The links of imaginary no-existing websites with The doctor takes the medication from a bottle to an injection in laboratory.

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

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  1. I believe that more work needs to be done on the implementation of distribution of scarce vaccines, as neatly presented by Mark Kuczewski. As of today, both in US and Argentina my home country, it is a patchwork of multiple, inconsistent and obscure layers of decision making (national, federal, municipal, etc. ). But I believe they are a reflection of the structure of the health system of each country. The anxiety experience in front of the several web pages is the same also. The Disney suggestion seems great and it signals a way of more empirical and normative thinking on what is known in the literature as “local justice” (Elster, Rawls). The problem I see with the analogy is the multi-level decision making of health systems. Disney World has complete authority, and therefore it is a more simple system for distribution.

  2. Given that we had nine months from the time when the need for mass vaccination became apparent, CDC could easily have hired a vendor with such expertise to create a sophisticated queuing system with adjustable factors that states could adapt to local needs. (For example, we serve Alaska, where the most extreme logistics of remote rural populations are a major concern that would not have been top of mind for developers in Washington or Atlanta.) States could establish a single point of registration, where individuals could answer the health questions and be placed in a queue. Before the mass confusion began, I believe most Americans would have entered their information honestly and those that exaggerated medical conditions would not be too disruptive. State ID numbers would provide age and address. Since ZIP codes are a generally accepted proxy for socioeconomic status, states could use them to increase priority of targeted areas where underserved minorities live. As Mark noted, upon entering the information, each registrant would receive confirmation and a means to monitor their expected wait time. If they entered a travel radius, an appointment could be made automatically, with user modification if needed. None of this requires AI. I would avoid machine learning in the process, because it is subject to confirmation bias and is front-loaded with the unrecognized biases of the programmers. This could increase advantage for the underserved groups the programmers thought of, but might disadvantage others they overlooked. Public health officials could easily monitor vaccination rates and target special interventions where rates are low.

    News articles are covering the army of volunteers that have arisen spontaneously to help the Internet-challenged find appointments. If they were not needed to patch the broken appointment system, they could sign up to drive people without transportation the vaccination site on their own.

    None of this is beyond the capability of a nerdy high school student to put together. We just missed the opportunity, and so the hours of thoughtful discussion at ACIP and other places in government would have actually achieved a good portion of the equity they sought to create. Efforts like this will not undo 400 years of harm, but they would at least begin to show the public that we want to do better and can act on it. Sharing resources with other countries would strengthen the global vaccination effort.

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