Who Gets It When- Bioethics of Vaccine Distribution

Since last March when COVID-19 restrictions changed life as we know it, Dr. Stephanie Brodine has taken every precaution. The San Diego State epidemiologist and retired U.S Navy infectious diseases physician switched to working from home, wearing a mask, and observing health guidelines. 

She and her husband, Dr. Dennis Amundson, stopped seeing their six children due to the exposure risk associated with his work as medical director of the intensive care unit at Scripps Mercy Hospital Chula Vista. There, he was treating some of the sickest COVID-19 patients. 

In October, they learned that Amundson was infected and two days later, Brodine also became ill. What followed was a harrowing period. Amundson, 70, recovered after a couple weeks, but Brodine, 71, needed to be hospitalized. Complications from pneumonia and secondary infections led to 27 days in the hospital, 11 of them in an intensive care unit. A full recovery will require months of rehab therapy. 

This made them think about the risks family members of health care workers face, and the need to prioritize them for vaccination. Who gets the vaccine when has been a hotly debated topic across the U.S and the world.

Bioethicist Joseph Stramondo with SDSU’s College of Arts and Letters explained that it’s a complex, multidimensional issue. 

“It’s very difficult to rank risk,” Stramondo said. “There are many ways to think about it from an ethics perspective. Who is the most vulnerable to catching it, to dying from it, and who do we owe? Do we prioritize just the people that are directly at risk or also their family members that they share a household with?”

Prioritizing people

Health care workers, essential workers such as first responders, police, postal workers, retail and restaurant workers, the frail and elderly, people with underlying medical conditions - there are many, many people who are especially vulnerable to catching the virus, including their family members. Those with chronic conditions such as asthma, diabetes and other illnesses, and the elderly are at high risk of dying from COVID-19.

“Since the pandemic began, essential workers have kept things going for the rest of us. We need to think about what we owe them, for the risks they take on a daily basis,” Stramondo said, referring to retail workers, Amazon truck drivers, and postal workers, as well as physicians, nurses, and first responders. 

“If we also begin prioritizing people in the same household as those that have taken risks for the rest of us, we should consider the needs of the elderly mother of the grocery store bagger or coffeehouse barista as well as the spouse of the ICU physician.”

Stramondo also worries about others who are vulnerable in different ways - the homeless, and those who are incarcerated in crowded prisons where there have been multiple outbreaks. 

Underserved community concerns

On the other hand, when it comes to promoting the importance of getting vaccinated, public health agencies have begun to focus on educating the hardest hit underserved communities, and some in those communities are pushing back. 

There is a deep and long history of distrust, especially among those in the Black community and in other communities. Stramondo emphasized that the distrust must be understood properly.

“We really need to recognize and honor that this is an individual choice that they’re making for themselves and their families — the option to get vaccinated or not,” he said.  

News reports also reveal vaccine skepticism among some health care workers and first responders, which reflects a comparable skepticism within the general population as well. 

This brings up the issue of legitimate influence versus coercion.

If someone is given information and persuaded to get the vaccine, that is informed consent and therefore legitimate influence, but when someone is coerced by having benefits taken away for non-compliance, or manipulated by not being given the complete information, that is illegitimate influence, Stramondo explained. 

“If data shows that the vaccine can prevent people from infecting others, we can use coercion to tell them they can’t work in the hospital unless they get it, because they can harm not just themselves but others too,” Stramondo said. “They have a right to bodily autonomy, but not the right to work in the hospital when they refuse the protection of the vaccine.”

Health care rationing

With the current ‘surge on top of a surge’ that has led to record numbers of cases and hospitalizations, there is a shortage of beds and oxygen tanks in hospitals. Ambulance crews wait hours to unload patients and in some cases are  told not to bring someone in if they can not be resuscitated. 

This so-called health care rationing has become a necessity for now, but Stramondo cautions that emergency medical technicians and paramedics should not get too comfortable making these decisions, since implicit bias can creep in and hurt someone who is disabled and very ill, or someone who is a minority.  

“For right now the policy to keep back someone who doesn’t respond to CPR makes sense, but we shouldn’t have first responders making rationing decisions that may rely on stereotypes instead of data. Someone’s likelihood of survival can’t be assessed by EMTs and paramedics, if they decide to expand this policy.”