The following is an edited transcript of an MDAdvantage podcast with Steve Adubato, PhD, and Carl Coleman, JD, that was recorded on April 1, 2021. Carl Coleman is Professor of Law and Academic Director, Division of Online Learning, at Seton Hall University Law School. The discussion covered the ethical and practical considerations of the COVID-19 vaccine rollout.
ADUBATO: How would you define bioethics, particularly as it relates to the past year plus of us dealing with the COVID-19 pandemic?
COLEMAN: Bioethics is a very broad topic, but generally, it is a field that considers the ethical issues raised by medicine and more broadly, the life sciences and health. In terms of the pandemic, there are a number of bioethical issues that have been brought forth, ranging from prioritization questions (who should get limited resources), duties to vulnerable people in society (whether that means essential healthcare workers or others who are vulnerable because of their social or economic circumstances), international obligations, issues relating to research on drugs and on vaccines, and the list goes on. There is no shortage of bioethical issues raised by this pandemic.
ADUBATO: As we tape this program on April 1, 2021, how would you describe some of the most pressing ethical considerations related to the distribution and the allocation of the COVID-19 vaccines?
COLEMAN: With many healthcare issues, you can look at two primary sets of ethical issues that often come up: ensuring efficacy and ensuring fairness. Sometimes, these issues can be in tension with each other. For COVID-19 vaccines, the key question is how to set up a distribution system that will ensure the quickest route to herd immunity to suppress the pandemic as quickly as possible for the benefit of everyone. But there are also questions about how you ensure that the vaccines are distributed in an equitable manner, which requires, of course, defining what an equitable manner is. Those are the two main issues. How do you prioritize who should get the vaccines first, and then how do you ensure that those priority groups actually get the vaccines, because that’s not always easy. If you are prioritizing groups who have difficulty accessing healthcare to begin with, then ensuring that they actually get the vaccines can be problematic. There are also international ethical issues. Right now, a few countries, including the U.S., have done relatively done well in terms of rolling out the vaccine, but most countries in the world don’t have any vaccines.
ADUBATO: Why is that an ethical issue? I will play devil’s advocate for a moment. In the United States, we are approaching 600,000 Americans who have lost their lives to COVID-19. Isn’t it the job of our government leaders and our public health experts to take care of our own citizens? What’s wrong with that from an ethical point of view?
COLEMAN: I don’t think there’s anything wrong with countries taking care of themselves from an ethical point of view, but even from a practical perspective, taking care of ourselves as a country requires paying attention to what goes on in the rest of the world. If the rest of the world isn’t vaccinated, it doesn’t do us a lot of good to pretend that we’re living in a bubble and won’t be affected. If large parts of the world remain subject to the pandemic, the virus is going to continue to mutate, and new variants are going to emerge, potentially rendering the vaccines we have now much less effective for us. Just from a purely self-interested perspective, it’s very important to consider distribution in other countries. Certainly if people in our country do not have access at all to the vaccines and the pandemic is continuing to spiral out of control in this country, addressing that is very important. There’s going to come a point when COVID-19 transmission rates have gone down to a level where it is just another disease that’s circulating in our country. When you compare the needs of our country in that situation to the needs of parts of the world where the pandemic is continuing to rage out of control, it isn’t a fair comparison. There comes a point where the needs of others can be so much more dramatic than our own needs that it really would be very selfish to keep hoarding everything to ourselves.
ADUBATO: There has been a fair amount of discussion about vaccine hesitancy recently. To play devil’s advocate again, shouldn’t we focus on giving vaccines to whoever wants them and is willing to take them, rather than trying to force anyone to get vaccinated?
COLEMAN: Distributing the vaccine to those who are most vulnerable may often require a lot more resources because of the difficulty these communities often face in accessing healthcare, and some of these difficulties may relate to attitudes that are often understandable and legitimate responses to a history of poor treatment. Part of the rolling out of the vaccine has to include efforts to make sure that communities that really do need this vaccine are given the appropriate resources to understand that this is something that is beneficial and to make is possible for them to access it and to feel comfortable accessing it. It’s going to take more work perhaps, but I don’t think it would be an appropriate response to decide the vaccine is unwanted and just accept that as fact. Part of the reason an individual or a community may not want the vaccine is because the system has not been accommodating to them in the past, and so we need to be more accommodating and meet people where they are.
ADUBATO: From your point of view, does an individual have the right to simply say, “No, I’m not going to take the vaccine because I don’t trust it, or I just don’t want it, or I don’t believe this disease is as serious as people are saying.” Is it an ethical issue if, in fact, by not taking the vaccine you potentially put others at risk, and not just yourself?
COLEMAN: Yes, of course that is an ethical issue. It is also a legal issue. The courts have been very clear that the starting point is that people in general do have a right to refuse medical treatment, but there are limits to this right. One limit is when there is a risk to the community. The Supreme Court has determined that it is within state power to require vaccination, and all states now currently do have vaccination requirements that apply generally as a condition of public-school enrollment for children. These requirements are considered constitutional with one general exception, which is if somebody has a medical contraindication to the vaccine. In that instance, it would be both legally and ethically inappropriate to force them to accept the vaccine. Beyond that, there is no inherent right to refuse a medical intervention that public health authorities consider safe and effective for preventing a threat to the entire community.
ADUBATO: Now let’s consider a healthcare provider who is involved in direct patient care but decides to pass on the COVID-19 vaccine. Does that make a difference from an ethical standpoint?
COLEMAN: From my perspective, it is not ethical for a healthcare provider who is dealing directly with patient care to refuse the vaccine. If they want to refuse to take the vaccine, then maybe they shouldn’t be dealing directly with patients. As the vaccine becomes widely available, health systems will need to take this issue on and determine what the appropriate response is for their organization.
ADUBATO: What about those individuals who are “jumping the line” to get their vaccine before others who may need it more?
COLEMAN: If we’re talking about people who actually are eligible to get the vaccine, I wouldn’t really call that jumping the line, because they are in the line if they are eligible. What I would call jumping the line is people making up or falsifying their circumstances so they appear to be eligible when they’re not. Then I would make a distinction between situations where they are getting vaccinated in a context where there’s relatively wide availability. I know that there are parts of the country where it is pretty easy to get a vaccine, and I see no problem with anyone who is eligible getting a vaccine there. I think it would be a little different if you are eligible but in a relatively lower risk category, and you know that in your community it is incredibly difficult to get an appointment for a vaccine, but you because you’re Internet savvy, you know how to get on the websites and get the appointments as soon as they’re released. On a personal level, I think a case could be made that you should hold back from getting a vaccine in that circumstance to allow other people who may have a greater need to get those very limited slots. But that’s really only in a context where you’re aware that slots are really hard to come by, and you’re taking them away from other people. That’s really not going to be the case in many situations, and soon, that probably won’t be the case anywhere because there will be enough availability.
ADUBATO: From an ethical and a practical point of view, how would you rate the success of the vaccine rollout to date, and what have you learned from the rollout that would potentially help us if we were to have another pandemic in the future?
COLEMAN: In the big picture sense, the U.S. has done relatively well compared to most other countries, with approximately one-third of citizens having received at least one dose as of April 2021. The biggest problem is the inequalities among different races and among people from different parts of the country. Black and Latino people are receiving smaller shares of vaccinations compared to the white population. Access should not have to depend on factors like your geography or your race. There are also international disparities, with many countries having no vaccine at all, and it isn’t only countries without resources. Countries in Europe are having problems getting access to the vaccine. In terms of a future pandemic, I think the urgency really is to come up with a more coordinated, centralized and equitable system on an international level that would ensure that in the next pandemic (and there will be another pandemic), there will be global accessibility on an equitable basis to not only vaccines but also to medicines and diagnostics.