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    Is it ever okay to jump to the front of the vaccine line? An ethics expert weighs in

    When a good is scarce, people sometimes behave badly to get it. Renowned bioethicist Arthur Caplan, PhD, offers advice on how to make the COVID-19 vaccine rollout more equitable, ethical, and trustworthy.

    A group of people standing in a socially distant line leading to a COVID-19 vaccine bottle

    COVID-19 vaccines bring the promise of a return to normalcy, a retreat from fear, and the human connection people have long been craving. But they also bring many daunting issues, both personal and societal.

    What does an ethical approach to distribution look like? Should someone reject a vaccine if they are offered one ahead of their turn? Should hospital board members qualify as health care workers? How can leaders inspire faith that the vaccine rollout is effective and fair?

    To tease out these and other complex questions, AAMCNews spoke with Arthur Caplan, PhD, founding head of the Division of Medical Ethics at NYU Grossman School of Medicine in New York City and a professor of bioethics at NYU Langone Medical Center.

    Caplan has given such issues considerable thought. In 2017, he co-edited Vaccination Ethics and Policy: An Introduction With Readings, the most recent addition to the dozens of books and hundreds of scholarly articles he has produced. He has also helped develop pandemic-related rationing policies for health systems across the country. And he’s advised the pharmaceutical companies Johnson & Johnson and Moderna on an ethical framework for distributing COVID-19 vaccines.

    In exploring the widespread tension and confusion over the U.S. vaccine rollout, Caplan points to what he considers a key issue. “This isn’t just a fight about who gets vaccinated. It’s a fight about who counts,” he says. “Who is ‘essential’? Who do we value?”

    Here are some of his insights into vaccination, the role of altruism, and how to handle line jumpers and vaccine hunters.

    Why do there seem to be so many ethical questions around COVID-19 vaccines?

    There’s long been consensus about ethical principles that should guide medicine — a whole set of agreed-upon expectations. These include principles such as “do no harm” and “put the patient first.”

    But because of the pandemic, we are now trying to establish public health ethics. We haven't had as much consensus around that.

    Public health ethics looks at treating whole communities as “patients.” Ethical principles for distributing vaccines are much more about, Should we maximize lives saved? Should we stop the spread? Should we help those most severely impacted? Those ethics can even clash with accepted medical ethics. If you are rationing ventilators, you’re not going to do what you normally would do, which is give the individual patient the best chance. Now you’re trying to do what’s best for a group. That’s a very different world.

    That's why, to some extent, it looks like we're in ethical turmoil.

    Who is involved in deciding how to ethically distribute vaccines?

    Normally, if there’s a hospital resource question, the senior leadership might decide, or a group of doctors might meet to set guidelines. But for vaccination questions, we have people like mayors and governors. Also, sometimes you want to get the public to buy in, so you ask the community what they think instead of just a bunch of cardiologists or immunologists.

    The primary thing communities wanted was to stop the exploding deaths. That meant prioritizing the elderly, nursing home residents, and nursing home staff. We also knew we had to stabilize the health care system. So health care workers zoomed to the top of the list.

    I have no problem with all that in terms of ethical principles. And most advisory bodies — whether at the national or community level — basically got a consensus around those priorities.

    But then the whole thing fell apart.

    What went wrong with applying ethical principles to vaccine distribution?

    First, it became hard to roll out the vaccines to the priority groups, particularly the elderly. It turns out it’s not a great idea to ask them to make appointments on the internet [since they often lack access]. Also, some of them were homebound, so they couldn't get to vaccination sites.

    As for health care workers, that term was never clearly defined. I think people had in mind front-line workers, but some hospitals and health systems were vaccinating everybody, including people who did psychotherapy remotely, even bioethicists and the board of trustees. So it looked to the public as though the rich were getting advantages. It looked like minority people weren't getting anything much — and they often weren’t.

    If people think you're prejudiced, the sense of fairness falls apart, and then fewer people are willing to follow the rules.

    In addition, once you opened Moderna and Pfizer [vials of] vaccines, you had to finish them. [Moderna has 10 doses per vial, and Pfizer has five or six.] But nobody issued any guidance about how to redistribute vaccines that are about to go bad. That destroyed trust because people said, “Well, you're just giving it to anybody who's nearby or somebody who waits in line for six hours.” All of that made better sense than throwing it away — but none of that was following any agreed-upon rules.

    The rollout has been unfair, inefficient, and frustrating. It’s made the public angry, and it’s made them not trust in government.

    Should hospital workers and medical students who don’t interact with patients wait to get vaccinated?

    Hospitals are not going to function without people like the IT department, but they should have emphasized remote work to reduce how many staff needed vaccination. The priority for vaccines had to be given to staff who do things like the laundry and transport patients. A lot of the public had in mind the glamorous ER doc or heroic ICU nurse. But it takes a lot to run a hospital, and you've got to make that clear to the public so they can support it.

    On the other end of defining who qualifies for vaccination, there’s been pressure to try to microallocate. Do you include teachers, UPS guys, grocery store employees, gym instructors? That has proven to be absolutely hopeless. So, after older patients and health care workers, we should do it simply, by age group. It may neglect a few younger people who are high-risk, but it's worth the efficiency and the lack of confusion.

    As for medical students who are just doing lectures on Zoom, they should not jump to the head of the line. If they do, I might say, “We’re going to sentence you to take an ethics class.”

    Should people who tested positive and therefore may have some immunity wait even if they qualify for vaccination? What about people who can self-isolate well?

    There is no single answer to people who tested positive because you have to weigh the variables. Do you live with a cancer patient, for example? If so, I’d want you to get vaccinated. If you’re living by yourself and you don’t go out, you could forgo it.

    It’s noble and just to hold off when you're really able to self-isolate. We’re talking about waiting a few more months — we're not talking about another year of watching bad television.

    What should leaders do about people who travel to other states to get vaccinated before their turn?

    Shopping around, claiming to be a Florida resident when you're not, or claiming to be a member of the Inuit peoples of the Yukon when you’re from Vancouver, which happened — that's not morally acceptable.

    I wouldn’t punish them by withholding the second vaccine, though, because that’s a waste. I would make them pay a fine. Or I'd do something like China would do, like maybe publish their names in the newspaper.

    Is awaiting one’s turn for vaccination a luxury some simply can’t afford?

    There’s a difference between altruism and ethics. Some forms of altruism are a luxury. Maybe I live in a crowded apartment, or maybe I'm exposed all the time because I'm a bus driver. I can’t afford to worry too much about other people. So, the better off you are, the more able you are to forgo things, delay things, be generous.

    Sometimes, people feel they’re “essential” workers when maybe they’re not. I’ve asked around 30 people over the past few months if they’re essential; 29 from all sorts of occupations believe they are.

    One of the reasons all this allocation debate commands so much attention is that it’s about more than just who gets vaccinated. It’s about, “Am I more important than you?” “Does society value me?”

    If you were creating a system for vaccine distribution, what would it look like?

    Some of what I’d do is make sure that everybody who is equally in need has an equal chance to get vaccinated. That means coming up with a system that ensures access that isn't driven by wealth, internet connectivity, or ZIP code.

    I’d also say we’re going to try to bring people to vaccines rather than asking them to find vaccines. I’d try to report numbers on who’s getting vaccinated for transparency and accountability.

    I’d also find people who have a lot of practical experience. I knew there were going to be certain problems with the rollout based on my 30 years rationing transplants. I know, for example, that some days you get a liver and you can't ship it to the neediest patient because the transplant team has the flu, and you have to decide quickly where it’s going instead. It isn't just having community or ethics or public health or medical input. We also need people involved with practical expertise.

    What are your thoughts as vaccination efforts move forward?

    Public health officials will need to think hard about their messaging. It’s very tough to tell people repeatedly what they can't do. I'm looking for experts to focus more on what we can do once we’re vaccinated. Can we bring grandpa over? Can we have parties with vaccinated buddies? Can we start traveling?

    If it just remains, “You better keep doing nothing because there’s new variants and because we don’t know how long the vaccines will last,” I don’t think people are going to listen. There’s just too much exhaustion with the whole “isolate and distance” thing.

    This interview has been edited for length and clarity.