US experts tackle ethical dilemmas posed by the vaccine rollout

The approval of multiple coronavirus vaccines has given people hope, but the rollout has also brought uncertainty of its own.

A nurse prepares the Pfizer COVID-19 vaccine [File: Frederic J Brown/AFP]

Boston, Massachusetts, United States – The approval of multiple vaccines in the United States has provided a sense of hope for many, but the rollout has also brought uncertainty of its own.

In some locations, demand is greater than supply. Some people wonder why they were excluded from priority groups. Vaccine doses due to expire or leftover from cancellations and no-shows are given to people regardless of priority status instead.

“We ought to vaccinate the greatest number possible in the shortest time possible – and not without regard to other fundamental ethics commitments related to equity and justice,” said Dr Tarris Rosell of the Center for Practical Bioethics in Kansas City, Missouri.

“In general, with adequate planning and preparations, these two goals ought not to be incompatible. In particular circumstances, even with the best planning and preparations, there could be understandable glitches and gaps. When that happens, we ought to note it, fix it and go on. If glitches and gaps become the norm rather than the exception, we have ethically failed as a society.”

The ethical questions the vaccine rollout presents are many and complex.

Al Jazeera posed some to a few experts: Rosell, also a clinical professor at the University of Kansas Medical Center; Dr Jonathan Marron, a bioethicist at Harvard Medical School’s Center for Bioethics; and Dr Laurie Zoloth, Margaret E Burton Professor of Religion and Ethics at the University of Chicago.

Al Jazeera: If a young, healthy person who is not on a priority list has the chance to get vaccinated with a dose that would otherwise be discarded, should they accept?

Laurie Zoloth: It is very important not to waste any vaccine, so pharmacies and other sites that have vaccine would be wise to think about this in advance by creating accessible lists that can be used to distribute leftover doses. The chance to hang around a pharmacy is not available to people equally. People who have to work, people who don’t have a car, people who don’t have access to a computer or skills to use it quickly may be unfairly excluded.

Tarris Rosell: In ethics, context matters. So, in general, my response to your scenario would be, yes, it could be ethically permissible to take a vaccine that is offered even if I am not yet in the priority group. Doing so would need justification, however. One always needs a rationale for doing something outside of agreed-upon norms. Violating norms comes at risk of harms. “Jumping the line”, especially in a queue for potentially life-saving vaccine, risks the harms of someone more needy going without, of deepening healthcare disparities, of being viewed as a self-centred “line jumper,” of creating a precedent.

In your scenario, a justifiable rationale for accepting the leftover vaccine would be that if I do not accept the vaccine, it will be discarded and help no one. Also, if I am vaccinated, that is one more towards the worthy goal of herd immunity. We all need to do our part. Systemically and logistically, however, one should question why better preparations had not been made so as to ensure that vaccine doses are not “left over”.

Jonathan Marron: The worst-case scenario as we try to optimise our vaccination policy and rollout nationwide is for vaccine doses to get thrown away at the end of the day. So, the short answer here is that, yes, I believe that if an unvaccinated individual is offered a vaccine at the end of the day that would otherwise be tossed, even if that individual is healthy and not in a high-priority group, it is ethically supportable for them to take that opportunity.

Residents wait in line to be vaccinated at a mass COVID-19 vaccination centre set up in a car park outside of the United Center in Chicago [Scott Olson/Getty Images]

Al Jazeera: What if you’re 74 but your state has only approved vaccine access for people 75 and older? Or what if you have a medical condition but not one specifically listed by your state?  Should somebody straddling the line be allowed to get the vaccine even if they don’t meet strict guidelines?

Zoloth:  Any system of justice, any system of allocation will have people just outside the cut-off point for inclusion and at that point, there will be heartbreak. But If we allow 74-year-olds, then 73-year-olds might wonder why the line has been drawn just above their age group, in an endless regression. The only solution is to continue to press other pharmaceutical companies to cooperate in making the vaccine more available.

Rosell: I would try to avoid issuing a condemnation of specific individuals who appear to be line-jumping, or straddling, but whose situation I don’t fully know. Their situation might constitute one of the justifiable exceptions. But it might not. If not, or if discerning right from wrong is done individually rather than collaboratively, which is the point of public policy, harms can be done to others even more vulnerable and needy. Bad precedents can be set, with more line-jumping and straddling to come.

It is likely that the public policies in place for coronavirus vaccine allocation are in some ways flawed. When that is noted, the better way – rather than violations – would be to advocate for change.

Marron: These lines must be drawn somewhere in order to have a process that is ethically supportable but also can be realistically put into practice. That transparency about what is being done  – and the consistency with which it is being done – is among the most important aspects of a process like this. It would be great to have a process for raising and considering appeals, including for those with medical conditions that might not be on the state’s official prioritisation list, with periodic review of the latest data and potential revision of conditions and other criteria, integrating such appeals into the process. But again, transparency and consistency here are key.

Al Jazeera: Some in high-priority groups are going without the vaccine because they lack the resources to schedule and get to appointments. Should we be making every effort to reach these people before opening up the vaccine to the broader population, and if so, what does that look like?

Zoloth: This is true, and it is even more important in communities that have been marginalised or excluded from healthcare services. Black and Latinx communities have traditionally had less access to computers, internet infrastructure and training, and we need to be certain that all our citizens are getting access to information and to appointments.

The University of Chicago medical school students are calling patients on the telephone in my community, the South Side of Chicago, to help them secure appointments and prioritising the most affected zip codes for distribution of the vaccine. These are important practices of equity. We could use mobile units, church sites and local community centres.

I look forward to the same sort of aggressive advertising to seniors that we see done by companies that sell Medicare supplement plans, which are constantly on television, urging seniors to register for vaccination, and offering phone numbers to call that are actually staffed.

Registered Nurse Angelo Bautista administers the Moderna COVID-19 vaccine to eligible people identified by homeless service agencies [File: Frederic J Brown/AFP]

Rosell: Yes. That would be in keeping with a commitment to health equity. There are means of doing so including mobile vaccination units, setting up vaccination sites in neighbourhoods with greater inequity and vulnerability, utilising faith leaders and facilities, etc.

Marron: Absolutely – we know that the elderly, disenfranchised and other vulnerable populations are at particularly high risk of severe disease and death from COVID-19.  Unfortunately, in many cases, these populations are those who are least able to get to vaccine sites to get the vaccine that is so important for them.

We’ve unfortunately been seeing this play out in real-time, where, in many places, the maps showing areas with the greatest number of deaths from COVID-19 and the maps showing areas with the greatest number of vaccines administered look like interlocking puzzle pieces, with very little overlap. This is simply unacceptable.

We must devote the time and resources to get vaccines to these vulnerable populations in whatever way that we can. This might mean opening up more vaccine sites in the communities where these individuals live, but it also might involve outreach programmes to work with them to help individuals make appointments and identify ways to eliminate barriers for them coming to these appointments.

This is a process that likely will look very different in different areas and with different communities. But if we are genuine in our interest in getting vaccines to those who need them most – and I certainly hope that we are – these on-the-ground efforts are essential for achieving that goal.

Susan Edelman receives a dose of the Johnson & Johnson COVID-19 vaccine, the newest vaccine approved by the US FDA for emergency use [Michael Ciaglo/Getty Images]

Al Jazeera: The state of Massachusetts started a companion programme last month, allowing anyone who accompanies a 75-and-older resident to a vaccine appointment to get the jab, too. This made caregivers happy but also prompted online solicitation of the elderly by strangers hoping to score their own shots. What is your take on this offer?

Zoloth: It made sense to offer the vaccine to caregivers for the elderly because it allowed them to get to appointments, and it honoured the sincere commitment made by families who care for their loved ones in the home. It was annoying to see this kind of policy used unfairly. Using money to tilt the system toward you is the very worst sort of manipulation.

Rosell: This anecdote is an example of a well-intended programme initiative that can be ethically justified, and that then allegedly was misappropriated by narcissistic persons without ethics justification for their actions. That sort of action is a negation of the principle of solidarity. If we want this societal and global crisis to resolve more quickly and with less loss of life, we will act according to public health principles about “we” rather than an ethics of individualism that focuses on “me”.

Marron: This is a very well-intentioned plan that has turned out to be fertile ground for “line jumping” and taking advantage of the system. I think that efforts to bring vaccines to those who need them most, rather than trying to find ways like this to get the people to the vaccines, will be a more effective and fair process. But it will also be a more expensive and time-intensive process, requiring significant investments into our public health infrastructure, something that historically we have not often done.

World War II veteran William Lloyd Roberts, 94, and his wife, Erma Lee Hanna Roberts, 91, receive the coronavirus disease (COVID-19) vaccine [File: Lucy Nicholson/Reuters]

Al Jazeera: If you have recently recovered from COVID-19, should you get vaccinated when it’s your turn in line or should you step back to allow others who do not have your immunity to get vaccinated first?
Marron: This is an area where the science hopefully will be able to drive decision-making. For now, I think it is perfectly reasonable for someone who had COVID-19 to get their first vaccine dose when it’s “their turn”, but as we learn more about immunity following infection, as well as the role for the second vaccine dose in this population, these recommendations might change.  Flexibility with new data – and clear communication with the public about these new data and how they inform guidelines – is paramount.

Rosell: This is a question more for immunologists than for ethicists. What I am reading indicates that we don’t know enough yet about immunity following infection and recovery so as to forgo vaccination or prioritise others. Also, there are now documented cases of reinfection in post-COVID-19 patients by one of the newer mutations/variants. So the message ought to be: Get vaccinated when it is your turn to do so.

Source: Al Jazeera