I followed the example of Professor Jonathan Van-Tam, England's Deputy Chief Medical Officer, who, in the wake of the announcement of two successful COVID-19 vaccines, stated that he had encouraged his elderly mother ‘to be ready.’ I did the same.
(See Professor Jonathan Van-Tam's announcement)
Yet my own 99-year-old mother’s response was interesting. It was that she didn’t think she deserved priority and that the young should get it first. I have no reason to think her reply was disingenuous or confused. Like many of her age she has a sober and realistic understanding of her own mortality and she is cognitively very able. Nor was it a question of being vaccine hesitant. She simply thinks the priority rule is wrong.
Yet that rule is widely endorsed and the very old are definitely at the front of the queue to get the vaccine. The UK’s Joint Committee on Vaccination (JCVI) updated its advice on priority groups for receiving the COVID-19 vaccine in September and offered a provisional age-based ranking guidance. It simply puts care home residents at number 1 and then moves down through the decades with those under 50 listed as ‘the rest of the population’ at number 11 with priority rules yet to be determined. ‘Health and care workers’ are at number 2 alongside those over 80. The Committee summarises its approach as based on a firm belief ‘that a simple age-based programme will likely result in faster delivery and better uptake in those at the highest risk.’
It is interesting then to compare the JCVI advice with that of the joint report of the German Ethics Council, Standing Committee on Vaccination, and the National Academy of Sciences Leopoldina. They identify three priority groups: those at risk of serious illness because of their age; health and care workers at risk because of exposure to infection; and those in key positions who perform essential state and social functions.
Although there are broad similarities between the two sets of guidance there are important differences. These are worth exploring, not necessarily to challenge the UK guidance but rather to prompt discussion about why we should make use of certain rules. Thinking about equitable access to the vaccine requires, as my Nuffield Council colleague Anne Kerr has argued, using the methods of the social sciences and the humanities. Moreover, we have throughout the pandemic been subject to the Government’s repeated insistence that in all its policy it is ‘led by science’. The Nuffield Council has repeatedly insisted on the need to show the justification for any policy adopted which cannot be found in the science alone and must be shown by appeal to values and moral principles.
The German guidance is interesting in its appeal to a number of underpinning ethical principles, of most relevance here being those of justice and solidarity. By contrast, the JCVI seems to rely only on a principle of reducing the overall loss of lives. Hence it opts for protecting in the first instance those most at risk – the elderly and front-line workers. It is intriguing to see the old prioritised for the vaccine when the principal rule adopted for prioritising life-saving care (such as ventilators) was to favour the young over the old and clinically frail. Seeing why there is the difference between the two priority rules would be useful. Moreover, it also helps in the context of vaccination to distinguish between the risks of direct harm (by contracting COVID-19) and of indirect harm (by transmitting the virus to others who then suffer its effects). Here, science and social science helps. For it may be, as some have argued, that the young pose a greater risk of overall harm by infecting others, albeit not themselves being at greater risk of suffering ill health, than do the old who may not be significant spreaders of infection. Hence prioritising the young might be the best way to protect the old.
But what of justice and solidarity? In the first place COVID-19 is a global pandemic and it should be tackled worldwide. In doing so, we need to recognise that some countries are relatively disadvantaged and will not have the access to the vaccines that richer nations do. Justice demands that we acknowledge and address this. Even if we do restrict ourselves to the population of our own country, we know that there are significant differences in the impact of COVID-19 that are not associated with age. Members of BAME groups have suffered disproportionately and we can reasonably judge that some of this is attributable to existing social and economic inequalities associated with ethnicity. Justice demands that we take account of this fact and act accordingly. The JCVI guidance concedes that BAME groups are at greater risk than others and live in areas of socio-economic deprivation but sees no reason to do anything other than to ensure ‘good [vaccine] cover’ in these areas.
Talking of justice and solidarity also allows us to make better sense of why we might give high priority to front-line workers. We might do so on the straightforward grounds of reducing overall harm and risks of harm. Yet it seems clear that there are other reasons to prioritise them: because that is fair, given the risks they have run on behalf of others, to do so. Indeed, inasmuch as they have consistently acted above and beyond their duty, they are owed a great deal. Or we might give them priority because solidarity or reciprocity demands that we who benefit from their sacrifices should recognize what has been done on everyone’s behalf. Of course, principles of vulnerability to risk and of justice or of solidarity might yield the same priority rule. Yet choosing the latter principles makes a huge symbolic difference to how, as a society, we view front-line workers - not just as people we want to be healthy enough to carry on working but as heroic, tireless, and occasionally self-sacrificing individuals who have done enormous good on our behalf.
Again, we may want those whom the German guidelines identify as holding ‘key positions in basic areas of services of general interest and are responsible for maintaining central state functions’ to have priority access to the vaccine. But such people do not deserve to be prioritised in the way that front-line workers do, even if they do serve the greater public good. It helps, as ever, to set out the ethical framework by which we make pandemic policy decisions.
Much more can be said about the principles and values that underpin our policy decisions and our guidance. The bottom line is that we need to be ethically clear and transparent in what as a society we decide to do and why. We need to facilitate the informed discussion of these matters and ensure that our policy is not only fair but is seen to be fair. As for my mother, I am still debating the matter with her.
Dave recently spoke on this topic in a Bioethics Forum - Who First? Allocation of Vaccines against SARS-CoV-2.