Accelerated COVID-19 vaccine development represents an important accomplishment and a milestone in the history of vaccine evolution. However, the vaccine’s scarcity made its equitable global allocation and distribution ambiguous. Despite the initial pledges from wealthy countries for fairness and inclusivity towards the poorer ones, the policies followed diverged significantly. Wealthy countries have vastly superior access to vaccines in a reality likened to an ethical disaster. This paper calls for the need for fair global vaccine (...) class='Hi'>allocation and distribution and examines the barriers that were met along the way, originating from different points, such as the nationalistic approach on the matter that most wealthy countries have adopted or the inability of poor countries to purchase or manufacture vaccines. Further, a suggestion regarding the ethical principles and values that ought to guide global vaccine allocation and distribution is provided with a higher priority given to helping the worst-off, saving the most lives, protecting people in high risk, such as frontline healthcare professionals, and minimising social gaps, along with an ethical theoretical background for each prioritisation. It is not too late for wealthy countries to realise that vaccine inequity prolongs pandemics, so that they change their policies in favour of the global common good that will not only provide immediate universal benefits but will also serve as a guide for future pandemic crises. (shrink)

This article sets forth a solidaristic approach to global distribution of vaccines against the SARS‐CoV‐2 virus. Our approach draws inspiration from African ethics and from the characterization of the Covid‐19 crisis as a syndemic, a convergence of biosocial forces that interact with one another to produce and exacerbate clinical disease and prognosis. The first section elaborates the twin ideas of syndemic and solidarity. The second section argues that these ideas lend support to global health alliances to distribute vaccines beyond national (...) borders. The third section introduces ethical criteria to guide global distribution, emphasizing priority to low‐ and middle‐income countries, which have the least ability to obtain vaccines on their own. It also justifies giving priority to people at high risk of infection and high risk of severe disease and death. (shrink)

In this article, we propose the Fair Priority Model for COVID-19 vaccine distribution, and emphasize three fundamental values we believe should be considered when distributing a COVID-19 vaccine among countries: Benefiting people and limiting harm, prioritizing the disadvantaged, and equal moral concern for all individuals. The Priority Model addresses these values by focusing on mitigating three types of harms caused by COVID-19: death and permanent organ damage, indirect health consequences, such as health care system strain and stress, as (...) well as economic destruction. It proposes proceeding in three phases: the first addresses premature death, the second long-term health issues and economic harms, and the third aims to contain viral transmission fully and restore pre-pandemic activity. -/- To those who may deem an ethical framework irrelevant because of the belief that many countries will pursue "vaccine nationalism," we argue such a framework still has broad relevance. Reasonable national partiality would permit countries to focus on vaccine distribution within their borders up until the rate of transmission is below 1, at which point there would not be sufficient vaccine-preventable harm to justify retaining a vaccine. When a government reaches the limit of national partiality, it should release vaccines for other countries. -/- We also argue against two other recent proposals. Distributing a vaccine proportional to a country's population mistakenly assumes that equality requires treating differently situated countries identically. Prioritizing countries according to the number of front-line health care workers, the proportion of the population over 65, and the number of people with comorbidities within each country may exacerbate disadvantage and end up giving the vaccine in large part to wealthy nations. (shrink)

For much of 2021, allocating the scarce supply of Covid‐19 vaccines was the world's most pressing bioethical challenge, and similar challenges may recur for novel therapies and future vaccines. In the United States, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) identified three fundamental ethical principles to guide the process: maximize benefits, promote justice, and mitigate health inequities. We argue that critical components of the recommended protocol were internally inconsistent with these principles. Specifically, the ACIP (...) violated its principles by recommending overly broad health care worker priority in phase 1a, using being at least seventy‐five years of age as the only criterion to identify individuals at high risk of death from Covid‐19 during phase 1b, failing to recommend place‐based vaccine distribution, and implicitly endorsing first‐come, first‐served allocation. More rigorous empirical work and the development of a complete ethical framework that recognizes trade‐offs between principles may have prevented these mistakes and saved lives. (shrink)

In many countries, the COVID‐19 pandemic varied starkly between different racial and ethnic groups. Before vaccines were approved, some considered assigning priority access to worse‐hit racial groups. That debate can inform rationing in future pandemics and in some of the many areas outside COVID‐19 that admit of racial health disparities. However, concerns were raised that “race‐responsive” prioritizations would be ruled unlawful for allegedly constituting wrongful discrimination. This legal argument relies on an understanding of discrimination law as demanding color‐blindness. We argue (...) that a, color‐blind understanding of discrimination would be hostile only to one of two rationales for prioritizing the relevant racial minorities in settings of racial health disparities. We also propose a method for incorporating appropriate race‐responsive concerns that is in many ways ethically and legally superior to ones suggested thus far. That method turns artificial intelligence, thanks precisely to its artificial and “black box” nature (features that underlie recent concerns about artificial intelligence's discriminatory potential), into an instrument of social justice. (shrink)

The issue of COVID-19 vaccine allocation is still highly controversial on the international as well as on the national level, and policy-makers worldwide struggle in striking a fair balance between different ethical principles of vaccine allocation, in particular maximum benefit, reciprocity, social justice and equal respect. Any political decision that implements these principles comes at a cost in terms of loss of lives and of loss of life years that could potentially have been prevented by a (...) different vaccination strategy. This article illustrates these trade-offs using quantitative analysis and shows how this approach can contribute to providing a rational and transparent grounding of political decisions on COVID-19 vaccine allocation. (shrink)

Equity was—and is—central in the US policy response to COVID-19, given its disproportionate impact on disadvantaged communities of colour. In an unprecedented turn, the majority of US states used place-based disadvantage indices to promote equity in vaccine allocation (eg, through larger vaccine shares for more disadvantaged areas and people of colour).We conducted a nationally representative survey experiment (n=2003) in April 2021 (before all US residents had become vaccine eligible), that examined respondents’ perceptions of the acceptability of (...) disadvantage indices relative to two ways of prioritising racial and ethnic groups more directly, and assessed the role of framing and expert anchors in shaping perceptions.A majority of respondents supported the use of disadvantage indices, and one-fifth opposed any of the three equity-promoting plans. Differences in support and opposition were identified by respondents’ political party affiliation. Providing a numerical anchor (that indicated expert recommendations and states’ actual practices in reserving a proportion of allocations for prioritised groups) led respondents to prefer a lower distribution of reserved vaccine allocations compared with the randomised condition without this anchor, and the effect of the anchor differed across the frames.Our findings support ongoing uses of disadvantage indices in vaccine allocation, and, by extension, in allocating tests, masks or treatments, especially when supply cannot meet demand. The findings can also inform US allocation frameworks in future pandemic planning, and could provide lessons on how to promote equity in clinical and public health outside of the pandemic setting. (shrink)

The Target Article by Sabatello et al. should prove significant in advancing recognition of, and discussion concerning how, race is embedded in allocation strategies adopted in pandemic resp...

The COVID-19 pandemic will likely recede only through development and distribution of an effective vaccine. Although there are many unknowns surrounding COVID-19 vaccine development, vaccine demand will likely outstrip early supply, making prospective planning for vaccine allocation critical for ensuring the ethical distribution of COVID-19 vaccines. Here, we propose three central goals for COVID-19 vaccination campaigns: to reduce morbidity and mortality, to minimise additional economic and societal burdens related to the pandemic and to narrow unjust (...) health inequalities. We evaluate five prioritisation approaches, assess their likely impact on advancing the three goals of vaccine allocation and identify open scientific questions that may alter their outcomes. We argue that no single prioritisation approach will advance all three goals. Instead, we propose a multipronged approach that considers the risk of serious COVID-19 illness, instrumental value and the risk of transmission, and is guided by future research on COVID-19-specific clinical and vaccine characteristics. While we focus this assessment on the USA, our analysis can inform allocation in other contexts. (shrink)

As vaccines against COVID-19 are scarce, many countries have developed vaccination prioritisation strategies focusing on ethical and epidemiological considerations. However, public acceptance of such strategies should be monitored to ensure successful implementation. In an experiment withN=1379 German participants, we investigated whether the public’s vaccination allocation preferences matched the prioritisation strategy approved by the German government. Results revealed different allocations. While the government had top-prioritised vulnerable people (being of high age or accommodated in nursing homes for the elderly), participants preferred (...) exclusive allocation of the first available vaccines to medical staff and personnel caring for the elderly. Interestingly, allocation preferences did not change when participants were told how many individuals were included in each group. As differences between allocation policies and public preferences can affect trust in the government and threaten the social contract between generations, we discuss possible strategies to align vaccination prioritisations. (shrink)

We propose 4 equity-advancing operational improvements to eligibility and sign-up processes at mass vaccination sites: (1) preregistration using existing information, (2) eligibility rules that recognize the greater burden of COVID-19 in underserved neighborhoods, (3) appointment assignment that prioritizes those with disadvantage, and (4) socioculturally informed outreach to lottery selectees.

When hospitals face surges of patients with COVID-19, fair allocation of scarce medical resources remains a challenge. Scarcity has at times encompassed not only hospital and intensive care unit beds—often reflecting staffing shortages—but also therapies and intensive treatments. Safe, highly effective COVID-19 vaccines have been free and widely available since mid-2021, yet many Americans remain unvaccinated by choice. Should their decision to forgo vaccination be considered when allocating scarce resources? Some have suggested it should, while others disagree. We offer (...) a framework for evaluating when it is ethical and briefly discuss its legality in American law. (shrink)

Although a safe, effective, and licensed coronavirus vaccine does not yet exist, there is already controversy over how it ought to be allocated. Justice is clearly at stake, but it is unclear what justice requires in the international distribution of a scarce vaccine during a pandemic. Many are condemning ‘vaccine nationalism’ as an obstacle to equitable global distribution. We argue that limited national partiality in allocating vaccines will be a component of justice rather than an obstacle to (...) it. For there are role-based and community-embedded responsibilities to take care of one’s own, which constitute legitimate moral reasons for some identity-related prioritisation. Furthermore, a good form of vaccine nationalism prioritises one’s own without denying or ignoring duties derived from a principle of equal worth, according to which all persons, regardless of citizenship or identity, equally deserve vaccine-induced protection from COVID-19. Rather than dismissing nationalism as a tragic obstacle, it is necessary to acknowledge that a limited form of it is valuable and expresses moral commitments. Only then can one understand our world of competing obligations, a world where cosmopolitan duties of benevolence sometimes conflict with special obligations of community membership. Once these competing obligations are recognised as such, we can begin the work of designing sound ethical frameworks for achieving justice in the global distribution of a coronavirus vaccine and developing practical strategies for avoiding, mitigating or resolving conflicts of duty. (shrink)

With the world grappling with continued spread of monkeypox internationally, vaccines play a crucial role in mitigating the harms from infection and preventing spread. However, countries with the greatest need - particularly historically endemic countries with the highest monkeypox case-fatality rates - are not able to acquire scarce vaccines. This is unjust, and requires rectification through equitable allocation of vaccines globally. We propose applying the Fair Priority Model for such allocation, which emphasizes three key principles: 1) preventing harm; (...) 2) prioritizing the disadvantaged; and 3) treating people with equal moral concern. Post-exposure prophylaxis (PEPV) has the most potential to mitigate harm, and so ensuring countries have sufficient supply for PEPV should be the first priority. And historically endemic countries, which face disadvantages that compound potential harms from monkeypox, should be the first recipients of such vaccines. Once sufficient supply is allocated for countries to apply PEPV, global allocation could move on to pre-exposure prophylaxis (PrEP), again prioritizing historically endemic countries first before distribution to the rest of the global community, based on projected number of cases and vulnerability to harm. (shrink)

Volume 20, Issue 7, July 2020, Page W15-W16.

In the event of a pandemic, demand for vaccines may exceed supply. One proposal for allocating vaccines is to use a lottery, to give all citizens an equal chance, either of getting the vaccine or of surviving. However, insistence on strict equality can result in seriously suboptimal outcomes. I argue that the requirement to treat all citizens impartially need not be interpreted to require equal chances, particularly where citizens are differently situated. Assuming that we want to save lives, we (...) should also seek to use vaccine efficiently, so far as this is compatible with equality. Thus, in allocating vaccine, we may want to be sensitive to different levels of need and/or effects on vaccine production. While such policies may result in unequal chances, they may even improve everyone’s chances. In such cases, the resultant inequality is not a violation of impartiality, but a consequence of considering each person’s claim seriously. (shrink)

Hugh V. Mclachlan Cet article est une réponse à la critique de Saunders de ma proposition de politique non conséquentialiste publiée précédemment concernant l’utilisation d’une loterie pour la distribution de vaccins rares par l’État face à une pandémie de grippe. J’y ai soutenu que, pour des raisons de justice, l’État devrait distribuer une partie du vaccin rare qu’il pourrait détenir à certains de ses employés de la santé et le reste aux citoyens de manière aléatoire et égale sur le principe (...) d’une loterie. Au coeur de la critique de Saunders se trouve l’affirmation selon laquelle j’ai omis à tort de prendre en compte les différences moralement pertinentes dans les besoins et la capacité de production entre les receveurs potentiels du vaccin. Le point central de ma réponse ici est que le fait que le besoin et la capacité de production soient ou non des facteurs moralement pertinents dépend de qui ou de quoi distribue le vaccin, à qui ils le distribuent et pourquoi ils le font. Par exemple, la discrimination entre les personnes dans la distribution de vaccins publics distribués à titre prophylactique sur la base de leur âge est injuste, qu’elle soit ou non moralement justifiable pour d’autres motifs. (shrink)

In the context of the global COVID-19 pandemic, the fast and equitable distribution of effective vaccines worldwide is one of the challenges faced by international institutions in charge, as global equity in vaccine supply has not yet been achieved. Our paper explains the current state of ethical research on equity in global COVID-19 vaccine allocation, focusing on the COVAX Facility established by the WHO, acting as the global vaccine distributor. The article presents a detailed analysis of (...) the first year of COVAX allocation in 2021 identifying problematic aspects of its allocation framework regarding the implementation of COVAX’s fundamental allocation principles. We argue that the COVAX Facility has developed a proper concept to deal with global vaccine allocation—but to address uncovered defaults, we introduce the ‘Prioritized Distribution of Equal Shares’ model—a both ethical and practically feasible alternative allocation framework to protect the value of human lives in both high- and low-income countries through fair and fast global vaccine distribution in health emergencies. Nonetheless, we argue that the COVAX Facility remains the main organization to provide equitable access to vaccines. Yet, the global community has to consider further aspects such as patent protection, vaccine production and the lack of power of global structures to address the inequities that have arisen. Since new wars and further crises have arisen, a shift in public global attention endangers the processing of COVID-19-related issues. That is why now more than ever extensive efforts to achieve vaccine equity are needed. (shrink)

The urgent drive for vaccine development in the midst of the current COVID-19 pandemic has prompted public and private organisations to invest heavily in research and development of a COVID-19 vaccine. Organisations globally have affirmed the commitment of fair global access, but the means by which a successful vaccine can be mass produced and equitably distributed remains notably unanswered. Barriers for low-income countries include the inability to afford vaccines as well as inadequate resources to vaccinate, barriers that (...) are exacerbated during a pandemic. Fair distribution of a pandemic vaccine is unlikely without a solid ethical framework for allocation. This piece analyses four allocation paradigms: ability to develop or purchase; reciprocity; ability to implement; and distributive justice, and synthesises their ethical considerations to develop an allocation model to fit the COVID-19 pandemic. (shrink)

In combating the ongoing global health threat of the COVID-19 pandemic, decision-makers have to take actions based on a multitude of relevant health data with severe potential consequences for the affected patients. Because of their presumed advantages in handling and analyzing vast amounts of data, computer systems of algorithmic decision-making are implemented and substitute humans in decision-making processes. In this study, we focus on a specific application of ADM in contrast to human decision-making, namely the allocation of COVID-19 vaccines (...) to the public. In particular, we elaborate on the role of trust and social group preference on the legitimacy of vaccine allocation. We conducted a survey with a 2 × 2 randomized factorial design among n = 1602 German respondents, in which we utilized distinct decision-making agents and prioritization of a specific social group as design factors. Our findings show that general trust in ADM systems and preference for vaccination of a specific social group influence the legitimacy of vaccine allocation. However, contrary to our expectations, trust in the agent making the decision did not moderate the link between social group preference and legitimacy. Moreover, the effect was also not moderated by the type of decision-maker. We conclude that trustworthy ADM systems must not necessarily lead to the legitimacy of ADM systems. (shrink)

This article proposes the adoption of a multi-modal system for allocating vaccine doses during large transnational outbreaks of infectious diseases. The chosen allocative criteria (public health need; country-income level; qualification through funding; and, subsidiarily, a modified lottery system) are adapted from a current embodiment of allocative multi-modality outside the context of public health: the New York City Marathon.

This paper addresses the just distribution of vaccines against the SARS-CoV-2 virus and sets forth an ethical framework that prioritises frontline and essential workers, people at high risk of severe disease or death, and people at high risk of infection. Section I makes the case that vaccine distribution should occur at a global level in order to accelerate development and fair, efficient vaccine allocation. Section II puts forth ethical values to guide vaccine distribution including helping people (...) with the greatest need, reducing health disparity, saving the most lives and promoting narrow social utility. It also responds to objections which claim that earlier years have more value than later years. Section III puts forth a practical ethical framework to aid decision-makers and compares it with alternatives. (shrink)

Inequity has been a hallmark of the COVID-19 pandemic in the United States, especially in the sharply disproportionate impacts among people of color. Recent studies have confirmed that t...

This article is about the potential justification for deploying some form of affirmative action (AA) in the context of healthcare, and in particular in relation to the pandemic. We call this Affirmative Action in healthcare Resource Allocation (AARA). Specifically, we aim to investigate whether the rationale and justifications for using prioritization policies based on race in education and employment apply in a healthcare setting, and in particular to the COVID-19 pandemic. We concentrate in this article on vaccines and ventilators (...) because these are both highly scarce resources in the pandemic, and there has been a need to develop policies for allocating them. However, as will become clear, the ethical considerations relating to them may diverge. We first set out two rationales for AAs and what they might entail in a healthcare setting. We then consider some disanalogies between AA and AARA, as well as the different implications of AARA for allocating ventilators as opposed to vaccines. Finally, we consider some of the practical ways in which AARA could be implemented, and conclude by responding to some key objections. (shrink)

What does vaccine justice require at the domestic and global levels? In this essay, using the COVID-19 pandemic as a backdrop, we argue that deliberative-democratic participation is needed to answer this question. To be effective on the ground, abstract principles of vaccine justice need to be further specified through policy. Any vaccination strategy needs to find ways to prioritize conflicting moral claims to vaccine allocation, clarify the grounds on which low-risk people are being asked to vaccinate, (...) and reach a balance between special duties toward countrymen and universal duties toward foreigners. Reasonable moral disagreement on these questions is bound to exist in any community. But such disagreement threatens to undermine vaccine justice insofar as the chosen vaccination strategy (and its proposed specification of vaccine justice) lacks public justification. Inclusive democratic deliberation about vaccine justice is a good mechanism for tackling such moral disagreement. By allowing residents and citizens to participate in the specification of abstract principles of vaccine justice, and their translation into policy, democratic deliberation can enhance the legitimacy of any vaccination strategy and boost compliance with it. (shrink)

Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, (...) quality-adjusted life-years, and disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles. (shrink)

Throughout the COVID-19 pandemic, shortages of scarce healthcare resources consistently presented significant moral and practical challenges. While the importance of vaccines as a key pharmaceutical intervention to stem pandemic scarcity was widely publicized, a sizable proportion of the population chose not to vaccinate. In response, some have defended the use of vaccination status as a criterion for the allocation of scarce medical resources. In this paper, we critically interpret this burgeoning literature, and describe a framework for thinking about (...) class='Hi'>vaccine-sensitive resource allocation using the values of responsibility, reciprocity, and justice. Although our aim here is not to defend a single view of vaccine-sensitive resource allocation, we believe that attending critically with the diversity of arguments in favor (and against) vaccine-sensitivity reveals a number of questions that a vaccine-sensitive approach to allocation should answer in future pandemics. (shrink)

As the federal government distributed remdesivir to some of the states COVID-19 hit hardest, policymakers scrambled to develop criteria to allocate the drug to their hospitals. Our state, Michigan, was among those states to receive an initial quantity of the drug from the U.S. government. The disparities in burden of disease in Michigan are striking. Detroit has a death rate more than three times the state average. Our recommendation to the state was that it should prioritize the communities that bear (...) a disproportionate burden of suffering in the allocation of the new potential treatment. This recommendation is justified not only for new drugs with uncertain effects, but also for drugs of certain benefit or vaccines. For states with significant health disparities, such as Michigan, this allocation priority may help to repair them. In fact, any other allocation strategy may make them worse. (shrink)

Initial vaccine allocations for the coronavirus disease 2019 (COVID-19) will be limited. It is crucial to assess the ethical values associated with different methods of allocation, as well as important scientific and practical questions. This Viewpoint identifies three ethical values, benefiting people and limiting harm; prioritizing disadvantaged populations; and equal concern for all. It then explains why these values support prioritizing three groups: health care workers; other essential workers and people in high-transmission settings; and people with medical vulnerabilities (...) associated with poorer COVID-19 outcomes. In contrast, two other groups, people over 65 without medical vulnerabilities and participants in clinical research, present more complex ethical questions. This prioritization also encompasses valuing direct benefits to vaccinated individuals, indirect benefits to individuals protected from spread of infection, and indirect health and socioeconomic benefits to those protected from harm as health system and societal functioning improve. Vaccine allocation that recognizes important ethical values and avoids arbitrariness, waste, and corruption can ensure that the distribution of a COVID-19 vaccine is both fair and perceived as fair. (shrink)

Coronavirus vaccines have made their debut. Now, allocation practices have stepped into the spotlight. Following Centers for Disease Control and Prevention guidelines, states and healthcare institutions initially prioritised healthcare personnel and elderly residents of congregant facilities; other groups at elevated risk for severe complications are now becoming eligible through locally administered programmes. The question remains, however: whoelseshould be prioritised for immunisation? Here, we call attention to individuals institutionalised with severe mental illnesses and/or developmental or intellectual disabilities—a group highly susceptible (...) to the damages of COVID-19, recent research shows, and critical to consider for priority vaccination. The language describing both federal-level and state-level intentions for this population remains largely vague, despite the population’s diversity across age, diagnosis, functional status and living arrangement. Such absence of specificity, in turn, leaves room for confusion and even neglect of various subgroups. We review data stressing this group’s vulnerability, as well as select state plans for priority vaccination, highlighting the importance of clarity when describing intentions to vaccinate, or even generally care for, diverse populations composed of distinct subgroups in need. (shrink)

This article discusses the triage response to the COVID-19 delta variant surge of 2021. One issue that distinguishes the delta wave from earlier surges is that by the time it became the predominant strain in the USA in July 2021, safe and effective vaccines against COVID-19 had been available for all US adults for several months. We consider whether healthcare professionals and triage committees would have been justified in prioritising patients with COVID-19 who are vaccinated above those who are unvaccinated (...) in first-order or second-order triage. Given that lack of evidence for a correlation between short-term survival and vaccination, we argue that using vaccination status during first-order triage would be inconsistent with accepted triage standards. We then turn to notions of procedural fairness, equity and desert to argue that that there is also a lack of justification for using vaccination status in second-order triage. In planning for future surges, we recommend that medical institutions base their triage decisions on principles meant to save the most lives, minimise inequity and protect the public’s trust, which for the time being would not be served by the inclusion of vaccination status. (shrink)

Reserve systems are a tool to allocate scarce resources when stakeholders do not have a single objective. This paper introduces some basic concepts about reserve systems for pandemic medical resource allocation. At the onset of the Covid-19 pandemic, we proposed that reserve systems can help practitioners arrive at compromises between competing stakeholders. More than a dozen states and local jurisdictions adopted reserve systems in initial phases of vaccine distribution. We highlight several design issues arising in some of these (...) implementations. We also offer suggestions about ways practitioners can take advantage of the flexibility offered by reserve systems. (shrink)

The rapid development of widely available and effective vaccines has been integral to the international response to the COVID-19 pandemic. However, a significant minority of those offered vaccination have refused, often due to their adherence to ‘anti-vax’ beliefs. These beliefs include that vaccines are dangerous, render the recipient magnetic or contain government microchips.During the pandemic, numerous calls were made for those voluntarily refusing vaccination to be deprioritised when allocating scarce healthcare resources. While these calls were rejected, the likelihood of the (...) same calls being made during future pandemics necessitates a thorough examination of the ethical implications entailed by such a policy.Here, I consider an intuitive argument for the use of vaccination status when allocating healthcare resources. This argument claims that, by avoiding vaccination, vaccine refusers are failing to fulfil a social obligation to protect those around them from harm by facilitating herd immunity. They are, therefore, less deserving of healthcare than their vaccinated peers.I explore three objections to this argument. While a first objection, asserting that no individual can be held responsible for a failure to develop herd immunity, fails, I find two further responses, respectively asserting the primacy of patient autonomy and highlighting the harms deprioritising vaccine refusers would cause to disadvantaged minorities, compelling. I, therefore, conclude that vaccination status should not be considered during healthcare resource allocation, as such discrimination would disproportionately harm marginalised communities. (shrink)

Policies for the allocation of COVID-19 vaccine were implemented in early 2021 as soon as vaccine became available. Those responsible for the planning and execution of COVID-19 vaccination had to make choices about who received vaccination first while numerous authors offered their own recommendations. This paper provides an account of how such decisions should be made by focusing on the specifics of the situation at hand. In that light, I offer an argument for prioritising those who are (...) likely vectors of the disease and a criticism of the victim-focused priority proposals put forward by the US Centers for Disease Control and Prevention, the National Academies of Sciences, Engineering, and Medicine, the UK National Health Service, and others. I also offer thoughts on how those authors may have gone astray. (shrink)

This article discusses the fairness of geographically targeted vaccinations (GTVs). During the initial period of local and global vaccine scarcity, health authorities had to enact priority-setting strategies for mass vaccination campaigns against COVID-19. These strategies have in common that priority setting was based on personal characteristics, such as age, health status or profession. However, in 2021, an alternative to this strategy was employed in some countries, particularly Norway. In these countries, vaccine allocation was also based on the (...) epidemiological situations in different regions, and vaccines were assigned based on local incidence rates. The aim of this article is to describe and examine how a geographical allocation mechanism may work by considering Norway as a case study and discuss what ethical issues may arise in this type of priority setting. We explain three core concepts: priority setting, geographical priority setting and GTVs. With a particular focus on Norway, we discuss the potential effects of GTV, the public perception of such a strategy, and if GTV can be considered a fair strategy. We conclude that the most reasonable defence of GTV seems to be through a consequentialist account that values both total health outcomes and more equal outcomes. (shrink)

Introduction: There is currently no binding, internationally accepted and successful approach to ensure global equitable access to healthcare during a pandemic. The aim of this ethical analysis is to bring into the discussion a legally regulated vaccine allocation as a possible strategy for equitable global access to vaccines. We focus our analysis on COVAX (COVID-19 Vaccines Global Access) and an existing EU regulation that, after adjustment, could promote global vaccine allocation. -/- Methods: The main documents discussing (...) the two strategies are examined with a qualitative content analysis. The ethical values reasonableness, openness and transparency, inclusiveness, responsiveness and accountability serve as categories for our ethical analysis. -/- Results: We observed that the decision-making processes in a legal solution to expand access to vaccines would be more transparent than in COVAX initiative, would be more inclusive, especially of nation states, and the values responsiveness and accountability could be easily incorporated in the development of a new regulation. -/- Discussion: A legal strategy that offers incentives to the pharmaceutical industry in return for global distribution of vaccines according to the Fair Priority Model is an innovative way to achieve global and equitable access to vaccines. However, in the long term, achieving the Sustainable Development Goals will require from all nations to work in solidarity to find durable solutions for global vaccine research and development. Interim solutions, such as our proposed legal strategy for equitable access to vaccines, and efforts to find long-term solutions must be advanced in parallel. (shrink)

America’s COVID-19 pandemic has both devastated and disparately harmed minority communities. How can the allocation of scarce treatments for COVID-19 and similar public health threats fairly and legally respond to these racial disparities? Some have proposed that members of racial groups who have been especially hard-hit by the pandemic should receive priority for scarce treatments. Others have worried that this prioritization misidentifies racial disparities as reflecting biological differences rather than structural racism, or that it will generate mistrust among groups (...) who have previously been harmed by medical research. Still others complain that such prioritization would be fundamentally unjust. I argue that, to pass muster under current law, policymaking in this area must recognize a crucial distinction: prioritizing minority communities, such as hard-hit neighborhoods, without regard to individual race is typically legal, but prioritizing individuals on the basis of their racial identity faces is likely not. I also explain how prioritization on the basis of Native American status is allowable and legally distinct from prioritization on the basis of individual race. -/- In Part II, I provide a brief overview of current and proposed COVID-19 treatments and identify documented or likely scarcities and disparities in access. In Part III, I argue that randomly allocating scarce medical interventions, as some propose, will not effectively address disparities: it both permits unnecessary deaths and concentrates those deaths among people who are more exposed to infection. In Part IV, I explain why using individual-level racial classifications in allocation is precluded by current Supreme Court precedent. Addressing disparities will require focusing on factors other than race, or potentially considering race at an aggregate rather than individual level. I also argue that policies prioritizing members of Native American tribes can succeed legally even where policies based on race would not. In Part V, I examine two complementary strategies to narrow racial disparities. One would prioritize individuals who live in disadvantaged geographic areas or work in hard-hit occupations, potentially alongside race-sensitive aggregate metrics like neighborhood segregation. These approaches, like the policies school districts adopted after the Supreme Court rejected individualized racial classifications in education, would narrow disparities without classifying individuals by race. The other strategy would address the starkly disparate racial impact of deaths early in life by limiting the use of age-based exclusions from vaccine or treatment access that explicitly deprioritize the prevention of early deaths and so disparately exclude minorities, and by considering policies that prioritize the prevention of early deaths. (shrink)

The U.S. FDA has issued emergency use authorizations for monoclonal antibodies for non-hospitalized patients with mild or moderate COVID-19 disease and for individuals exposed to COVID-19 as post-exposure prophylaxis. One EUA for an oral antiviral drug, molnupiravir, has also been recommended by FDA’s Antimicrobial Drugs Advisory Committee, and others appear likely in the near future. Due to increased demand because of the Delta variant, the federal government resumed control over the supply and asked states to ration doses. As future variants (...) with increased infectivity and/or severity emerge, further rationing may be required. We identify relevant ethical principles and priority groups for access to therapies based on an integrated approach to population health and medical factors. Using priority categories to allocate scarce therapies effectively operationalizes important ethical values. This strategy is preferable to the current approach of categorical rules based on vaccination, immunocompromise status, or older age, or the ad hoc consideration of clinical risk factors. (shrink)

The allocation of vaccines and therapeutics for Covid‐19 obviously raises ethical questions, and physicians and ethicists have begun to address them. Writers have identified various criteria that should guide allocation decisions, but the criteria often conflict and need to be balanced against one another. This article proposes a model for thinking about how different considerations that are relevant to the distribution of vaccines and scarce treatments for Covid‐19 could be integrated into an allocation procedure. The model employs (...) the construct of a weighted lottery, which is a construct that has been employed in other contexts that involve the distribution of scarce resources. The article highlights the advantages of applying a weighted lottery to the Covid‐19 context and offers an illustration for how it might work in practice. The primary aim of the article is to articulate the structural features of a weighted lottery for this context and to bring out its advantages over other methods for allocating Covid‐19 medications. (shrink)

Countermeasures for mpox (formerly known as monkeypox), primarily vaccines, have been in limited supply in many countries during outbreaks. Equitable allocation of scarce resources during public health emergencies is a complex challenge. Identifying the objectives and core values for the allocation of mpox countermeasures, using those values to provide guidance for priority groups and prioritisation tiers, and optimising allocation implementation are important. The fundamental values for the allocation of mpox countermeasures are: preventing death and illness; reducing (...) the association between death or illness and unjust disparities; prioritising those who prevent harm or mitigate disparities; recognising contributions to combating an outbreak; and treating similar individuals similarly. Ethically and equitably marshalling available countermeasures requires articulating these fundamental objectives, identifying priority tiers, and recognising trade-offs between prioritising the people at the highest risk of infection and the people at the highest risk of harm if infected. These five values can provide guidance on preferable priority categories for a more ethically sound response and suggest methods for optimising allocation of countermeasures for mpox and other diseases for which countermeasures are in short supply. Properly marshalling available countermeasures will be crucial for future effective and equitable national responses to outbreaks. (shrink)

The Covid-19 pandemic has led to a health crisis of a scale unprecedented in post-war Europe. In response, a large amount of healthcare resources have been redirected to Covid-19 preventive measures, for instance population-wide vaccination campaigns, large-scale SARS-CoV-2 testing, and the large-scale distribution of protective equipment to high-risk groups and hospitals and nursing homes. Despite the importance of these measures in epidemiological and economic terms, health economists and medical ethicists have been relatively silent about the ethical rationales underlying the large-scale (...) allocation of healthcare resources to these measures. The present paper seeks to encourage this debate by demonstrating how the resource allocation to Covid-19 preventive measures can be understood through the paradigm of the Rule of Rescue, without claiming that the Rule of Rescue is the sole rationale of resource allocation in the Covid-19 pandemic. (shrink)

The COVID-19 Vaccines Global Access Facility represents an unprecedented global collaboration facilitating the development and distribution of vaccines for COVID-19. COVAX pools and channels funds from state and non-state actors to promising vaccine candidates, and has started to distribute successful candidates to participating states. The WHO, one of the leaders of COVAX, recognised vaccine doses would initially be scarce, and therefore, prepared a two-staged allocation mechanism they considered fair. In the first stage, vaccine doses are distributed (...) equally among participating countries, while in the second stage vaccine doses will be allocated according to a country’s need. Ethicists have questioned whether this is the fairest distribution—they argue a country’s need should be taken into account from the start and correspondingly, have proposed a framework that treats individuals with equal moral concern, aims to minimise harm and gives priority to the worst-off. In this paper, we seek to explore these concerns by comparing COVAX’s allocation mechanism to a targeted allocation based on need. We consider which distribution would more likely maximise well-being and align with principles of equity. We conclude that although in theory, a targeted distribution in proportion to a country’s need would be more morally justifiable, when political realities are taken into account, an equal distribution seems more likely to avert a greater number of deaths and reduce disparities. (shrink)

This paper stems from the current global worsening of the scarcity of resources for healthcare, which will deepen even more in future public emergencies. This justifies strengthening the reflection on the allocation of resources which, in addition to considering technical issues, should also involve ethical concerns. The two plans in which the allocation of resources develops—macro and micro—are then systematized, both requiring the identification of ethical criteria for the respective complex decision-making. Then, we describe how the complexity at (...) the macro level focuses on the joint consideration of the rectitude of the principles, the goodness of the ends, and the integrity—respectively the deontological, teleological, and procedural perspectives; and at the micro level, it focuses in prioritizing people, which can result in the exclusion of some, as happened with the elderly during peaks of COVID-19. The main objective of this article is to show that, in public health emergency situations, in which the daily criteria for prioritizing access to health care are not efficient, it is possible not only to ration the available means but also to rationalize them. We argue that rationing and rationalization are different concepts, entail different consequences, have different ethical foundations, and draw different guidelines for patient care. We apply them to the distribution of intensive care and vaccines to the elderly thus demonstrating the ethically legitimate domain of implementation of each of these two prioritization criteria. We conclude that rationalization respects more strictly the core ethical principles of our common morality. (shrink)

Implementing equity principles in resource allocation is challenging. In one approach, some US states implemented race-based prioritisation of COVID-19 vaccines in response to vast racial inequities in COVID-19 outcomes, while others used place-based allocation. In a nationally representative survey of n=2067 US residents, fielded in mid-April 2021, we explored the public acceptability of race-based prioritisation compared with place-based prioritisation, by offering vaccines to harder hit zip codes before residents of other zip codes. We found that in general, a (...) majority of respondents supported the place-based approach, and a substantial proportion supported the race-based plan. Support was higher among Democrats compared with Republicans. All US residents became eligible for vaccines on 19 April 2021 but as of this writing, equitable uptake of vaccines remains urgent not only for first doses for adults but also for boosters and for children. Our findings also provide a benchmark for future pandemic planning that racial and social justice in vaccine allocation are salient considerations for the public. The findings may furthermore be of interest to policy makers designing vaccine allocation frameworks in countries with comparable health disparities across social, ethnic and racial groups, and more broadly, for those exploring ways of promoting equity in resource allocation outside of a pandemic setting. (shrink)

BackgroundViral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic with governments and health authorities currently facing questions of distribution of COVID-19 vaccines.Main textIn this article, we critically evaluate the most (...) common ethical arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For illustrative purposes, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation.ConclusionsWe argue that there are deontological and utilitarian cases for prioritising HCWs. Indeed, the widely held view that we should prioritise HCWs represents an example of ethical convergence. Complexities arise, however, when considering who should be included in the category of HCW, and who else should receive priority in addition to HCWs. (shrink)

When the demand for a medical resource exceeds the supply, we have a problem of scarcity. There are many instantiations of this issue. The time of health care providers during an emergency, organs for transplantation, a bed in an intensive care unit, and a slot in a research protocol can all be scarce resources. Interest in this issue has been renewed because of recent concerns about a pandemic and shortages of vaccines. In each of these cases there is a problem (...) of distributive justice. If the resource is lifesaving, then the question is especially poignant: Who shall be saved when not all can be? This was the problem faced by Sir Dr. Colenso Ridgeon in Bernard Shaw's 'The Doctor's Dilemma', a play first performed a century ago. (shrink)