal freedom from others who think they know what is best for me. Spoiler alert. No one can assess the relative value of a human life.
Herd immunity forms when a sufficient proportion of the population become immune such that individual cases cannot spread far and wide. This can be achieved with natural infection or vaccination.
While I suspect that fully asymptomatic transmission is rare at least between healthy persons, I do suspect that mild cases are fueling the spread to vulnerable persons. Therefore it would be logical to vaccinate the even healthy persons to avoid transmission during cases with mild symptoms.
I for one will not rush out to get vaccinated against a virus that kills people in my age group
Does that mean you will take the vaccine if it is offered at your doctor’s or local pharmacy? I agree completely with the rest of your post. I have the same sort of life and life expectancy. However, being in the vulnerable age group and having shopping, drs appointments and other errands to do outside, I would like to get the vaccine early on. Meanwhile, I don’t stress out about it and get on with my life in the same manner.
My opinion on vaccine distribution.
First group to get the vaccine should be healthcare workers in hospitals and clinics and all hospital patients; we must have a healthy healthcare workers to have an effective healthcare system.
The second group should be K-12 school age children and school employees thus opening all the schools across the United States and giving the parents the freedom to return to work.
Third groups should be students actually in college and college employees.
Fourth group should be anyone over 60. (This is when I’d be getting the vaccine)
Fifth group is everyone else.
Oops, I intended but forgot to include in the second group Police, Firefighters, and Ambulance personnel.
Interesting that many here are rating by occupation. That seems like nonsense to me based entirely on emotion.
The CDC data indicate that 94% of C-19 mortality is linked to co-morbidities. They are, in order: Alzheimer’s/Dementia; Hypertensive diseases; Ischemic heart disease; Diabetes, and Cerebrovascular diseases. If the intention is to save lives, those over 60 with those conditions are the most vulnerable.
Obesity is a primary driver of deaths by C-19, as it leads to the conditions noted above, including Alzheimer’s/Dementia. Targeting the obese population, 42% of the population (per the CDC 2017-2018 report), by existing co-morbidity, then by age, would be a sensible approach, if the desire is to save lives.
Vaccinating school children, or indeed those under 25, would be a waste, as their mortality rate from C-19 is effectively zero. A morbidly obese 18 year-old with diabetes would by covered under my suggested protocol. A fit, 27 year old firefighter doesn’t need to be anywhere near the front of the line for a vaccine.
The misperception of risk of C-19 has caused the government to make many bad decisions managing the response. Here is an interesting Gallup-Templeton poll, examining the age risk perception, and how many have it wrong: https://us.beyondbullsandbears.com/2020/07/28/on-my-mind-they-blinded-us-from-science/
You make a lot of sense. What I don’t comprehend is why those ranking by occupation do not mention those research scientists and tech’s whose work create the vaccines and therapeutics that keep the vast majority of people functionally healthy.
Why are farmers and food producers high on the list? Who will feed us if they get sick. What about personnel working in sanitation jobs such as trash removal to water purification. The list is endless.
What I see is a ranking that assumes that we will experience a collapse of social order because of covid 19. The current unemployment rate in Maryland is 6.3% across the country we are no where close to depression era unemployment rates. There may be pockets of high unemployment but some of that is due to government policies not disease. The world is not coming to an end.
Once we start ranking social value by occupation consider that you are saying retirees have less social value. Further, I want you to explain to those non-government funded workers why they are less socially valuable. Keep in mind that without all those others there would be no one to create the income that pays all those higher valued persons.
If we’re ranking occupations, can we agree to put government bureaucrats last? 🙂
Beat me to it.
The reasons for giving a higher priority to K-12 schoolkids is not that they are at great risk, nor that they are terribly likely to spread the disease to other folks. It is because teachers are afraid to come back to school and this would eliminate any real excuses. I exclude those teacher’s unions who are attempting to hold the system hostage for their pet projects (like eliminating charter schools, banning homeschooling, getting rid of vouchers, etc) — they don’t even pretend to give rational reasons.
Getting the kids back in school is critical for continuing the recovery of our economy. If parents can’t go back to work because they’re stuck at home with their kids — we have serious problems.
I think we’re getting to the point where the actual health concerns are receding, and we have to focus on restarting the economy as the best way to do a lot of things, including saving lives overall. I just wish we could get the governor of North Carolina to think about this (and not keep insisting on a ‘one size fits all’ approach for the whole state).
School age children have not proven to be ” carriers” or a significant vector in any study that I’ve seen. Can you recommend any for me? The fear of this appears to be groundless.
Sorry, I misread your first paragraph.
Shouldn’t be doing this while driving, drinking coffee and smoking, in a storm.
Joe, I hear what you’re saying. But having spent some years in that world (as major-city-and-suberbs EMT, which takes you into a LOT of nursing homes and hospitals, to say nothing of the streets and homes) – I know of what I speak when it comes to priorities to those folks. If NOTHING else, it gives those staffers – and, more importantly, the people they deal with – a degree of assurance. This is why I place them first.
True, that 27-year-old firefighter almost certainly won’t have long-term consequences from exposure. But he/she DOES need to be protected, because he/she is going into environments in which he/she may be exposed – or, in some cases, be asymptomatic to mildly symptomatic, and keep working – thence to expose OTHERS. He/she will be sent home if testing positive, meaning that other members of the department will have to do more overtime, increasing the odds that THEY will get exposed. And everyone may emerge out the other end just fine, but in the meantime, buildings burn and patients die because the first response agencies were understaffed due to “an abundance of caution.”
I walked those streets 40 years ago. I know what happens. Those folks need to be protected FIRST, for public health reasons.
I understand your point, and I expect that some degree of vaccine theater will be needed to reassure various segments of the population, and if I had to vote between reassuring first responders with a vaccine or the parents of school children, I would certainly vote for the first responders.
I expect that every time I hear the phrase “abundance of caution” for the rest of my life I will be angry as I recall this year and the lives ruined, the Constitution shredded, and the lives stupidly lost (Yeah, YOU Governor Cuomo).
I understand what you are saying, but let’s not get overly dramatic. This is not a disease that takes months to recover from. Most healthy people seem to recover in 3-4 days and only suffer allergy/cold/flulike symptoms. We have hospitals shut down all over this country from lack of patients. We have EXCESS nurses in this pandemic, many are still furloughed. Think about this, we have the only pandemic in the world with a shortage of patients. We don’t actually need every first responder we have right now. Many are currently benched on the sidelines due to lack of need.
I’m talking cops, firefighters and EMT/Paramedics here. Those folks aren’t exactly sitting on the sidelines these days.
Yes, but it isn’t like coronavirus is going to sideline them for any significant time. Once they get COVID-19, they don’t die. They aren’t incapacitated for a long period of time. They could be back at work in a few days, in most cases, if they were really needed. Maybe in overworked places like New York in would be a problem, but in most places, it won’t be any worse than when there is a bad flu outbreak.
I believe HT is correct in his assessment that only a relatively small fraction of the population is actually going to choose to be vaccinated right away when the vaccine is available. I work in a hospital and it is difficult to get all the staff to get their flu shots. As a 72-year-old doctor, I’m going to be innoculated when the vaccine becomes available but I have heard many other staff state that they will not. At this time, I don’t know how strongly the hospital is going to push vaccination. I’m with Chris in that I’m not going to give up things I enjoy to try to live my life risk free but I do try to minimize the degree of risk. I continue to ride my bicycle but I choose to wear a helmet.
Looking at the proposals on how to prioritize vaccine distribution, I think everyone basically agrees that health care providers, including essential non-clinical staff, should be first and then other essential type personnel. The primary difference of opinion seems to be on the question of whether to hit oldsters or youngsters first. Read the ACSH article.
The reality is that Covid is not the Black Death, an apocalyptic zombie plague, or an asteroid strike. It is a serious illness but the fact is that the majority of people who catch it survive and there are ways to minimize the risk of catching it. Once the vaccine is available, it is not going to be a case of get it today or you’re going to die.
As an aside, the American Council on Science and Health is a great resource. They cover a wide range of topics, debunk a lot of junk science, and Josh Bloom’s hilarious “Dreaded Chemistry Lessons from Hell” are a must read if you are at all interested in chemistry.
Josh Bloom’s “Dreaded Chemistry Lessons from Hell” are a must read even if Organic Chemistry is the reason one dropped any fantasy of ever becoming a physician and became a psych major instead.
As a theoretical exorcise, like thinking how to spend lottery money I’ll never win, this is about on the same level concern. If and when there is a vaccine, my likely hood of getting it is practically nil. Which is the same as my likely hood as the yearly flu vaccine, shingles vaccine, and other optional vaccines that make afternoon TV unbearable to watch.
However, watching people, especially those in government, and especially Nancy Pelosi, front and center when the vaccine does come out, under a President Trump administration, it will be almost worth the cost of all the suffering just to see the looks on their faces when they have to either get the shot or try to get out of getting the shot.