Almost as soon as different vaccines received Emergency Use Authorization (EAU) in the US, bioethicists and public health officials struggled with the question of how to best distribute vaccines, and what standards to create for their distribution. The debate about vaccination groups created a larger debate in the US about what citizens were “essential” or otherwise valued above others. Given that COVID-19 threatened lives, this debate was inherently about protecting lives or protecting the right that individuals have to live. While in some cases skipping a vaccine line can be justified, in the vast majority of cases skipping a vaccine line is not an ethically sound or justifiable decision.
Implicit in this debate was another debate - one about what the goals of society should be. Should stopping the spread of COVID be of utmost importance? Or, should saving lives be prioritized? Should random distribution be used to maximize equality in the treatment of citizens? Or, should some other standard be used as to how to distribute vaccines?
The CDC’s Advisory Committee on Immunization Practices voted 13-1 in favor of a two-phase system for distribution. The first phase of this prioritization system was divided into three subgroups: Phase 1a (healthcare and nursing home workers and long term residents of care facilities), Phase 1b (frontline workers and individuals over the age of 75), and Phase 1c (individuals aged 65-74, individuals with high-risk conditions, and essential workers not included in the prior phase). Then, Phase 2 was simply defined as “people 16 and older not in phase 1.” Thus, implicitly the CDC prioritized saving lives over stopping the spread, increasing patient education, or any other potential end. In placing healthcare workers at the top of the list, the healthcare system was prioritized. This was intended to stabilize healthcare access, so the system could continue to function and save lives. Secondly, the lives of the most vulnerable were prioritized - this includes high-risk individuals, individuals over the age of 75, and individuals that are otherwise exposed to more risk due to the nature of their jobs.
From an ethical standpoint, the CDC’s end was clearly defined and justified within the mission of the CDC itself. However, ethical questions arose when the rollout of vaccine distribution ran into problems. In some areas like Danville, VA, vaccine allocation was significantly greater than the number of community members who were interested in getting vaccinated. In other cases, because different states had different regulatory boards and systems for vaccination setup, people who were partial residents (or in some cases, even tourists) could be vaccinated ahead of the time they otherwise would have been if they registered for a vaccine in a different state.
These loopholes created the question of whether it is ever acceptable to “skip” the vaccine line. In some cases, it is morally justifiable. For instance, if an open vial of either Pfizer or Moderna vaccine is available, and no one from the eligible groups is interested in being vaccinated, it is always preferable to use as much of the vaccine as possible, even if it means people who were not technically eligible are injected. However, in many other cases, skipping the vaccine line is not justifiable. If a region was misallocated vaccines, which were not imminently about to expire, it is not justifiable to travel to that region in hopes that vials of these vaccines will be opened for use. While it is true that more vaccinations are preferable to fewer vaccinations, the CDC’s standard of protecting the most vulnerable first must also be upheld. Allowing local or state health departments to correct for misallocation and redistribute vaccines to the next-hardest hit community serves to protect more highly vulnerable individuals, rather than protecting communities who may not have as high of a risk. There are a variety of cases that fall in between these two standards: Danville, VA is an example of this.
In Danville, VA, conflicting information was presented by the VDH, the Federal Emergency Management Agency (FEMA), and healthcare workers at the vaccination site itself. The vaccination site was intended to spread vaccines to disenfranchised residents of Danville (where ¼ of the residents are below the poverty threshold) who were hard-hit by COVID. However, outside residents were provided with vaccines due to low turnout from Danville residents. While the site was ultimately closed to these outside residents, residents far outside of Danville were initially given vaccinations. This presents an ethical quandary - given that Danville’s residents appear to be unable to access the vaccination center in numbers predicted by VDH, are outside residents who have the means to afford taking time off of school or work to drive to Danville justified in doing so?
Given the previous framework about imminent expiration, the answer to this question depends on whether the vaccines were actually about to expire en masse, or whether only parts of the supply were about to. Broadly, it would have been preferable for the VDH to redistribute vaccines themselves, as long as the vaccines were not imminently going to expire. This would have allowed for more equitable distribution to the next hard-hit and vulnerable population, rather than arbitrary distribution to anyone who could afford to drive to Danville. But, if it is the case that Danville’s vaccines were all about to imminently expire, then it is justified for non-Danville residents to acquire them because more vaccine distribution is a net good. Ultimately, this question comes down to conflicting information - the VDH told residents that there was no need for external residents to travel to Danville, but healthcare workers at the vaccination center themselves said the opposite. Thus, both sides of the debate can be justified, depending on which source one chooses to believe.