There’s nearly universal agreement that a safe and effective SARS-CoV-2 vaccine should be available and affordable to all countries—rich or poor—both as a moral imperative and because the globe’s health and economy will depend on it. But the rollout of a vaccine will be hugely expensive and time consuming, potentially leaving poorer countries and disadvantaged communities last in line and also forcing tough decisions about which members of society ought to get it first.

Ethics in Health Care

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During a recent “Ethics Talk” videocast from the AMA Journal of Ethics® (@JournalofEthics), Ruth Faden, PhD, MPH, professor of biomedical ethics at the Johns Hopkins Berman Institute of Bioethics, summarized efforts underway to head off inequity in distributing vaccines and outlined the top-level ethical arguments around who should get the vaccine first when supply is limited.


A global public health good

The need for countries to balance their commitments to securing vaccines for their populations without simultaneously depriving low- and middle-income countries of access to doses is a “global ethics sweet spot,” Faden said.

The COVID-19 Vaccines Global Access (COVAX) facility, headed by the World Health Organization (WHO), the Coalition for Epidemic Preparedness Innovations and Gavi, the Vaccine Alliance, was organized to help with this. By pooling demand, it provides countries that have entered into bilateral agreements with manufacturers an insurance policy in the form of a larger portfolio of vaccine candidates. At the same time, it gives governments lacking bilateral agreements—typically low- and middle-incomes countries—a reliable supply of vaccines, with financial support coming from various donor sources.

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As of early September, more than 170 countries had signed on to the effort. The U.S. wasn’t one of them, though, ostensibly because of its objection to the WHO’s involvement. But there are “prudential, self-interested reasons” for getting behind it, Faden noted.

In public health, she said, it’s axiomatic that, “if there are outbreaks anywhere, there are outbreaks everywhere.”

Read about one expert’s predictions of “bottleneck” issues for a COVID-19 vaccine.

How to define essential workers

Front-line health care workers should be prioritized for vaccination because of their societal value during a pandemic, Faden said. But determining who else is essential is more challenging.

For starters, decision-makers need to avoid the elitist bias that “essential” necessarily means highly skilled, well-trained or professional. Within health care, for example, essential workers ought to include custodial staff and food preparers, she said.

Outside of health care, they might include people who are critical to the country’s food supply, transportation system and power grid, but this is normatively charged territory, Faden added. Primary, middle and high school teachers illustrate the point.

“Are they essential workers or not?” Faden asked, noting that many essential workers are, in fact, highly skilled and cannot be replaced easily. “I would make a big plug for K–12 workers being essential workers. Someone else might want to throw in university professors into that category as well.”

Making such a determination is also a matter of assessing whether additional risk of infection comes with the occupation, whether risk can be mitigated by PPE, whether there is adequate availability and quality of PPE and potential for physical distancing at the work site.

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But while limited vaccine supply might prevent some essential workers from getting doses as soon as they are available, Faden added, U.S. health care workers should enjoy priority for another reason: The country owes it to them.

“We also need to incentivize people to continue to do those jobs,” she said, “to make them feel not only acknowledged and that expression of national gratitude, but also, ‘OK, I can keep doing this because I'm going to be protected.’”

Explore more COVID-19 ethics topics

Check out previous episodes of the “Ethics Talk” podcast or subscribe to the series in iTunes or other services.

The AMA and the Centers for Disease Control and Prevention are closely monitoring the COVID-19 pandemic. Learn more at the AMA COVID-19 resource center. Also check out pandemic resources available from the AMA Code of Medical Ethics, JAMA Network™ and AMA Journal of Ethics, and consult the AMA’s physician guide to COVID-19.

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