Who Chooses the Choosers? — Ethical Considerations For Distribution Of COVID-19 Vaccines
By Kenneth I. Moch
Editor’s Note: The following commentary was sparked by an Ask The Board question, “What are some of the ethical considerations government's should be taking into account regarding how a COVID-19 vaccine (assuming one is developed) should be distributed (e.g., elderly and high risk first) within a given country and why?,” posed to Life Science Leader editorial advisory board (EAB) member, Kenneth Moch. As the length of the response exceeded the word-count restrictions for this monthly print edition column, it is being published as a Beyond The Printed Page. Life Science Leader is grateful to have such an active and engaged EAB.
How do you triage a country? When it comes to the distribution of the first COVID-19 vaccines within a specific country, this question is not only at the intersection of science and ethics, but also at the crossroads of economics and nationalism as well as the pressures, politics, dictates and desires of governmental leaders.
But as part of this answer one needs to ask an even more fundamental question: How do you triage the world? This is a question with deep implications not only for Americans (focusing just on the US) but for geopolitical and geo-economic stability (taking an international perspective).
It is unfortunately safe to assume that allocation decisions must be made when a vaccine first becomes available. A recent article in Foreign Affairs, entitled “The Tragedy of Vaccine Nationalism” argues that due to the limitation of manufacturing and distribution, “providing [vaccines] to some people will necessarily delay access for others. That bottleneck will prevent any vaccine from becoming a truly global public good.” This issue, of hording medical countermeasures which are in short supply, is not new; it happened in prior potential medical crises like the H1N1, and it has happened with medical supplies necessary for protection against COVID-19.
If a government is trying to set criteria for receiving a vaccine that is in short supply, what level of specificity do you set for the allocation priorities – how long and detailed is the criteria decision-making list? Is the basis actual or projected economic need, medical status or, being realistic, political considerations? If the key criterion is economics, is the focus on at-risk workers, whether domestic or international, who are necessary for the economic wheels to turn, providing income and producing products critical for the health of the population over the longer term? Or, if the key criterion is medical need, is the focus on elderly individuals or those with pre-existing conditions that are associated with higher morbidity and mortality? How does one gain consensus on the ranking of these or other criteria?
Over the past months wealthier countries have placed scientific and economic bets on the potential success of experimental medical countermeasures, both vaccines and therapeutics, in return for guaranteed access to the initial supply. One can argue that governments have a reason to solely focus on the well-being of their citizens, but can and should there be an aggressive counterargument that global stability is of equal importance for the global common good? Would it be wrong if these major investments result in the countermeasures first being used in the investing country, but then made available globally as quickly as possible to the benefit of others? Arguments have been made in the past, and again are currently being made, on both sides.
Consider this at a global level: How would you choose between an economically depressed third world country where the virus is rampant, and an economically depressed Midwest city where the virus is rampant? If it were the early days of a vaccine’s availability, when long term safety data is less robust, would this influence your decision making?
Consider this at a local level: How would you choose between an elderly diabetic and a middle-age father with a family of four who needs a vaccine to go back to work? What if the elderly diabetic was your grandfather, or the father was you? If that choice is clear to you, consider this: how would you choose between two people of exactly the same medical characteristics and exposure risk, but where one is supporting two family members and one supporting six family members? Would a lottery system be the fairest, given that it is based on an immutable characteristic like birthdays and agnostic to any underlying factors?
One final consideration: who should do the choosing amongst these many criteria? How do we as a society value the input from our scientific leadership, economic and business leadership and our political leadership? In the end, are these not judgement calls, hopefully made with the best available information by those we hope have the best minds and the best intent to address the issues? Who chooses the choosers?
---
Kenneth Moch has been the co-founder or CEO of six life science companies. His most recent essay, “Bioethics and the Need for Ethical Leadership During the COVID-19 Pandemic,” was published in Biotechnology in the Time of COVID-19, edited by Jeremy Levin.