It did not take long for the difficult moral questions around who gets the Covid-19 vaccination first to get ugly. At Stanford University an algorithm for distributing the vaccine prioritized older doctors working remotely over young interns and residents who are in daily contact with Covid patients, resulting in a public shaming demonstration. After the bad public attention, the university changed its prioritization system. Numerous other incidents now pop up regularly on social media, such as EMT personnel handling critically-ill Covid patients daily who cannot get a spot in the line for immunization. Moral questions get messy when the stakes are high.
In 2018 I wrote a series of posts (the thread begins here) summarizing my approach to ethical reasoning that I had developed after formal graduate study in the subject and a period of teaching professional ethics. I call the approach the moral conversation because it can be seen as listening, not just to others, but critically to different parts of your own brain “arguing with itself” as it applies several, sometimes conflicting, options called to consciousness when faced with a moral dilemma. Indeed, the very definition of “moral dilemma” might be said to be the unresolvable conflict of these reasoning patterns.
Which of these positions are you hearing from the pundits regarding Covid vaccine immunization?
I simplify this process by the four colored boxes and direction arrows above, but these boxes are really better described as “vectors” of fuzzy direction and magnitude rather than clean categories. Good people disagree about important ethical problems like this one in large part because we have developed a rich language over many centuries for outwardly discussing these multiple “voices in our heads.” And they usually do not fit into nice boxes.
You can start anywhere in the diagram, and there is no single pathway through your brain. One part (or parts) of your brain processes the many rules and duties you have been taught by your religion or culture to follow in making life’s tough choices. However, you likely keep thinking of exceptions to those rules that might apply to you, because you really have a different “good end” in mind.
Because other parts of your brain “feel” rather than “think,” you may realize that this “good end” for yourself might have an unintended “bad end” consequence for someone else. Humans feel empathy for the other person who is impacted by the moral choices of others. But when you start pondering about all of the other people in the world who face the same dilemma, you may realize that your initial simple solution likely can’t save everyone.
Finally, your “deep thought” brain function might step back to consider the “big picture” meta-ethics of principles, values or virtues that are supposed to help guide you through life. However, those principles are usually not specific enough to easily decide this dilemma at hand. And so, you find yourself back into the first vector pondering how you need some more detailed rules, thus completing this circle.
You may think that you are disagreeing with the “other guy” on moral issues. But if you honestly “walk around” this circle in your head, you more likely will find that you disagree with yourself. If you have only one answer to an ethical dilemma, then you probably aren’t thinking very hard.
Expanding the circle to coronavirus dilemmas
As contrasted with professional ethics for lawyers and accountants, where I cut my teeth, the discipline of medical ethics has a long history of pulling the writings of the great philosophers and theologians into the discussion.  Indeed, the first “doctors” were theologians and the line between the ancient Greek physicians and philosophers was thin. This tradition gives the medical community a richer “ethical language” that helps them talk with patients as well as with each other.
The Centers for Disease Control’s Advisory Committee on Immunization Practices (ACIP) has posted a summary of a major presentation on the ethical conflicts and logistical obstacles to distributing Covid vaccines. We don’t have access to the full study behind this presentation, but the summary linked here is an unfortunate mish-mash of ethical language, demographic analyses, and brief summaries of alternative on-the-ground implementation strategies. That mash-up has drawn criticism from several quarters.
In the language of my model, the ACIP started their “moral conversation” in the green “meta-ethics” box, establishing four principles used to set the initial rules. That is not a bad place to start. The principles draw from the entire “conversation” to bring some good broad-based ethical language in coming up with their recommendations for vaccination priorities. However, your favorite “guiding principle” may not be on their list, and it is not clear why these four survived the cut while other principles did not.
The first principle addresses a directed “good end” desired for the immunization campaign, seeking a utilitarian maximization of benefits, moderated by the classic medical “do no harm” outcome on the downside. Their second and third principles, focusing on justice and health inequities, come right from the “empathy” box.
Much of the modern philosophical discussion of the ethics of justice and social inequity owes its language to John Rawls’ classic 1971 text, A Theory of Justice. Rawls proposed getting over the hurdles of social inequity and injustice by imagining a “veil of ignorance” where, using this case as an example, we would not know the race, religion, socio-economic level, or political-connectedness of the people getting immunized, so that these classic factors of injustice do not creep into prioritization decisions. That “veil” is easier imagined than implemented in practice. Indeed, the veil has already been ripped widely as youngish, healthy senators have scored their place at the front of the line after months of downplaying the virus.
The last principle, transparency, has risen in recent years as a critical ethical principle in governmental decisions, as “hard choices” made in public are less likely to hide political biases. As noted in the opening news item above, the exposure of the Stanford vaccine prioritization process evoked public shaming, and the algorithm was then changed as a result. We have learned over the last four years that some political figures are immune to shaming, but generally I see it as an underrated ethical strategy. Most of us want the social acceptance of our peers and families, and so we try to minimize our personal shame. Sometimes, shame is the only “bullet in the holster.”
Nailing down the rules
An example of the need for these principles in order to determine priorities came early. The out-of-the-gate rules specified that immunizations would go first to Covid-facing front-line health care workers, followed by patients in nursing homes. This was relatively uncontroversial to the general public. By one estimate, over one-third of all Covid deaths have been in nursing homes and other “congregate care” settings, and some governors have failed miserably in protecting these folks. This is an application of the first principle, the maximization of benefit, in action.
My diagram above notes that the first objection usually coming from the “rules and duties” box is a claim of exception from the rules. Just as the first vaccine was being shipped, reports were emerging that the White House staff had arranged to “jump the queue” to get early inoculations. Even for an administration that had shamelessly ignored masking rules and other acknowledgements of the seriousness of the coronavirus pandemic, the public embarrassment of jumping the queue proved to be too much, and the plan was quickly rescinded. The principle of transparency won that round.
Here is where it gets sticky!
Front-line workers and specific types of congregate care facilities are easy to identify and manage. But who comes next? In the prescient 2011 Steven Soderbergh pandemic film Contagion, immunizations against the contagion were administered on the basis of a lottery determined by birth dates. A key difference between that film and the current coronavirus infection is that there are clear demographic differences this time in the rate of fatalities and serious complications based on age, race, and certain medical conditions.
This has led many to assume that age and pre-existing medical conditions would take the lead in the next round of priorities, and these considerations come into the ACIP report. “Essential workers” in addition to front-line medical personnel have also been assumed to be getting priority. Race is always a hot-button factor, and the numbers are quite compelling, but that messy subject seems to be intentionally avoided.
The New York Times posted an online simulation for determining where you likely fit in the vaccine waiting line based on these early rule projections and current U.S demographic data. It turns out to be a long waiting line for many of you, even if you think you are in a “priority” category. By the ACIP’s own estimations, there are likely over 200 million Americans who are arguably in at least one of these priority groups. That is just not going to work from a logistical standpoint.
And so, we are likely to see some different attempts at prioritization, perhaps at a state or even local level. The ACIP has run simulations on prioritizing people 65-plus in age, those with key contributing conditions, and essential workers. All strategies reduce the rate of Covid deaths significantly, but no one of these works decidedly more than another. And so, who gets the “permission slip” first?
One option rising in popularity in social media discussion is simply to start at a high age and work down, with your turn eventually coming up as older Americans get inoculated and more vaccine supplies continue to come online. This option has the benefit of being a clean and easy-to-administer rule, but many at-risk younger people will cry foul. In the language of the moral conversation diagram above, this is an “unintended consequence” of a reasonable solution, and so this allocation method alone will just not fly.
Complicating this is that the “good end” sought is not just the minimization of death, but also a decrease of the contagion spread. It is currently unclear whether the vaccine slows the spread of the coronavirus. If it does, the inoculation of grocery store clerk who comes in contact with hundreds of people daily might do more for this goal that hitting a high-risk person like myself who has been avoiding other people (ahem) like the plague.
And the “exception to any rule” arrow will continue to be strong. Already reports are surfacing of a vaccine “black market” arising for the “concierge medicine” crowd, those rich Americans who contract with medical providers for a high annual flat fee, avoiding the “slumming” messiness of insurance headaches and waiting rooms. We have also seen how badly coronavirus testing was rolled out. The “fun ride” of implementing a difficult moral decision has not yet begun.
“Morality must be based on reality”
This phrase, which I cribbed from a Jesuit ethicist mentor of mine, says that the reality of the world in which we live is that the really tough moral questions will get messy, and thus inevitably political. The answer likely lies in multiple solutions.
At this writing, the vaccine distribution has been extended to an estimated 60 million people. Those over the age of 75 and “essential” workers are slated to receive the vaccine next. The latter category is more problematic than the first. How do you prioritize 60 million people, and exactly how do you demonstrate that you qualify as “essential”? This is easier for some than for others. Expect some hostility arising.
At the risk of cynically catering too much to the “reality” side, we might even want to consider putting a very high “free market” price on a batch of the vaccine specifically for controlling the black market. Like the growing acceptance of legalized marijuana, perhaps it is better to get some cash back into the government coffers from those rich folks who would otherwise find less-than-legal ways to get vaccinated.
Searching for empathy in a tough system
The American medical system is not particularly well-positioned when the empathy factor demands attention. Our for-profit, employer-based healthcare system routinely leaves so many people out of the process that it only seems natural to us that a good Blue Cross insurance policy should get you a vaccine “fast pass.”
With the exception of some very good not-for-profit community health centers in poor urban and rural areas, we generally do not have an efficient way to get medical care to the most vulnerable citizens. Just maybe this crisis will kick us in the behind and set us on a path to providing better and more consistent healthcare to all Americans. One can only hope.
Asking the good questions
When you next hear someone place a marker down on a particular immunization strategy, go back to the boxes above and ask yourself, “Which moral questions is this pundit trying to address?” Followed by, “Have I honestly covered all of the bases in this moral conversation myself?”
- “Professional ethics” in the legal and accounting professions rarely strays beyond the anal parsing of complicated statements of rules and duties. I wrote a very tedious masters thesis a long time ago documenting this.