There is optimism about the coming availability of SARS-CoV-2 vaccines. However, supplies are likely to be limited, at least initially. Thus, various groups have suggested prioritization schemes to allocate limited vaccine supplies.

In a viewpoint article, Persad et al suggest that three main ethical issues relate to vaccine allocation, and they discuss these issues in light of COVID-19.1 First, they claim that providing benefit while limiting harm is a universal value and that a vaccine could reduce illness and death while also mitigating unemployment, poverty, and educational deprivation. Second, they believe that it is fundamental to prioritize disadvantaged populations, including the medically vulnerable who risk earlier death if infected, as well as those who have been subject to socioeconomic deprivation and oppression. Third, they suggest that differences of race, gender, and religion should not enter into consideration in simplistic ways that could actually harm or de-prioritize disadvantaged population groups — while, of course, not ignoring relevant differences.

The authors believe that their main ethical principles support individual and societal benefit when prioritized immunization is targeted for healthcare workers, people in high transmission settings, and medically vulnerable individuals who have medical conditions that put them at risk of poorer outcomes if they were to be infected with SARS-CoV-2. Focusing on healthcare workers would reduce iatrogenic spread of illness and provide reduced risk for patients with risk factors who frequent healthcare settings and live in medical housing situations. Focusing on people working in high transmission settings would reduce direct harm and minimize spread; this would include school personnel, childcare providers, and food supply workers. It is reported that 200 million people in the United States have high-risk medical conditions, so further prioritization within the high-risk groups also will be necessary.

Thus, the authors urge that COVID-19 vaccines be allocated to prevent harm, prioritize those who are disadvantaged, and achieve equal treatment. They caution against simplistic schemes that prioritize only the elderly or those of certain racial groups without considering the individual’s actual risk factors for becoming infected or suffering extreme illness if infected. They then practically propose that the vaccine be allocated so that half the supply goes to frontline healthcare workers, with one-fourth of the initial vaccine supply going to people living and working in high-risk settings, and the final fourth going to other people. Within those categories, priority would be given to individuals with high-risk medical conditions.

Beyond Safety and Efficacy

Believing in individualized medicine, we often select diagnostic testing and therapeutic interventions based on what is deemed best for each individual patient. Early in the COVID-19 pandemic, however, it became shockingly clear that resources were not infinite and that even resource-rich societies needed to think through priorities of allocating limited resources. With at least 25 vaccines currently being evaluated, and even as we anticipate the availability of COVID-19 vaccines, our consideration of vaccine delivery systems must go beyond infection and immunity, beyond safety and efficacy.2 We will need to consider the ethics of allocation of limited vaccine supplies. In the medical field, we often espouse a “do no harm” approach. Of course, risks and benefits must be balanced carefully. Almost no medical intervention carries zero risk of harm, and new rapidly produced interventions should be recognized as inherently risky.

Persad and colleagues wisely look beyond race in considering the prioritization of vaccination. Clearly, race is related to poor outcomes with COVID-19, and new data confirm this finding.3 But race is, to at least some degree, a marker for risk factors, rather than a fully independent risk factor. Even in the county where I live, recent pre-publication epidemiologic data suggest that COVID-19 is, indeed, more common in minority racial groups, but the geospatial clustering of cases reveals that the risk actually is associated with living in crowded housing (apartment buildings and trailer parks) and with neighborhoods with lower socioeconomic levels. Race is a statistical marker for risk, but considering race alone would lead decision-makers to inappropriately include many low-risk individuals (those of racial minority groups who have high socioeconomic status and live in single-family dwellings) in the “high risk” category.

Another ethical issue has been raised about a few of the candidate COVID-19 vaccines. As with some routine childhood vaccines, some of the adenovirus vector-based COVID-19 vaccines have used decades-old cell lines from aborted fetal tissue during the manufacturing process. “Moral complicity” is the notion that using the products of an unethical act, as some see abortion, makes one complicit to the initial act. Does the use of abortion-derived vaccines make vaccinators and vaccine recipients complicit with and “guilty of” the initial abortion? A similar issue was raised when the popular press realized that researchers were benefitting from studies involving HeLa cell lines that had been used without the patient’s consent. Most of us do not see the moral complicity argument as a limitation to the use of specific vaccines any more than we see a kidney transplant recipient who received an organ from a deceased murder victim as being complicit with or guilty of the murder of the organ donor.

Already, governments of some wealthy countries have purchased huge stocks of not-yet-produced COVID-19 vaccines, with more than 2 billion doses already bought. The World Health Organization recommends that richer nations ensure that resource-limited countries receive early access to vaccines, too. It is hoped that national and international law will serve as a means, rather than as a barrier, to just and equitable distribution of vaccines around the globe.

REFERENCES

  1. Persad G, Peek ME, Emanuel EJ. Fairly prioritizing groups for access to COVID-19 vaccines. JAMA 2020; Sept. 10. doi:10.1001/jama.2020.18513. [Online ahead of print].
  2. Poland GA, Ovsyannikova IG, Crooke SN, et al. SARS-CoV-2 vaccine development: Current status. Mayo Clin Proc 2020;95:2172-2188.
  3. Goyal MK, Simpson JN, Boyle MD, et al. Race and/or ethnic and socioeconomic disparities of SARS-CoV-2 infection among children. Pediatrics 2020;146:e2020009951.