by Daniel J. Hurst, PhD, ThM, MSc and Matthew Arbo, PhD
The Advisory Committee on Immunization Practices (ACIP)—the group advising the Centers for Disease Control and Prevention (CDC) on how to allocate COVID-19 vaccines, has made their recommendations based upon a phased system with high-risk healthcare workers and first responders receiving the vaccine first (Phase 1a), followed by persons with comorbidities as well as older adults living in congregate settings (Phase 1b). Phase 2 of the plan would then include many other essential workers as well as all older adults. The underlying ethics principles that the recommendations are based upon include maximizing benefit and minimizing harm, promoting justice, and mitigating health inequities.
It has been thought for some time that affluent persons could attempt to jump line for a vaccine ahead of others or that, given the intense demand, even a black market for the vaccine could emerge. Instances of the wealthy offering to pay significant sums for a vaccine, or making a large financial donation to a health system, have been reported. A recent article by Alan Levine in the highly-regarded health and medicine news site, Stat, made the case for having the “wealthiest and most influential Americans donate large sums of money to get to the front of the vaccine line, and use that money to fund the broader effort to vaccinate people against Covid-19.” It’s the classic question of whether the ends—money for infrastructure—justify the means—large payment to jump line. We think not. While the goal of subsidizing a quest for herd immunity is worthy, we question the ethical justification of the practice. The ethical principles laid out above yield specific recommendations for practice, and each principle would be compromised if the wealthy were able to jump line.
Principle 1: Allowing the ultra-rich to buy their way to the front of a line, much like a Disney Fast Pass that allows guests to pay an added fee to avoid long lines at attractions, is uncertain to maximize benefits and minimize risks. In Levine’s proposal, the ultra-rich would pay exorbitant sums, in some instances upwards of $100 million, for the vaccine and those profits would then be used to subsidize a wider vaccination campaign. An added benefit, according to Levine, is the positive publicity of having high-profile business executives, celebrities, and other “influencers” take the vaccine which could, hypothetically, persuade segments of society wary of the vaccine. It’s an understandable proposal, only with ethically troubling means to realization. There seems little way around the conundrum that allowing the ultra-rich to jump line, particularly those not in Phase 1a or 1b, would delay vaccination for higher-risk persons. Even if the number of individuals delayed vaccination amounts to half a million people, as Levine suggests, that’s still half a million more needy who should receive the vaccine as soon as possible but who must wait for the rich to receive their reward. Under conditions of resource scarcity as currently exist, priority should be given to those persons of instrumental value in fighting the pandemic (frontline essential workers) and those persons with high burden of COVID associated hospitalization and mortality.
Principle 2: When demand for a healthcare resources outpaces its supply, it is imperative to allocate resources in an equitable manner. Doing so respects the basic principle of justice. Prioritizing the groups in Phase 1 of the ACIP guidelines is based upon the instrumental value of frontline healthcare workers to combat the virus and also upon the limited ability to work from home and control social distancing, like those persons living in congregate settings. The ultra-rich, including business executives, celebrities, and others are typically in a much more privileged position to work from home or secure an environment conducive to social distancing.
Ethically speaking no one is intrinsically more valuable than another and thus none are more deserving than another. Wealth makes a person more ‘valuable’ in a strictly monetary, not an ethical sense. All human beings possess dignity. Principles of prioritization should be based on respecting human dignity. Making vaccine allocation transactional, even if projected to secure social benefits, violates the basic principle of justice because it values subsidizing costs of a national vaccination program over the urgency of vaccinating frontline workers and the vulnerable.
Why not simply invite the ultra-affluent to act altruistically and simply donate monies to support a more effective national vaccination campaign? Many people are indeed motivated primarily by self-interest. But doing some good primarily for self-serving reasons undermines the goodness of an otherwise generous act. Levine’s proposal misunderstands the logic of philanthropy; anyone who pays to jump line forfeits the marketable appearance of altruism. The celebrity paying $100 million to jump line does far more to foster the public’s contempt than inspire it to vaccinate.
We are also concerned with the broader message a Fast Pass system may signal. Our country has seen incredible polarization lately, including a heightened recognition of pronounced structural inequalities many communities face. Allowing the ultra-rich to jump line and obtain a vaccine with a payment between $25,000 – $100 million USD would serve to exacerbate these inequalities.
Principle 3: Mitigating health inequities is the final ethical principle that ACIP explicitly referred to in setting their recommendations. We believe that allowing COVID-19 vaccines to be sold to highest bidders would ethically compromise the allocation system. The market may sometimes be an efficient way to subsidize costs for structural advances, but in this case Fast Pass vaccinations would have the effect of deepening already fraught social inequities. Imagine the droves of people who have followed all CDC safety protocols and watched news of vaccine development patiently, and who learn their date of eligibility has been postponed so that celebrities and the wealthy can be rewarded for their ‘donations’ to a campaign they as a taxpayer have helped underwrite! Subjecting vaccine allocation to often arbitrary market forces is incompatible with basic principles of equality. In fact, it compounds it.
In light of the above, we think such a plan is wrong-headed. Yet, we also recognize the need to instill confidence of vaccine safety to many in our society. Having public figures take the vaccine in high-profile ways may assist in this effort—similar to Elvis Presley’s televised polio vaccination—but selling the vaccine to highest bidders who would jump line over persons at greater risk is not the way to go about it.