On December 13th, news outlets in the United States featured images of trucks pulling away from a Michigan manufacturing plant. The precious cargo: Pfizer’s vaccine against COVID-19. The massive delivery apparatus was poised and ready to roll in what seemed like moments after the Food and Drug Administration had approved the vaccine for emergency use. It appeared as a Christmas miracle, and I confess that my family and I got choked up at the sight, our eyes glued to the television. We also tuned in to watch the first healthcare workers receive the vaccine, and it felt like the earth itself heaved a sigh of relief. A physician friend sent word that she had received her shot with all the enthusiasm you would expect from winning a lottery.
On December 13th, the third Sunday of Advent, we lit our rose-colored candle. Gaudete! Rejoice! The liturgical calendar matched the moment and it was a fitting break in the bleak midwinter that has lasted a year. We glimpsed a different future even as infection rates, hospitalizations due to serious illness, and mortality rates climb. Hope sparked even as millions face un- and underemployment, learning disruption, food insecurity, eviction and homelessness. We remembered that God is good and has come to save us. And yet the challenge remains: to live as if we really believed it.
The very good news about an approved vaccine (as of this writing, a second vaccine developed by Moderna was nearing approval) continues to raise and reveal a number of ethical issues. The issue receiving the most attention in the media, understandably, is the question of allocation. Who will receive the vaccine, when, and in what order? Who is best suited to making this determination? What kind of calculus will health officials use to make this determination? Who runs the greatest risk of exposure? Who runs the greatest risk of serious illness and death if infected? Whose work, and so health, is most essential and for whom? These are difficult decisions that require balancing a number of interests that are in tension with one another: nursing home residents, healthcare workers, the elderly, people with underlying medical conditions, teachers, child-care workers, students, the college-aged super spreaders, people who are incarcerated, prison personnel, essential workers of all kinds.
It comes as no surprise that there is, as they say, an app for that. The New York Times published a calculator that enabled individuals to estimate their place in the vaccination distribution timeline. A consumer driven approach to health care cannot help but to envision individual people jockeying for position. Even those whose stated political views demonize any proposal for nationalized healthcare in the United States have not challenged “universal” access to the vaccine provided at tax-payer expense.
In the United States, where medical ethics frequently revolves around a patient’s right to refuse treatments and interventions, another issue is whether and to what extent immunization is a moral obligation. The question of who has a right to the vaccine is matched by the question of who has the responsibility to be vaccinated. Political resistance to vaccines, particularly those administered in early childhood, has been on the rise, leading to outbreaks of illnesses that had long been thought eradicated like measles and mumps. Will people be able to refuse the vaccine and still be able to attend school or places of employment? Will the tendency to favor individual rights and immunity from government interference be over-shadowed by reasonable fear of illness and concern for civic and economic stability? Who, if anyone, will be compelled, by whom, and with what leverage?
Concerns are also being raised about vaccine hesitancy among African Americans in the United States, due in no small part to the history of the exploitation of people of color in medical experimentation and the enduring problem of racism in healthcare generally that has led to the denial of adequate care. Writing for CNN, Tina Sacks of the U.C. Berkeley School of Social Welfare notes, “We must ensure that marginalized groups like Black, Indigenous and people of color, immigrants, disabled people and people in prison can receive this vaccine. We must also ensure people are allowed to ask questions to make informed and uncoerced decisions about their health care.”
One of the “firsts” to be vaccinated before the TV cameras was Sandra Lindsay, an African American nurse. Notable too was that the vaccine was administered by an African American female physician. What to make of this? At last, black women are first in line for healthcare? A gesture to reassure communities of color about vaccine safety? Or another racist manipulation? Or one more instance of experimentation on black women, most of whom will find themselves last in line for the vaccine and seriously ill from covid-19? One white male undergrad student noted, “I don’t know what to think about this. I am damned if I don’t and damned if I do.” My response, “Yes, that’s right. That’s what it means to sit with complicity in racism and white supremacy.”
These are only some of the ethical questions around covid vaccination in the United States. We must ask other fundamental questions around “vaccine nationalism” and the competition among the world’s more affluent governments to develop, regulate, and procure vaccines for their populations. As with healthcare resources more generally, this leaves most of the world’s people without access to lifesaving prevention and treatment. The cost of the pandemic will ultimately be borne by the poor and vulnerable without a global effort aimed at vaccine justice as a common good and guided by the principle of subsidiarity.
At the heart of these ethical challenges lies a crucial insight: health is a personal, social, and communal experience and aspiration, and so it is both a personal and a common good. Vaccination has long provided a fruitful case for illustrating this point, even more so now in the covid era. Covid vaccines prevent serious illness and evidence is being gathered around their efficacy in preventing infection and transmission. The theory of herd immunity that was so damaging before a vaccine was available is crucial now. Vaccines do protect individual people, but they are essentially public health measures. Those who are able are vaccinated for themselves and for others in an act of self-care, fidelity, and justice, to use Jim Keenan’s schema for the life of virtue.
As we embark on a new year, still in the grips of the pandemic, ethicists must continue to highlight the profoundly personal and social nature of health and healthcare and the concrete implications of that commitment:
- Health emergencies demand steadfast adherence to, and not the suspension of our best ethical protocols. The regulatory system in the US allows for an expedited process in the case of an emergency, but rigorous testing, evidence-based decision-making, and protection of the dignity and rights of research subjects and patients remain paramount and intact.
- Health emergencies demand cooperation, not competition, that moves both horizontally across borders and boundaries as well as vertically from the grass roots to global networks. A neo-liberal, market-based approach to our common life, including healthcare and the infrastructures that support it, undermines the common good and is made even more insidious by disenfranchising racism and sexism.
- Health emergencies demand shared risk and sacrifice that resist patterns of unjust burden and the maldistribution of suffering in the world. Participation in the struggle against covid must be open to all people and taken on in freedom. While this surely requires people in places like the US to take up relatively easy precautions like mask-wearing that do not present unreasonable limits on freedom, the more urgent element of participation in the struggle is universal access to vaccines and other public health measures.
- Health emergencies demand prudential decision-making in the context of very difficult decisions but they also demand that we loosen the stranglehold that neo-liberal rationality has on the distribution of resources that enhance health and wellbeing for persons, communities, and entire regions of the world.
It is likely that you are reading this in the new year, 2021. Recall though the scripture passages read in the third week of Advent, Isaiah 61 announcing “a year of favor from the Lord” and Mary’s Magnificat in the gospel of Luke, proclaiming that the Lord has “remembered his promise of mercy.” If the vaccine is to be a game-changer and this is indeed to be a year of favor, it will not appear by magic, but by living into and out of the promise of mercy in a suffering world. #2021.
For basic information about vaccines, Centers for Disease Control, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/index.html (accessed 20 December 2020).
For global healthcare and vaccine justice, Partners in Health, https://www.pih.org/ (accessed 20 December 2020).