COVID-19 Vaccination Raises Ethical Questions

John Whyte, MD, MPH; Arthur L. Caplan, PhD

Disclosures

January 28, 2021

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  • Healthcare professionals who are patient-facing should get the COVID-19 vaccine as soon as they can. Furthermore, priority vaccination lists should include all hospital staff to keep the facilities functioning.

  • The goal of public health is to control the spread of the epidemic, which is why prisons should be prioritized.

  • "Vaccine nationalism" is when countries prioritize their own vaccine needs. The United States should make sure its at-risk populations are vaccinated before providing vaccines to other countries.

  • It may be difficult for some employers to require vaccination while the vaccines are under emergency use authorization. However, employers in such places as nursing homes, hospitals, and home healthcare companies should mandate vaccines now.

  • Once clinical trials show that the vaccines are safe for children, they will probably be added to the required immunization schedule for children.

  • Most likely, people will have to show proof of vaccination before taking part in activities such as getting on a plane, checking into a hotel, and entering a sports stadium.

This transcript has been edited for clarity.

John Whyte, MD, MPH: Welcome, everyone. I'm Dr John Whyte, chief medical officer at WebMD, and you're watching Coronavirus in Context.

We've been watching videos of vaccine distribution, and you might be having some questions. Is it fair who's getting it first, in terms of age and other risk factors? To help talk about all things ethics around COVID-19, I've asked back the world's leading bioethicist, Dr Arthur Caplan, from NYU Langone Health. Dr Caplan, welcome back.

Arthur L. Caplan, PhD: Thank you for having me, John.

Whyte: Let's get right to it. In some states and some jurisdictions, it's people over the age of 75. In others, it's 65. We're hearing other stories about there being vaccine left over at the end of the day and people's family members are getting it. Where's the fairness, Dr Caplan? Do we need to have a centralized process?

Caplan: We don't have consistency in the states or, for that matter, in localities, about who can get vaccinated. I haven't seen it, but I've heard that in some communities in Florida, you just get in line, or get in your car and get in line, and they'll vaccinate you whether you're a native, a snowbird, or even Canadian. They don't care much; it's just kind of "line up." In New York (and near where I am in Ridgefield, Connecticut), the governor's saber-rattling and saying, "If you don't follow our standards, we're going to penalize you. There'll be big institutional penalties."

You need consistency in order to get compliance. We sometimes say in ethics that there's a difference between fairness and justice. Justice is what you just described, John: over 65, over 75, healthcare worker, high-risk, a nursing home resident, somebody with comorbidities. Fairness is, does everybody get the same chance? Are we being treated equally?

We don't have fairness, and that undermines people's willingness to go along with justice — meaning that if I think you're getting ahead of me because you have some money or you're in a state that doesn't care or doesn't enforce it, I get angry. And then I start to say, "Well, then I'm going to start to see if I can push to the head of the line one way or another."

One other source of trouble, in a broad policy sense — you know what the biggest scandal is? There's too much vaccine in warehouses. While we're arguing about who goes first and who's the priority, you look state to state and say, "You gave out 9% of what you were sent. You gave out 11% of what you were sent." This is a scandal. We need vaccine in arms, not in warehouses. If we're trying to follow standards and criteria too tightly about who goes first, if it becomes too burdensome, is that hindering us from giving out the vaccines at all?

Whyte: It's really an issue of distribution, not supply.

Caplan: It is.

Whyte: Some health professionals are choosing not to get vaccinated, even those that are involved in clinical care. Is it unethical for health providers not to get vaccinated?

Caplan: I'm going to answer that with a mild yes. I don't mean to be critical of those who are trying to help others and trying to put someone else's interests ahead of their own. But the way the system is now, if you pass on a vaccine, it doesn't mean that it's going to go to someone who's needier. It just means it's going to someone further down the line at the institution —a hospital or a nursing home — where they have a supply.

The way this has worked is that, in most cases, states roll out a supply of vaccine to, let's say, a hospital. The hospital then looks at it and says, "We've got to track it, two doses. We've got to refrigerate it. We're going to work our way through our employees because we can keep tabs on them." If I say, "Don't vaccinate me — I stay at home. I'm not patient-facing. I'm not that big a risk. I don't need it for disease reasons," then all that's going to happen is it's going to go to the guy who's next on the line. It's not going to a nursing home.

So you have to think hard. You don't want to pass up a vaccine. If you are patient-facing, even minimally, that becomes important to protect yourself and them. You don't want to miss work or make others sick, although our evidence on transmission is still weak. I think there's a duty to get nurses, doctors, cleaning people vaccinated to keep the system going.

Does it prevent me from infecting you? We think and hope so. But what it really does is keep the workforce intact and the place running.

Here's the thing that I think people have to be a little generous about: The states have said healthcare workers who are in clinical settings, nursing home residents because they're high-risk, nursing home staff. If you went to many hospitals, they'd say, "We can't run this place without IT people. We need the billing department. We have to have security. We need people to greet people at the door and send them on to the right parts of the facility. They're essential."

Now, they're not in the list that ethicists, committees, governors, or whoever made up. But the hospital often will say, "If I don't have my management team, this place isn't going to run." If the goal is to keep the system going — and that's what we hear the point is of these priority classifications: Keep the healthcare system working — then I think you have to give some discretion to the hospital, nursing home, and even the prison in those states where they're vaccinating, about what they consider essential, because I'm not sure that the criteria that have been promulgated do a good job.

Whyte: All right, you opened it up with mentioning prisons, so I'm going to ask you about that. Some states are choosing to vaccinate prisoners before vaccinating people over the age of 65. And some people are outraged, saying it's wrong. Is it wrong? Is it unethical? How do we factor that into the distribution?

Caplan: It's a tough one because people think prisoners lose their rights, liberty, and freedom. But I'm going to say that the goal of public health is not to get into who's good and who's bad. It's to try to make sure that you control the spread of the epidemic. Prisons are notorious places for infecting not only prisoners but also the guards, food handlers, and people who visit and come in and out.

You don't want to do what they do in Russia; they have tuberculosis in the prisons, and it spreads out all over the community because they ignore the prisoners. I think we have an image (partly from Hollywood) that everybody in prison is working out in the yard, is a musclebound 30-year-old who's waiting to get into a gang war. But many of them are old and many are sick. A lot of them are there for, let's call it, not super-serious crimes. It's not one-size-fits-all when we think about prisons. But more to the point, you want to get bang for the buck. You want to stop outbreaks. From a public health point of view, we know that prisons are trouble spots. Anywhere there's conjugal living.

Another group — not as controversial but one that gets ignored — is psychiatric facilities and people in homes for those with intellectual disabilities. I keep looking for them on lists. A couple of states list them, but most don't. If you have Down syndrome, the death rate from the virus is four times what it is for others, probably due to immune disorders. You don't want to ignore them either.

What we need to be paying attention to is not that I want to save murderers and rapists, but that I do not want to have infection outbreaks that are going to spread back out to the community.

Whyte: You're taking it from the perspective of public health and who's most at risk, and really trying to cut down on infection spread. As you know, I'm an avid reader of your writings, so I want to pursue this.

Caplan: By the way, there's nothing worse than having somebody read what you wrote and then ask you about it.

Whyte: That's what I'm going to do. Recently on Medscape you mentioned that we shouldn't be sharing the vaccine with other countries. America first. Is this a problem, this mentality? Look, the developing world is not going to have the resources. But you're suggesting, let's take care of our own people first. What's the ethical issue?

Caplan: You can describe this as "vaccine nationalism." Should countries (United States, Britain, or others) try to take care of their own people before they move to help others? I sometimes think of the airline analogy: Put on your own face mask before you try to help your child or neighbor. If you're in trouble, you're not going to do much good for anybody else. The reason I argue for this is that we have to take care of those in need in our own country first. There may be people who are relatively healthy, not super high-risk. But if you have a healthcare workforce that's broken... I don't see the point of giving vaccine away to anybody else until our healthcare system is up and running, and we are able to take care of COVID patients and people who are seriously ill or injured.

I feel the same way about protecting our most at-risk populations — comorbidity, age. The point is, if I am a citizen, I expect my government to look out for me, not look out for the world. Another example, if I'm trying to decide morally: I have some food. I know that there are kids starving in other countries, but my kids are hungry too. I don't flip a coin. I feed my kids first.

Once they're taken care of, I then start to think about what I owe to others. I'm not against considering the needs of others, but I want to treat equal needs equally. I don't want to just vaccinate every American and then get to foreign assistance, but I do want to first get through the populations at risk and most likely to die. Then we should start to think about what we are going to do for the rest of the world.

By the way, the rest of the world has no money. There are some initiatives [offering aid] (COVAX, the World Health Organization, and the Gates Foundation), but it's not really going to make much of a dent. If we are going to do something for other countries, our government is going to have to buy vaccines and send them elsewhere. There's no other way I can see that happening.

Whyte: It's a global economy, a global world. If you don't vaccinate in other countries, it's just going to come back and impact those that aren't.

Caplan: Right. So do we get it to our groups in need first? Then we can't ignore elsewhere. You don't want outbreaks in Italy coming back, or an outbreak in Brazil or South Africa with a new strain coming back. I get that, and I take it seriously. But let's be ready to understand that they're not going to be able to pay. It's going to be us, or other rich countries, who are going to have to throw some resources in that direction. Sometimes Americans get mad about that. They don't want to spend money on foreign aid or helping others. I think they should. But they should also be reassured that we did try to take care of the neediest here first. I'll go that far.

Whyte: "Vaccine nationalism" — I have not heard that. We heard it here first. Let me ask you: Is it ethical to make vaccination mandatory? I'm going to parse it out a little. Right now, technically, it's authorized but it's not fully approved or a licensed product. It's probably not until April or May that Pfizer and Moderna will submit for full approval. Some employers are currently saying that it is legal to require to make it mandatory. And the Equal Employment Opportunity Commission put out an advisory that says employers can mandate COVID-19 vaccination right now while it's authorized. Is it ethical?

Caplan: Another tough one, and I'm not going to duck it.

Whyte: I only ask you tough questions. And I don't tell you the questions ahead of time, just so people know.

Caplan: That's all right. I respect it. I also like that you actually get ready and you've read through controversial things I've said and said, "Really? Do you want to believe that? Tell me why." That's part of what ethics is all about ─ pushing to make sure the arguments and the reasoning hold up. It's absolutely fair and good to do so.

I think it's going to be tough to mandate emergency use. While the data are there and the FDA is convinced that it's safe enough in effectiveness to get it out there, it's partly because it's an emergency and a terrible plague that they're going to allow early approvals to take place.

I have a feeling that if you went to court and said, "They mandated that I have to get this vaccine, but it's not licensed. It's not yet fully approved, and I'm doing it on partial evidence," I think you might win that court fight. Having said that, I think there are settings where I would try to mandate and take on the legal battle.

As for nursing home staff, I just had a friend of mine who told me that in the Cleveland, Ohio, area, refusals by both patients and staff are 60%. Now, if you've got a 60% refusal rate, you're killing the elderly and the staff is going to get sick. We already know that 100,000 or more long-term care residents and nursing home staff have died in nursing home settings . They've been decimated by this outbreak. I'd try to mandate. I can't put up with a 60% refusal rate in the worst danger zones that we've got.

Whyte: Would you mandate on the health professionals? You said it's their professional responsibility.

Caplan: Yeah, I would. I think I might also push into the ICUs. I'm hearing refusal rates even at hospitals ─ approximately 30% of nurses, 15% of doctors. You're putting yourself and others at risk in a terrible way.

Whyte: We don't force influenza vaccines. We don't mandate influenza — well, we do in the medical community ─ but we don't mandate shingles, pneumonia, or Pneumovax vaccines.

Caplan: Right. Shingles, I wouldn't mandate. If you get shingles, it's not fun. I would tell you to get the shingles vaccine, but you're not going to make anybody else sick. I pushed hard for flu vaccination mandates for healthcare workers. I'm the guy who originated that idea along with Paul Offit from the Children's Hospital in Philadelphia (CHOP). We pushed it at Penn Medicine and CHOP, brought it to NYU Langone, and pushed it all around the country, and people do it. And we fired people for not doing it.

I think there's a special obligation to take vaccines when you're putting others at risk and when you yourself might not be available to work. That's why I'm tough on the nursing home and the hospital setting, and on the home care setting for that matter, too. I think those groups are different, and I would try to mandate. But I'll say, I got pushback. The nurses' union sued. I don't know if I'm going to win that one because it's still a tentative approval. I tried.

Whyte: What about the role of vaccination in children? We know the risk is lower. There haven't been trials yet.

Caplan: No studies yet. You've got to get some data on kids. It's going to be hard. Once vaccines get licensed and approved, I think we're going to see some creep — people are going to start to say, "I don't know. You're 17. You're 16. We don't have data on that, but maybe it would be better." I think you're also going to see some other countries just say, "Well, we don't care about the data. We're going to start vaccinating kids."

Whyte: But 17 is different from 10.

Caplan: It is, and it's different from age 5 ─ to get into nursery school. Still, I hope that we can launch some studies in kids once we're convinced that adults seem to be doing okay. I don't think you're going to see mandates pushed as fast there until the data come in for approval. Will they eventually make it to the mandated vaccine list? I think so.

And by the way, once vaccines get approved, I also think we're going to see something else happen. Airlines, cruise ships, trains, hotels, they're going to say that you need—

Whyte: You'll need a passport.

Caplan: You're going to have to show something on your iPhone or a tattoo on your forehead — I don't know — something that says "I got vaccinated." Those industries are ruined because people rightly are afraid that they're going to get infected if they head to the airport and so on.

I think the private sector, particularly those with big public interactions, are going to say, "You have to be vaccinated in order to use our service." And I know some people are going to say, "You can't make me do that." But they don't have to let you on the airline, either. I mean, you have no right to be there; it's a private service.

I think we'll see athletes starting to vaccinate so that they can carry out their sports activities. Maybe to get into the stadiums, you're going to have to show that you've got a vaccination passport, a certificate — proof. I think you'll start to see other businesses say, "If you want to come back to work here, we can't easily accommodate you in terms of social distance or masking options. Either stay home and work or you've got to be vaccinated." In the future, I think healthcare workers, yes, once it's approved. Private employees and then probably kids as data come in and it looks safe.

Whyte: Your level of optimism that we'll reach 70%-80% immunity — we want people to take personal responsibility, but at the same time, you also need to have a perspective of community. Not just to protect yourself, but protect your family, your immediate community, and broader national and world community. Is that where we are currently? Do you think we'll get there?

Caplan: We're not there. We have too many people who put personal liberty and personal choice in front of the consideration of others. Also, there was just plain fatigue. I think people just said, "I can't stay in anymore. I'm going out." I talked to some young people who said, "I have no social life. I can't meet anybody. I want to go to a bar. I want to get out there." Partly, I don't excuse it because it puts others at risk, including when they go home or see their relatives who may be medically compromised or older, but I do kind of understand it. I get what leads people. It's tough to follow a year of quarantine and all the restrictions on behavior that we ask, and also loss of jobs, mental stress, and the rest of it.

But I think we're starting to get a little better and we're starting to understand. I see less vocal opposition to the mask issue than we were seeing 6 months ago. I think the vaccine helps give us some hope that if we can do that, maybe we could get back to some semblance of normal by the end of this year.

So, I'm going to say that I am a little more optimistic in terms of offering people some hope of getting out of fatigue ─ quarantine fatigue, COVID lockdown fatigue ─ plus realizing that the people who were telling us about masks weren't crazy.

Look at California. Look at the crunch in the ICUs in many parts of the country. Look at the escalation of COVID after motorcycle rallies, political rallies. Look at what happened in the Trump White House as the virus spread through all of the staff and many — many — of the leading politicians. It wasn't made up. It wasn't a hoax. Mask behavior, more studies keep showing, does help. If you really establish that it works and it matters, and add in more concern about others as the virus gets worse and affects more and more people, then yeah, I'm more optimistic.

Whyte: That's a good note to leave it on — optimism.

Caplan: We haven't had a lot of that with COVID.

Whyte: No, we have not. I want to thank you for sharing your optimism and insights, as well as for helping us to work through some of these difficult ethical issues as we think about immunizing ourselves as well as loved ones. Thanks, Dr Caplan.

Caplan: I very much appreciate the opportunity. Thank you.

Whyte: And if you have questions about COVID, drop me a line. You can email it to me at drjohn@webmd.net. Thanks for watching.

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