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The Ethics of Prioritizing COVID-19 Vaccination

In the United States and some other countries, members of disadvantaged racial and ethnic minorities have a lower-than-average life expectancy, and therefore are under-represented among those most likely to die from COVID-19. How should policymakers weigh this and other factors specific to population sub-groups?

Now that COVID-19 vaccines are being rolled out, policymakers are wrestling with the question of how to distribute them quickly and equitably. There has been wide agreement that health workers should be vaccinated first, because they are needed to save the lives of those who are ill because of the virus. But deciding who should come next has spurred considerable debate.

One relevant fact is that people over 65 have a higher risk of dying from COVID-19 than younger people do, and those over 75 are at even higher risk.

Another relevant fact is that, in the United States and some other countries, members of disadvantaged racial and ethnic minorities have a lower-than-average life expectancy, and therefore are under-represented among those over 65. If we give priority to older people, the proportion who are members of those minorities will be lower than their proportion in the population as a whole. In light of the many disadvantages members of these minorities already experience, this seems unfair.

This sense of unfairness appears to motivate the suggestion by Kathleen Dooling, a public health official at the US Centers for Disease Control and Prevention, that a different approach be taken. In a presentation to the CDC’s Advisory Committee on Immunization Practices, Dooling argued that “essential workers” – a group numbering approximately 87 million – should be vaccinated ahead of the 53 million Americans aged 65 and older, even though this would lead to between 0.5% and 6.5% more deaths. (The wide range reflects the fact that we don’t yet know whether the vaccines merely prevent COVID-19 or also prevent people from becoming infected and transmitting the SARS-CoV-2 virus that causes it.)

A policy of making older Americans wait longer for the vaccine on the grounds that they are disproportionately white would therefore sacrifice lives to avoid the apparent inequity of giving priority to a group in which disadvantaged racial and ethnic minorities are under-represented. But that’s not all. The under-representation of these minorities among people over 65 years old is slight compared to the huge over-representation of people over 65 among those who die from COVID-19. As several commentators, among them Matthew Yglesias and Yascha Mounk, have pointed out, giving preference to essential workers would thus also cause more deaths in the minority communities that are supposed to be receiving more equitable treatment.

The CDC’s Advisory Committee rejected the suggestion that all “essential workers” be given priority, and instead narrowed the group to about 30 million “frontline essential workers,” such as emergency responders, teachers, and grocery store employees. In addition, it recommended that people aged 75 and over have the same priority.

These recommendations are a compromise between giving priority to those most at risk, and giving priority to all essential workers, frontline or not. It is clearly important to keep those who really are frontline essential workers safe and at work. Giving a similar level of priority to those aged 75 and over will mean that fewer people overall and fewer members of disadvantaged minorities die from the virus.

The CDC recommendations are not binding, and states can and should fine-tune them, both to treat disadvantaged minorities equitably and to save more lives. Ngozi Ezike, the director of the Illinois Department of Public Health, gave a clue to how this could be done in a recent New York Times roundtable discussion on vaccine distribution. She pointed out that there are medical conditions for which the guidelines on the treatment of racial and ethnic minorities differ from those that apply to whites.

The example she gave was prostate cancer screening. Because the disease is more common in African-American men than it is in white men, it is recommended to screen African-American men at an earlier age than that recommended for white men. The point is to screen everyone who is at the level of risk for which the screening is considered worthwhile.

If the US retains the current vaccination priorities, but adds the principle of equal treatment for people at an equal level of risk, policymakers will need to estimate at what age members of African-American, Latinx, and Native American communities run the same risk as 75-year-old white or Asian Americans, and then consider race and ethnicity in deciding who is eligible at what age. I do not have data indicating how much difference this would make, but it might mean that, say, an African-American 72-year-old man is eligible while a white 74-year-old man is not.

Some may object that this is a kind of reverse racism. It is not. In the absence of more individualized evidence, race is used as an indicator of risk from the virus. The guiding principle is not that members of different racial and ethnic groups should be vaccinated in numbers proportionate to their share in the community as a whole. That is not ethically significant. The goal is to save more lives, which should be our overriding concern.

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