Who should get COVID-19 vaccine first?


When the first 6.4 million doses of an approved COVID-19 vaccine are shipped, likely by mid-December, it will be a moment of triumph for health care research and technology. It could also be one of the most difficult ethical decisions in a pandemic that has been full of them.

How we distribute the limited first doses of vaccine will involve painful and frustrating cultural discernment.

The New England Journal of Medicine published an article in May that laid out the wickedly complex problem of distributing resources generally by listing four fundamental values:

1. Maximizing the benefits produced by scarce resources

2. Treating people equally

3. Promoting and rewarding instrumental value

4. Giving priority to the worst off

The wording here could be improved (“instrumental value” turns out to mean “giving priority to those who can save others, or to those who have saved others in the past”). We may like to add one or two more. But the real difficulty of this list is the impossibility of honoring all of these principles at the same time.

The co-authors assert that, “in the context of a pandemic, the value of maximizing benefits is most important.” Significantly, they think this means not only saving the most lives, but also increasing “length of life.”

This kind of reasoning is obviously in some tension with values like equal treatment and prioritizing the worst off.

It also assumes that we can all somehow agree on what it means to maximize benefits — in a pluralistic culture that doesn’t seem to be able to agree on anything lately. And it requires us to resist the kind of utilitarian reasoning that undermines the values we hold most dear: History is full of similar moments — the early 20th-century era of eugenics to name one — when leaders focused on maximizing benefits and in the process ended up abandoning the worst off.

In an RNS column near the beginning of the pandemic, I underscored the danger of using cultural emergencies as a pretext for undermining basic civil rights in order to “maximize benefits.” Three months later, my fears were realized when it became clear we had virtually abandoned our elders in nursing homes so that hospitals could treat younger patients.

We have now passed 100,000 dead nursing home residents and staff. (That number may be even higher, given that states like New York still won’t release data on those who were infected in nursing homes but died in the hospitals.)

It’s in this context — one of ableism and ageism coming from clinicians and medical ethicists in pursuit of “maximizing benefits” — that I’ve been looking with concern for the forthcoming recommendations for vaccine distribution coming out of the CDC.

No formal vote has been taken, but the signals sent by an “expert advisory panel” the Monday before Thanksgiving were not good.

Though, thank God, they appear to finally be prioritizing residents of nursing homes along with health workers in hospitals and clinics, the CDC appears to be making the disturbing recommendation to prioritize 87 million people designated as essential workers ahead of the dozens of millions of seniors and those with high-risk medical conditions.

Estimates from both Pfizer and Moderna about how many doses will be available when make it likely that adults over 65 with high-risk medical conditions wouldn’t be offered a vaccine until March. One member of the committee gave her reasoning: “These essential workers are out there putting themselves at risk to allow the rest of us to socially distance.”

While it certainly makes sense to prioritize healthy essential workers over healthy people in other fields, it’s difficult to understand why they should be prioritized over older Americans and those who are at far more risk for morbidity or mortality. Giving a healthy 17-year-old supermarket cashier a vaccine before a 67-year-old with diabetes and asthma cannot be defended.

If any essential workers deserve to get priority, based on the CDC’s own reasoning, it is nursing home staff. Yet they are not being included as front-line health care workers, a fact that merits our close attention.

Vaccine distribution for nursing home patients will be a priority, but the way nursing home staff “seem to be an afterthought” in the government’s plan, said Michael Wasserman, the president of the California Association of Long Term Care Medicine, is keeping him “up at night.”

These workers have accounted for a significant percentage of virus spread into nursing homes, and because they are low-wage workers from disproportionately disadvantaged backgrounds, they are more likely to have come into contact with the virus.

Whatever comes out of the CDC, happily, will be recommendations only. States and municipalities have the final say about how best to allocate the vaccines they receive based on the situations on the ground. But the time is now for Christians and others committed to prioritizing the world’s worst off to let our state legislatures and municipal governments understand that the most vulnerable, not the most visible, deserve our protection.

-Charles C. Camosy

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