Bioethics Forum Essay
Making Vaccine Appointments Is Tearing Us Apart
The Covid-19 vaccine rollout is currently a hub of individual, sociopolitical, and ethical activity. As we watch the numbers of daily doses administered rising, we may feel engaged in a successful, miraculous scientific project that will help end the yearlong nightmare that is this pandemic. President Biden sees it as a focus of national unity and urges everyone to get vaccinated as a civic duty. Unfortunately, the on-the-ground experience of trying to get vaccinated often feels more like a war of all against all. Under such competitive and stressful conditions, vaccine seekers are primed to become hostile toward important efforts to assure that vaccine distribution is done in a way that is fair and equitable. We should take lessons from this pandemic to improve future systems that distribute scarce resources so that they foster rather than undermine social virtues.
The amount of individual activity focused on securing appointments is enormous. Day after day, millions of Americans who believe that they are eligible for vaccination go online and check multiple websites and repeatedly attempt, usually in vain, to make appointments. Depending on the locale, they are checking the websites of local health systems, state and county government sites, pharmacy web pages, and other sources. They may enter preliminary information that does an initial eligibility screen and then get a message that there are no appointments available. If they are lucky, they get a message telling them that an appointment is available and asking for additional information. In the short time it takes to enter that information, the appointment is usually gone. Of course, eligible residents repeating this process many times may receive an appointment in the coming days or weeks. But this process produces significant anxiety and frustration across the nation as it creates the experience of competing against everyone else to get into the metaphorical lifeboat.
Most states have tried to create a reasonable prioritization system that gives first shot at a vaccine to workers who are essential to the health care system and critical social infrastructure in addition to those at the highest medical risk from the pandemic. But risk has turned out to be an evolving category as new data is acquired and advocates set forth persuasive arguments for inclusion of additional comorbidity categories. This has led to elected officials moving more categories of persons up the prioritization ranking based on a plausible case and the political peril of denying sizable constituencies. This only increases the competition for appointments on the websites.
Moreover, public health officials, bioethicists, and many policymakers have been concerned with mitigating the effects of structural inequities that disadvantage people of color. Several strategies have been employed, including limiting vaccination appointments at some sites to residents of underserved areas. This seems to be a commendable strategy since it mirrors the easily understandable concept of allocating resources to each community. Of course, it can go terribly wrong as when there is a suspicion that some communities are getting resources because they are politically favored, as has occurred in a high-profile case in Florida.
Even more disconcerting is the possibility that efforts to ameliorate structural inequities could produce a backlash. By creating a sense of heightened competition and fostering “vaccine envy,” the current system plays into the tendency of white Americans to see themselves as engaged in a zero-sum game and reject attempts at equity. Incidents such as recently occurred in Chicago–where a mass vaccine site at the United Center was initially advertised as open to all Illinois residents, but then accepted appointments only from Chicago city residents and later served residents from particular zip codes–is a case study in how to produce resentment toward an equity initiative.
So, what do we do? The current situation may be beyond repair, and we simply must hope that the increasing supply of vaccine meets the demand before too much additional damage is done to the social fabric. But the takeaway lesson is that the particulars of an implementation system that distributes scarce resources should be considered at least as important as the ethical principles on which the system is premised. This is a difficult lesson for many policymakers and academics who work mainly at higher levels of generality and whose thinking is more suited to the “lifeboat ethics” framework of prioritization lists than to devising user-friendly interfaces.
We can learn simple techniques from the business sector. For instance, visitors to Disney World know that when they get into a line, they will be consistently updated regarding how long it will take until they reach the front. Anxiety is alleviated and a sense of control created through this simple, reassuring information. Contrast that with the experience of waking up each morning to begin visiting websites, hitting the refresh button hundreds of times per day, and wondering if you will ever get an appointment before you catch the virus.
In this age of artificial intelligence, it is quite possible to design electronic systems in which people enter their relevant information and are updated each day on their expected wait time and even automatically issued an appointment when they reach the front of the queue. Their wait-time status can be routinely updated with some minimal explanations, such as whether the number of vaccine doses being received by a locale is less or more than was expected that week. While this approach sounds almost too simple a matter to have moral relevance, consider how it can make the participants feel included in the system rather than making them feel like intruders in a hostile domain. Calls by political and societal leaders to get vaccinated as a civic duty will reinforce their virtue rather than make a mockery of their efforts. They deserve as much.
Mark G. Kuczewski, PhD, HEC-C, is the Michael I. English, S.J. Professor of Medical Ethics and director of the Neiswanger Institute for Bioethics at the Stritch School of Medicine at Loyola University Chicago. He is a Hastings Center fellow, @BioethxMark