Months before the US Food and Drug Administration even authorized the first Covid-19 vaccine, there were many conversations and debates going on about who should be put at the front of the line to get it. Different advisory panels and patient advocacy groups came out with suggested recommendations.
Eventually, the US Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) — the group that actually develops recommendations for vaccine usage — issued its guidelines. At the top of the list, in Phase 1a: health care workers and residents of long-term care facilities. Next was Phase 1b, which included people 75 years and older and frontline essential workers who didn’t work in the health care sector. Following that, Phase 1c included people 65 to 74, people ages 16 to 64 with high-risk medical conditions and other essential workers.
At the time, it all seemed so logical. But soon after the first vaccines were authorized by the FDA, things started to become a bit confusing. Some states started creating their own guidelines, resulting in a patchwork of eligibility. Stories emerged about people receiving the vaccine in one state who would not have qualified in another state. For many, the rollout of one of the most precious commodities on the planet seemed luck-of-the-draw, unfair or smacked outright of inequality.
It also opened up opportunities for people, eager to be vaccinated sooner rather than later, to game the system for their shot at a shot. Aside from those egregious examples of line jumpers, like the Canadian couple who flew to that country’s westernmost community and allegedly posed as motel workers at a mobile vaccination clinic, there are legitimate gray zones. For example, if your state isn’t vaccinating your age group yet, can you go to a neighboring state? What if you have a second home there? What about if you bring your grandmother food once a week — does that qualify you as a “caretaker”? And exactly how severe does your asthma have to be?
To sort through some of these issues, I spoke with bioethicist Arthur Caplan, director of the Division of Medical Ethics at New York University’s Grossman School of Medicine, who has been researching vaccine ethics and public policy for years. I wanted to find out whether it’s ever OK to cut the line, what our choices about who we prioritize say about our society and what it means now that a growing number of states have completely opened eligibility — essentially eliminating the line, but not necessarily eliminating the wait.
What follows are some excerpts from my conversation with Caplan, edited for clarity and length.
Dr. Sanjay Gupta: When the CDC and the ACIP came out after the first vaccine was authorized and they said, health care workers and people over a certain age should be first in line for the vaccine. What did you think of that?
Arthur Caplan: I fully agreed with it. I think if we look back, we were in the middle of massive deaths — exploding deaths all over the country — and the thing to do, morally, was to stop the deaths. I think that was priority one, and that led you to the nursing homes and the elderly and the health care workforce. I agreed with it.
However, I didn’t anticipate what was going to happen after that. And I’ll say two things about that initial determination [for] which I will blame myself — I had some input into some of these communities and decision-making/rule-making groups. We didn’t clearly define “health care worker.” So, all of a sudden, the public sees … a board of trustees guy is getting it, and someone who does psychotherapy by Zoom 100 miles away from the hospital is getting vaccinated. There are all kinds of people popping into the picture under the rubric “health care worker.” And that starts to make the public think, “Wait a minute, this is a little fishy.”
The other thing that happened pretty quickly was people began to say, “What if I gave you a donation? What if I spent some money?”… I don’t know that many people yielded to that, but the impression came across pretty quick that you could buy your way around this.
And I would add one other nasty thing happened. Our dear politicians jumped to the front and said, “I have to vaccinate to build confidence in the American people in vaccines”… What I thought was, “Yeah, that makes some sense.” But not vaccinating your spouse and your kids and your staff and your next-door neighbor. That looks like you’re just shoving to the front of the line. So, I agreed with the initial moral determination, but I think it was undercut by these kinds of factors very quickly and led to a loss of support.
Gupta: Is it ever OK to “jump the line?”
Caplan: You have to sort of explore a little bit what [line jumping] is because … sometimes yes, sometimes no. Here’s the sometimes no: I bribed my way to the head of the line. I lied my way to the head of the line. You say, “Do you have asthma?” And I say, “Oh yeah, I got that.” And you’re just lying and you know it and you’re just cutting to the front of the line to make yourself eligible.
In other situations — and this happened to me personally — I got my second vaccine and they said, “We just opened up a package of Pfizer and we’ve got nine more units. Anybody know anyone who can get in here in the next hour?”… It was: call your friends, call somebody. It wasn’t: call the sickest or call people who have chronic conditions. It was just get anybody. So people did call and they came in and they technically weren’t eligible and they technically jumped the line. But I think that’s morally defensible. I don’t want any vaccine tossed out. I don’t want any vaccine wasted.
The silliest story I saw about line jumping was the doctor in Houston who had surplus supply, ran around and tried to vaccinate anybody he could including his wife and some other people, and then they fired him. I mean, that’s ridiculous.
So, I know I’m giving you the one hand/the other hand kind of an answer but: Don’t lie, don’t bribe, don’t pretend to be somebody you’re not. That’s unacceptable line jumping. But don’t waste.
Gupta: In a situation where there’s tremendous demand and limited supply, it seems like you would have to anticipate that not everyone is going to behave in a high-integrity way … So, if you know that that’s going to be the case, [whose responsibility is it to] make sure and prevent line jumping from happening? What is the obligation of the people who are actually administering the vaccines?
Caplan: Great question. First, we rolled out a bunch of rules with no penalties — that probably is pretty weak. You’d think you might want to find somebody if they jumped the line or you proved that they’d lied or they used somebody else’s I.D. We don’t have any penalties — the real inducement to cheating, if you will.
Secondly, I’ve moved into the camp that says, “Keep it simple, stupid.” Trying to allocate by micro-allocation — is the UPS guy more important than the grocery store clerk? Is smoking worse than vaping? — in a mass rollout of vaccine, the vaccinators don’t want to be the cops. The vaccinators are busy; you’ve got huge lines of people trying to get in there. I say, open the doors; once you get past the highest risk folks, just vaccinate according to age — that’s easy to establish; we have IDs. And keep it simple.
Is that fair, in terms of who’s the least well-off, all the time? Is that fair, in terms of who’s poor, all the time? Probably not. But if you really look at how the distribution has been, those groups aren’t making it in any way …
So, I guess my answer to you is twofold: Put some penalties on, if you really want to stop cheating. And then, don’t try to fine-tune this more than the system can handle. Just get vaccine out there. I think Connecticut, Mississippi, Alaska, some other states are starting to open the doors. Biden, I think, said ‘Everybody eligible’ [by May 1]… I favor that.
Gupta: What kind of grade would you give to the overall vaccine distribution?
Caplan: I’ll give it a C. We have rolled out some vaccine and a pretty big percentage of people have had their first or second shots — and that’s good. But not an A or a B because a number of failures occurred, some of which we might have anticipated, some of which just surprised us.
For one thing … states drive distribution, not the [federal government]. So if you want to roll it out in a more coherent way, you’ve got to have more consistency between the states. So next time, we’ve got to get all the governors on board and say, ‘Here [are] the rules. Buy into them or we’re not shipping supply to you.’ It’s bad when you have one state with one set of rules, and another state with another set of rules …
The other thing I think we learned was, it isn’t just who’s first in terms of the rules, it’s where the vaccine is. So, if you can’t get there, even if you’re high priority, it just doesn’t matter because you can’t take a day off or you can’t get a ride to the civic center or the sports stadium. It’s really important to have, let’s say, wide distribution and many people ready to go to administer the vaccines — doctors, nurses, pharmacists, dentists, physician aides — because where vaccines are being given drives who gets them.
Gupta: I remember us having a conversation about organ donation and just looking at these really scarce resources in our society and trying to determine who would get an organ or who would benefit from these scarce resources. You’ve been involved with … the conversations about who should be prioritized for these vaccines … I’m just curious, were there some non-tangibles that were fueling those discussions? Because you could say older people are at higher risk of becoming ill, needing hospitalization and dying, therefore, they should go first. But then what about race? What about people who are living in certain communities? How much of that fueled those discussions?
Caplan: Well, one thing you learn quickly from [organ] transplant is that …if you have a hard time getting into the health system, you don’t have a fair shot at getting an organ; flat out access to health care drives who gets a transplant… Same is true, as it turns out, for vaccinations. If you’re poor and you don’t have health insurance, if you’re poor and you don’t have primary care, if you’re poor and you don’t even trust doctors because no one ever helps you or when you go to the hospital, you get a hard time at the E.R. — that drives your access. So, if you want the big take-home lesson for me, I’d say, until we get everybody into the system, we’re always going to have equity issues about rationing organs or vaccines.
Gupta: I was talking to representatives from COVAX and I think people generally understand that we live in a very globally connected society — you have an outbreak anywhere, it can be an outbreak everywhere. In wealthy countries right now, the statistic is that a person is getting vaccinated almost every second and yet there are some countries around the world that have yet to start vaccinating at all … What is our obligation to the rest of the world? How should we think about this? Should we feel guilty that other countries aren’t getting vaccinated at all yet?
Caplan: It’s the biggest, toughest ethical question of the whole problems of Covid and vaccination. It’s really tough.
I believe in a form of what I’m going to call moderate vaccine nationalism. Here’s what I mean: I think each country has an obligation to its community, its citizens, its neighborhoods, to get stable, to make the economy begin to go up, to get people able to go back to work, to get people able to send their kids back to school, cut the death rates down significantly. And when you reach that point, then and only then would I say you have a duty to start worrying about others. I’m not saying forget about the rest of the world, I’m not saying you even have to vaccinate everybody in the US before we start worrying about others… But get stable, get things under control, start to reopen, then start to share. Does that make sense?
By the way, I’ve been I’ve been interested to see [that] this isn’t just ‘America First’ or some sort of muscle flexing. I’ve been in conversation with some people in India. India has a lot of vaccination capabilities; it has a big supply of vaccine that they’re making. But they have decided 60 to 70% is going to India first and they’re going to try and work through their population to the point of stability before they’re sharing with other nearby… countries. So it isn’t just American, it’s a view that I think a lot of countries have to think about and work through…
It’s easy to say … ‘everybody counts’ and ‘all lives are equal’ and ‘we have to not value some lives over others.’ But I think that’s wrong: we do value some lives over others. I value my children’s lives over random children that I don’t know… I think those are deep rooted concepts that sometimes fall away when you hear the WHO or some of the COVAX people talk. They’re not acknowledging the moral realities of affinity, relationship, community.
Gupta: That’s a great point, and it is worth pointing out that the United States is, giving some $4 billion to COVAX as well. So, we’re trying to do our part.
There’s a lot of people who aren’t necessarily hesitant about vaccines, but they’re thinking, ‘Hey, we’re good now; this thing is in the rearview mirror. I don’t need to bother [getting vaccinated].’ How do you convince them to do that?
Caplan: You’ve got to message it, at this point, in terms of telling people what they get if they do good things. It isn’t: ‘You’re going to die!’ It’s got to become: ‘If you keep doing this, you can keep going the restaurants; if you keep doing this, you can keep your kid at school.’ I want to see the framing shift toward a more positive response because we’ve been locked up for a year… [and] denied access to … things we love. It can’t just be a negative message all the way. I don’t think that that’s going to wash.
Gupta: Carrot, more than the stick. It’s funny, I had this exact conversation with my parents… They’ve been really diligent, but they’ve been worried … they both have preexisting conditions and they’re older. And then the vaccine… and that seemed like a really strong incentive. But what I saw, to your point, was that… we’ve shown you something that can save your life, but now we’ve got to make sure it’s something that gives you a life.
Caplan: I would make it part of the policymakers’ task to think a little bit more about quality of life, like your [parents]. I mean, you don’t want to just be in the nursing home; you want to have visitors, you want to see your grandchildren… you want to do things. Who wants to just sit there?
Gupta: Final question, more of a personal one: I’ve always been curious… when you work through these issues in your own mind, what is your process?
Caplan: I’ll tell you what: I spend time reading. I do try to pay attention to practical literature– that is, I’m not just reading the philosophers. I want to know what somebody who’s an expert in vaccine distribution says … I try to maintain a very broad network of people to feed me information, whether it’s behavioral psychology or economics or whatever. So, listen broadly, read widely is part of my advice. And then I have something else that I can draw on, which is, I’ve been through some of these policy fights. So, experience helps.
The last thing I would say is…there’s an old philosophy principle that I admire. Immanuel Kant, the [18th] century famous philosopher-ethicist, said, ‘Ought implies can.’ Before I tell somebody what they ought to do, I want to know, can they do it? …It isn’t just what’s right or the best, it’s what can we do… So, try to inject realism. I try to teach my students to think that way, too.