Justice and Vaccination Priority: A Response to CDC and NASEM Proposals

by Rosamond Rhodes, Ph.D.

As vaccine for COVID-19 becomes available, we anticipate that the initial supply will be inadequate for vaccinating everyone who wants it.  Those responsible for distribution will have to decide who receives vaccination first. To secure the public’s trust that justice is being done, and to promote public support of the implemented allocation policies, the prioritization rationale will have to be coherent and clearly explained.

A number of groups have already posted criteria for vaccine prioritization. The ones that I’ve reviewed are similarly on target in their stated aim, but problematic in their justifications.  To illustrate, I shall discuss two recent examples, the posted guidance from the US Centers for Disease Control and Prevention (CDC) and the National Academy of Medicine (NASEM).

The October 23^rd guidance for the CDC, “The Advisory Committee on Immunization Practices’ Ethical Principles for Allocating Initial Supplies of COVID-19 Vaccine” declares in its first sentence, “To reduce the spread of SARS-CoV2, the virus that causes coronavirus disease 2019 (COVID-19) and its associated impacts on health and society, COVID-19 vaccinations are essential.” [p.3] That statement identifies spread reduction, in other words, disease containment, as the appropriate aim for vaccine distribution now that community spread is increasing at an astounding rate.  Similarly, NASEM’s October 5^th  “A Framework for Equitable Allocation of Vaccine for the Novel Coronavirus” endorses the utilitarian aim, “to achieve the primary goal of maximizing societal benefit by reducing morbidity and mortality caused by the transmission of novel coronavirus.”  In essence, both guidance documents point to saving the most lives by reducing transmission as the appropriate goal for addressing today’s urgent situation. That consensus should give us confidence that saving the most lives by curtailing the spread of COVID-19 is the appropriate goal for vaccine allocation, the goal required by justice. Because containment is the most effective means for reducing COVID-19 spread and preventing disease-related deaths, containment should be accepted as the vaccine allocation strategy for so long as disease transmission is not adequately controlled. I therefore support the CDC and NASEM recommendations to prioritize healthcare workers and those at greatest risk of contracting and transmitting the disease.

CDC Allocation Principles

The December 1^st Guidance from the CDC lists the first three groups that are to be prioritized for vaccination: 

• Phase 1a Health care personnel and Long Term Care Facility residents;
• Phase 1b Essential workers;
• Phase1c Adults with high-risk medical conditions and adults 65+.

Unfortunately, the rationale that supports those lists is missing, leaving us with some confusion as to who is to be included for prioritization and why. 

Because COVID-19 is an airborne disease, people who live, work, or interact in close proximity to many others are more likely to become infected than those who live, work, or interact with just a few others. Congested living also increases the chance of contracting and spreading the disease for people who live in homes crowded with many others and people who live in large high-rise apartment buildings where residents crowd together waiting for elevators then squeeze in for the ride.  

Furthermore, the work circumstance of health care workers, first responders, and other essential workers entails their being on site. By maintaining the social functions that they fulfill, their isolation is impossible. The circumstances of people who can work from home and those not likely to be harmed by continued isolation make their isolation feasible. It may be unpleasant, but it is not likely to have enduring untoward effects. 

The CDC’s October 23^rd and December 1^st guidance does not connect their recommendations specifically to the risk of contagion and the possibility of maintaining isolation.  By not explaining the underlying reasons for their decisions, they fail to distinguish two discrete groups among those with underlying health conditions that make them vulnerable to the serious effects of COVID-19: (1) people who cannot maintain isolation and (2) people with similar conditions who can feasibly isolate themselves and largely protect themselves from infection. Those in the first group of adults with high-risk medical conditions and adults 65+ should be prioritized because they are at high risk of becoming victims and vectors of COVID-19. Those who can maintain isolation are not at high risk, so prioritizing them is not justified at this point.

In addition, the CDC’s broader October 23^rd guidance document is distracted by additional well-meaning goals. As the authors note, “[a]llocation of limited vaccine supplies is complicated by efforts to address the multiple goals of a vaccine program.” When justice requires containment of the virus, policy should focus on that end and eschew complications introduced by trying simultaneously to promote other aims that might impede achievement of the immediate, urgent goal. 

Although the Committee correctly notes that “the COVID-19 pandemic has highlighted long-standing, systemic health and social inequities,” [p.3] that serious social problem is best addressed by creating dedicated programs aimed at ameliorating such disparities.  Deviating from the goal of disease containment in the face of a run amok pandemic will divert resources to counter-productive agendas while leaving those who are socially and economically disadvantaged most at risk of exposure to the virus. Whereas reducing health and other disparities should be addressed, vaccination priority is not the means for achieving that important, but different, goal.   

The CDC’s Committee statements also demonstrates limited understanding of promoting justice (its second guiding principle). They accurately proclaim that “[a]llocation of COVID-19 vaccine should promote justice by intentionally ensuring that all persons have equal opportunity to be vaccinated, both within the groups recommended for initial vaccination, and as vaccine becomes more widely available.” [p.2] Equal treatment of those who are similarly situated is the hallmark of justice. Yet, we need to understand that prioritizing all “adults with high risk medical conditions and adults aged >65 years” [p.3] would not provide justice for the entire population because allocating the initial vaccine supply to those who can stay at home would hardly contribute to reducing virus spread.

We rightly employ different principles in making different decisions.  After taking all of the relevant considerations into account and setting aside irrelevant distractors, justice is the conclusion about what is ethically required under those circumstances. What makes achieving justice difficult is that often enough it is not easy to identify which principle(s) to employ in making a particular kind of allocation. Too often people mistake a principle (e.g., fair equality of opportunity) which is appropriate guidance for some circumstances as the substance of justice. By mistaking some specific conception of justice as the unique starting point for moral deliberation, they erroneously assume that ethical conclusions follow simply from it, and thereby reach conclusions that are incompatible with what should be done. This appears to be the underlying problem in the Committee’s reflections on justice.

Furthermore, after nine months of learning and practice, medical professionals are now better prepared for making decisions about who requires hospitalization and caring for people who are seriously ill. They’ve learned about anticoagulation, proning, avoiding ventilation in favor of high-flow nasal cannulae, and therapeutics including antibodies. In some New York City hospitals mortality rates have dropped by 75%, average length of stay decreased from 11 days to 9, and the percentage of patients needing ventilators has declined from 17% to 9.5%. This suggests that protecting those most vulnerable to serious illness who can isolate is now less critical to flattening the curve than it was at the start of the pandemic. Presently, the best way to avoid overwhelming our hospital capacity is by encouraging those who can isolate, including those vulnerable to serious complications, to stay at home.

The Committee’s October 23^rd document further complicates and undermines its containment agenda by expanding it to include “mitigate health inequities.” People who have been socially disadvantaged, and people in racial and minority groups, are situationally among those who are most vulnerable to contagion. Often they live in high occupancy environments, use public transportation, and work in close proximity to others. Therefore, they are among those most likely to benefit from disease containment and most likely to suffer when policies deviate from that critical goal.

The NASEM Framework

In their analysis, the NASEM Framework authors list four criteria for guiding vaccine allocation decisions. Three of the four align with their goal and their phased approach for prioritizing groups for vaccination.

• Risk of acquiring infection
• Risk of negative societal impact
• Risk of transmitting disease to others

Their second criterion is, however, out of place in a response to the current situation of a run amok pandemic.

• Risk of severe morbidity and mortality: Higher priority given to individuals who have a greater probability of severe disease or death if they acquire infection.

Here the problem with the NASEM’s guidance is the same as what I identified in the CDC guidance.  For the most part, those at risk of severe morbidity and mortality can isolate at home with little likelihood of contracting the disease, and therefore little risk of serious illness or death. When that point is noted, its implication should be incorporated into phased recommendations.  Because most people over 65, and most whose underlying conditions make them vulnerable to the effects of COVID-19 can isolate themselves from the risks of contagion, they should be grouped in Phase 4, the last group on the NASEM list. 

Conclusion      

In sum, both the CDC Advice and the NASEM Framework are more convoluted and vague, and less clear and transparent, than they should be. To meet our society’s needs of for a coherent explanation that can be trusted and supported by our people, we require a plan that is focused and closely tied to achieving the containment goal that we urgently need to address. 

Both national and local considerations will actually be involved in determining where the initial vaccine supply should be sent and when and where to move down the priority list. Along the way, those responsible for planning and implementation of COVID-19 vaccination will need to make more fine-grained distinctions.  They will also have to hold the line of justice and resist the influences of both politics and political correctness.