Bioethics Forum Essay
Ethics Supports Seeking Population Immunity, Not Immunizing Priority Groups
Public health officials, policy makers, and national, state and local health system administrators have strived to determine the most ethical and effective way to triage a scarce resource: vaccinating the population for the coronavirus. Given the limited supply of vaccine, current distribution guidelines seek to protect those most at-risk—either at-risk of serious illness if they become infected (the elderly or chronically ill) or at-risk of being infected (health care and other essential workers). Considerations of fairness, reciprocity, and societal well-being support protecting those whose work on behalf of others places them at increased risk. Reducing the risk of infection for those most likely to become severely ill may not only protect them from harm, but also reduce the risk of overwhelming health care systems with the need for intensive care.
However, implementing these guidelines necessitates considerable administrative work (sometimes taking weeks) to identify people meeting established criteria for early vaccination, schedule appointments, and then confirm the occupational and/or health status of individuals presenting for vaccination. This is creating a bottleneck that has resulted in doses stuck in freezers, not in arms of those eager for vaccination, as well as either wasted doses or vaccination outside of the guidelines in order to avoid such waste. Recent reports indicate less than half the available vaccine has been administered. Requirements of implementation are thus delaying achievement of the guidelines’ own triage goals. The ethical priorities of equity, reciprocity, and protection of those at highest risk are not being met. Moreover, implementation challenges siphon much needed resources away from achieving the overarching goal of vaccination: creating enough immune people to end the pandemic.
There have been some calls for a more pragmatic approach eschewing micromanaging distribution and instead focusing on speed and access. While there are indeed practical considerations supporting a more logistically streamlined system, we believe there are, more importantly, ethical reasons to prefer an approach that vaccinates more people more rapidly.
The gap between available and delivered vaccine represents the squandered opportunity to save lives—both the lives that might have been protected by inoculation with doses remaining in freezers and those that may be saved by reducing the spread of coronavirus. Though studies have not yet determined that being vaccinated reduces one’s risk of transmitting the infection, this is a reasonable speculation. Greater infectiousness has been associated with higher viral load and with more severe Covid-19 symptoms. Thus, it is reasonable to proceed with vaccination programs on the assumption that among those vaccinated, the vaccines substantially reduce infection by Covid-19 and reduce viral load in those infected. These effects will amplify the impact of any vaccination program.
Acting more quickly to achieve herd immunity, or a level of population-wide immunity necessary to have major impact on disease spread, would reduce the risk of infection faced by everyone, including those meeting the criteria to be in those earliest vaccination groups who have not yet been vaccinated, as well as those in the next group, and the next. It would benefit those who cannot receive the vaccine for medical or other reasons. Even antivaxxers would benefit—population immunity benefits all.
While it is ethically admirable to protect those most at-risk for being infected or for suffering serious illness or death, pursuing those goals directly has proved counterproductive, delaying maximum vaccine delivery and costing a significant number of lives. Achieving the goals of protecting those most at-risk and those who place themselves in harm’s way for others’ benefit (essential workers) can be better achieved indirectly by seeking to achieve population immunity as rapidly as possible.
Approximately 70% of the population—or more, depending upon whose calculation you note—must acquire immunity. That means we need something like 200 to 250 million people to have had either the vaccine or the disease (presuming that the disease confers immunity). If a million people were vaccinated a day, it would take well into the fall to achieve population immunity. With more than 4,000 deaths a day, that is too long. We must go faster. We need to vaccinate 3 million a day to have significant impact in three months. The delay in achieving population immunity puts huge swaths of the public at continued risk. This is an ethical as well as public health concern.
There is a huge number of people who want the vaccine, but do not meet the criteria to receive it yet. Giving these people access will dramatically increase—and meet—demand for vaccine and advance the ethically prioritized goal of achieving population immunity. Removing criteria-based barriers to access, and the administrative work to ensure criteria fulfillment, would speed the process and benefit the populace. Policy or guidelines embracing an open access approach would be fairer than the current practice of than having some get vaccinated just because they are nearby when doses have been thawed and will otherwise go to waste. The reduced administrative burden of an open access approach would reduce variation between jurisdictions, which currently results in, for example, a 65-year-old qualifying for vaccination in one state but not in another.
To be sure, appointments are still going to be needed, but creating more appointment opportunities will be possible by upstaffing with people repurposed to the sequence of tasks: vaccine distribution from the supplier, scheduling, inoculation, post-inoculation observation, and record keeping. Involving more health care professionals in moving patients through the vaccination event can enable greater parallel delivery of vaccine: more people vaccinated per hour.
By focusing on specific risk groups, the more important goal of population protection is currently being compromised. It doesn’t matter as much whether the “right people” are vaccinated as that the required percentage of the population is vaccinated as soon as possible. What matters most—practically and ethically—in ending a pandemic is the immune status of the population, not of particular individuals. Opening access to vaccination is the practical and ethical path to achieving adequate population immunity.
Michael A. DeVita, MD, FCCM, FRCP, is director of palliative care at Harlem Hospital Center in New York City and a professor of clinical internal medicine at Columbia University Vagelos School of Physicians and Surgeons. Lisa S. Parker, PhD, is director of the Center for Bioethics and Health Law at the University of Pittsburgh and a Hastings Center fellow.