As we pass the one-year mark of the ongoing COVID-19 pandemic, we can finally see a light at the end of the tunnel — the increasing accessibility of approved vaccines. With the Pfizer-BioNTech, Moderna, and Johnson & Johnson vaccines now under emergency authorization, nearly 2.5 million shots go into arms every day in the United States. In North Carolina, roughly 14% of the population is fully vaccinated, and Governor Roy Cooper recently announced plans to move forward into group four out of five in the state’s vaccine rollout plan. However, with so many Americans left to vaccinate, substantial distrust of the vaccine in many communities, and thousands of vaccines going to waste every day, how can we create policy to distribute vaccinations in an efficient and ethical manner?
There are over 300 million Americans and far fewer vaccine doses upfront, highlighting a clear need to prioritize some people over others. Dr. Arthur Caplan, NYU Director of the Medical Ethics Division, notes that vaccine rationing requires two moral values, justice and fairness, in order to work and earn public support. A just vaccine rollout plan must set out principles for prioritization transparently and ethically. A fair vaccine rollout plan ensures that, given these principles, everyone has equal access to the vaccine, so that no one is able to ‘cut the line.’
In terms of justice, many different parties have set out their own principles and frameworks for just vaccine rollout. The CDC and the National Academies each made recommendations at the federal level, and each state adapts these recommendations into their own vaccine distribution framework, including North Carolina. All of these justice frameworks center around a morally relevant goal — most ethicists agree that the number one goal in COVID vaccine distribution should be to minimize deaths by protecting those most at risk of severe illness. The implications of this goal are to vaccinate healthcare providers first, who are necessary to save lives, followed by populations at high risk of dying from the virus.
Shortly behind preventing deaths is typically the secondary goal to prevent spread. This implies vaccinating those at high risk of contracting the virus, such as frontline essential workers and prisoners. It is important to note that scientists have not been able to confirm whether or not the vaccines control the spread of the virus, which partially accounts for the prioritization of controlling deaths over controlling spread. Dr. Caplan also emphasizes that while these big-picture justice frameworks are essential to prevent chaos, the vast majority of vaccine prioritization decisions occur on a case-by-case basis by individual providers, which can be a lot more difficult to do.
In terms of fairness, the U.S. has struggled to distribute vaccines equitably and to prevent people from skipping the line. In particular, people of color and poverty-stricken populations have struggled to obtain the same access to vaccines as their white and upper-middle class counterparts. In Washington D.C., for instance, Black residents comprise roughly 45% of the population and 76% of COVID deaths, but have only received 26% of the vaccines. Health officials in many cities have noted that wealthier, predominantly white individuals have been flooding appointment systems and taking a disproportionate share of available vaccines, despite the lower death rate in these upper-class populations.
Marginalized communities face a wide variety of access issues to the vaccine — lack of transportation to appointments, an inability to take time off of work, and a lack of time or internet savvy necessary to search for available appointments, among others. It is also essential to note that beyond access issues, people of color have a legitimate distrust in the healthcare industry stemming from historical medical mistreatment. Many cite the Tuskegee Study, in which researchers denied hundreds of Black men treatment for syphilis for forty years without their knowledge. However, this medical mistreatment is ongoing, as people of color still face medical racism and many go undiagnosed for serious illnesses. Both of these issues — access barriers and medical distrust — run far deeper than COVID vaccine distribution, and both require careful attention, public campaigns, and widespread education to resolve.
This racial and class-driven gap in vaccinations raises a new ethical question: does ‘cutting the line’ really matter? The answer is more complicated than a simple ‘yes’ or ‘no.’ On one hand, when people lie to qualify for an earlier vaccination group, flood poor neighborhoods to take unused vaccines, or receive special treatment for their high status, it undermines confidence in the system as a whole. This loss in community confidence can create chaos and foster even more distrust in the long-term. Yet, on the other hand, many ethicists say to take the vaccine if you are offered, even if it feels like someone else is more deserving. Thousands of vaccines get thrown away every day, and every vaccine does more good in someone’s arm than in the garbage. Even a low-risk individual becomes more able to take care of ill family members and slow the spread of infection upon getting vaccinated.
As vaccine supply increases over the next few months, anyone who wants a vaccine will be eligible to get one, regardless of any justice frameworks. At this point, the problem is no longer deciding who to vaccinate when, it is instead ensuring that enough people get the vaccine to put an end to the pandemic. It is unclear how many Americans need to get vaccinated to reach herd immunity, with estimates generally ranging from 70% to 90%, but current polling suggests that only 55% of Americans want to get the vaccine as soon as possible. The remaining 45% distrust the vaccine for a variety of reasons, and either want to wait and see how the vaccine works (22%), will only get it if it is required (7%), or will definitely not get it (15%). Among the most hesitant are non-health essential workers, Republicans, Black adults, and rural residents. How do we address this distrust?
One option is to effectively mandate the vaccine. Such a mandate would likely not take place nationally, but could instead take the form of a penalty or fine, or a prerequisite to school, work, or government services. Many states and tech companies have begun developing vaccine passports, digital records of vaccination that serve as a requirement to travel or to attend school, work, or public gatherings. A vaccine mandate would quickly and effectively advance herd immunity if done properly, but the costs could outweigh the benefits. To many, a vaccine mandate represents a violation of personal freedom, and forcing vaccinations onto populations with legitimate concerns is likely to create even more distrust of vaccines in the long-term. On top of this, digitally-based mandates like vaccine passports could bar disadvantaged populations from public services if they require smartphone access. Beyond its ethical issues, a vaccine mandate is also legally infeasible, at least for the time being — employers cannot mandate vaccines under emergency use authorization, and the research to support full FDA approval of all three COVID vaccines is still underway.
Another option is to address the root of the distrust through substantive research, direct outreach, and public health campaigns. Among those who are hesitant to get the vaccine, many cite fears that the vaccine was not tested for safety on their race, that they will contract COVID from the vaccine, that they will have to pay out of pocket for the vaccine, or that COVID itself is a hoax. Through research and widespread outreach, public health officials can begin to address the misinformation behind all of these fears. Many have cited the need for a public health campaign that encourages the vaccine through trusted Black, Hispanic, and Indigenous peoples’ voices. Similarly, a 20-person focus group of vaccine-hesitant Trump voters highlighted a need for straight and honest facts from public health officials, rather than political-based appeals from either party, to sway Republicans and rural residents to get the vaccine. “We want to be educated, not indoctrinated,” one participant said. While potentially not as effective as a vaccine mandate, such methods could begin to address marginalized communities’ distrust in medicine, as well as vaccine-hesitant communities’ various fears, rather than ignoring them.