Prioritising access to pandemic influenza vaccine: a review of the ethics literature

How Do Past Immunization Strategies Compare With the COVID-19 Immunization Rollout: A New Zealand Analysis

OBJECTIVE

The aim of this study was to compare past New Zealand immunization strategies with the New Zealand coronavirus disease 2019 (COVID-19) immunization roll-out.

METHODS

Using the READ document analysis method, 2 New Zealand immunization strategies (for influenza and measles) were analyzed for how the disease, context, vaccine supply and demand, ethical principles (equity, individual autonomy, and maximizing benefits), and the Treaty of Waitangi impacted the immunization programs. The findings were compared with the ongoing COVID-19 mass immunization program in New Zealand, as of October 15, 2021.

RESULTS

Several themes common to the case-studies and the COVID-19 pandemic were identified including the importance of equity, obligations under the Treaty of Waitangi, ethical mandates, and preparedness.

CONCLUSIONS

Future emergency planning should integrate learnings from other infectious disease responses and immunization programs to avoid repeating mistakes and to create better health outcomes. This study has provided a basis for ongoing research into how an appropriate immunization plan can be developed that incorporates ethical values, the Treaty of Waitangi (in the NZ context), and evidence-based research to increase trust, equity, health, and preparedness for future outbreaks.

Justifying a morally permissible breach of contract: kantian ethics, nozickian justice, and vaccine patents

Although some have argued that COVID-19 vaccine patents are morally justified, a broader argument on the morality of breaching contracts is necessary. This article explores the ethics of breaching unfair contracts and argues that it is morally justified to breach contracts with pharmaceutical companies concerning vaccine patents. I offer two arguments to support this view. Firstly, contracts may be breachable in some situations. The ones I point out are that contracts can be broken when the costs of not violating vaccine patents are too high or when the process for agreement is not fair, or when an urgent ethical issue needs to be addressed and it is possible to compensate the other party for their loss. Secondly, I argue that because the contracts with the pharmaceutical companies do not treat people as ends in themselves, there is no moral obligation to respect them.

Can Geographically Targeted Vaccinations Be Ethically Justified? The Case of Norway During the COVID-19 Pandemic

This article discusses the fairness of geographically targeted vaccinations (GTVs). During the initial period of local and global vaccine scarcity, health authorities had to enact priority-setting strategies for mass vaccination campaigns against COVID-19. These strategies have in common that priority setting was based on personal characteristics, such as age, health status or profession. However, in 2021, an alternative to this strategy was employed in some countries, particularly Norway. In these countries, vaccine allocation was also based on the epidemiological situations in different regions, and vaccines were assigned based on local incidence rates. The aim of this article is to describe and examine how a geographical allocation mechanism may work by considering Norway as a case study and discuss what ethical issues may arise in this type of priority setting. We explain three core concepts: priority setting, geographical priority setting and GTVs. With a particular focus on Norway, we discuss the potential effects of GTV, the public perception of such a strategy, and if GTV can be considered a fair strategy. We conclude that the most reasonable defence of GTV seems to be through a consequentialist account that values both total health outcomes and more equal outcomes.

What Type of Person Should I Be? About the Appeal to Virtues in Public Health Interventions

In line with how ethics has developed for the last three centuries, public health ethics has been widely dominated by a deontological as well as a utilitarian approach. The latter is a version of consequentialism, which states that maximizing utility is the primary goal of the majority of individuals or group action, while, on the other hand, virtue ethics, or at least the appeal to virtues, has been largely marginalized. The aim of this article is twofold. Firstly, we aim to highlight the political and ethical nature of public health interventions, often interpreted and presented as mere scientific enterprises. Secondly, we try to highlight the need to integrate or at least recognize the value of appeal to virtues in public health measures. The analysis will reference the Italian COVID-19 vaccination program as a case study. Initially, we will explore the political and ethical nature of any public health measure, using the implementation of the COVID-19 vaccination program in Italy as an example. Subsequently, we will illustrate the deontological approach to ethics, the utilitarian one, and the virtues one, focusing on the dynamic of the agent’s perspective. Lastly, we will briefly analyze both the Italian COVID-19 vaccination program and the communication campaign that promoted it.

The needs of the many: Exploring associations of personality with third-party judgments of public health-related utilitarian rule violations

Safeguarding the rights of minorities is crucial for just societies. However, there are conceivable situations where minority rights might seriously impede the rights of the majority. Favoring the minority in such cases constitutes a violation of utilitarian principles. To explore the emotional, cognitive, and punitive responses of observers of such utilitarian rule transgressions, we conducted an online study with 1004 participants. Two moral scenarios (vaccine policy and epidemic) were rephrased in the third-party perspective. In both public health-related scenarios, the protagonist opted against the utilitarian option, which resulted in more fatalities in total, but avoided harm to a minority. Importantly, in vaccine policy, members of the minority cannot be identified beforehand and thus harm to them would have been rather accidental. Contrariwise, in epidemic, minority members are identifiable and would have needed to be deliberately selected. While the majority of participants chose not to punish the scenarios' protagonists at all, 30.1% judged that protecting the minority over the interests of the majority when only accidental harm would have occurred (vaccine policy) was worthy of punishment. In comparison, only 11.2% opted to punish a protagonist whose decision avoided deliberately selecting (and thus harming) a minority at the cost of the majority (epidemic). Emotional responses and appropriateness ratings paralleled these results. Furthermore, complex personality × situation interactions revealed the influence of personality features, i.e., trait psychopathy, empathy, altruism, authoritarianism, need for cognition and faith in intuition, on participants' responses. The results further underscore the need to consider the interaction of situational features and inter-individual differences in moral decisions and sense of justice.

Vaccine Allocation and Distribution: A Review with a Focus on Quantitative Methodologies and Application to Equity, Hesitancy, and COVID-19 Pandemic

This review focuses on vaccine distribution and allocation in the context of the current COVID-19 pandemic. The implications discussed are in the areas of equity in vaccine distribution and allocation (at a national level as well as worldwide), vaccine hesitancy, game-theoretic modeling to guide decision-making and policy-making at a governmental level, distribution and allocation barriers (in particular in low-income countries), and operations research (OR) mathematical models to plan and execute vaccine distribution and allocation. To conduct this review, we adopt a novel methodology that consists of three phases. The first phase deploys a bibliometric analysis; the second phase concentrates on a network analysis; and the last phase proposes a refined literature review based on the results obtained by the previous two phases. The quantitative techniques utilized to conduct the first two phases allow describing the evolution of the research in this area and its potential ramifications in future. In conclusion, we underscore the significance of operations research (OR)/management science (MS) research in addressing numerous challenges and trade-offs connected to the current pandemic and its strategic impact in future research.

Prioritization of COVID-19 vaccination. The added value of the "VALIDATE" approach

Prioritization of COVID-19 vaccines is one of the most relevant topics in the current pandemic emergency. Prioritization decisions are political decisions that are value-laden, and as such of ethical nature. Despite the clear political and ethical nature of this topic, prioritization decisions are often interpreted and presented as scientific decisions. The aim of this article is twofold. First, we aim to show critical points that characterize certain pandemic vaccination plans from the ethical viewpoint using four dimensions (problem definitions, incorporation of different perspectives, context, and specification). The four dimensions were drawn from findings of the European project “VALIDATE” (VALues In Doing Assessments of healthcare TEchnologies”, https://validatehta.eu). Second, we aim to reframe the issue about prioritization itself in the light of the four dimensions mentioned. Our conclusion is that policy-problem definitions, incorporation of different perspectives, contextual considerations and specification of moral principles seem to be common critical points of some vaccination plan documents. The European project “VALIDATE” seems to be able to provide a useful and profitable approach to address many of these critical points.

Ethical health security in the age of antimicrobial resistance

OBJECTIVE

Owing to its potential human, social and economic costs, antimicrobial resistance (AMR) is frequently referred to as a threat to health security. Simultaneously, health security and the preservation of antimicrobials are often described as a global public good. However, how the term 'public good' is used in the context of health security, and the values that underpin it, remains ambiguous. Policymaking is never value-free, and a better examination of such values is critical to understanding how issues such as AMR are problematised and how policy decisions are informed.

DESIGN

We used McDougall's version of critical interpretive synthesis to capture the recurring concepts and arguments within public policy, political science and applied ethics literature on AMR. Articles were analysed by identifying recurring ideas and developing themes across the literature.

RESULTS

A total of 77 papers were included in our review. In the context of health security and AMR, the concept of 'public good' appears to be used interchangeably with 'common good', reflecting confusion, but sometimes meaningful differences, regarding how antimicrobials, as a good, are conceived. Main approaches to addressing AMR are statism, globalism and regionalism, which appeal to different values in guiding policymakers. Common justificatory values underpinning preservation of antimicrobials as a public good were prevention of harm, solidarity, justice and rights.

CONCLUSION

The findings suggest that within the literature there is a lack of conceptual clarity as to whether antimicrobials constitute a public good or a common good. Moreover, the way in which antimicrobials are conceived and the approaches through which AMR as a threat to health security is addressed appear to be grounded in values that are often implicit. Being explicit about the values that underpin AMR and health security is not simply an intellectual exercise but has very real policy and programmatic implications.

Why should HCWs receive priority access to vaccines in a pandemic?

Background

Viral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers (HCWs) should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic with governments and health authorities currently facing questions of distribution of COVID-19 vaccines.

Main text

In this article, we critically evaluate the most common ethical arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For illustrative purposes, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation.

Conclusions

We argue that there are deontological and utilitarian cases for prioritising HCWs. Indeed, the widely held view that we should prioritise HCWs represents an example of ethical convergence. Complexities arise, however, when considering who should be included in the category of HCW, and who else should receive priority in addition to HCWs.

Who should be tested in a pandemic? Ethical considerations

BACKGROUND

In the initial phase of the Covid-19 pandemic, difficult decisions had to be made on the allocation of testing resources. Similar situations can arise in future pandemics. Therefore, careful consideration of who should be tested is an important part of pandemic preparedness. We focus on four ethical aspects of that problem: how to prioritize scarce testing resources, the regulation of commercial direct-to-consumer test services, testing of unauthorized immigrants, and obligatory testing.

MAIN TEXT

The distribution of scarce resources for testing: We emphasize the use of needs-based criteria, but also acknowledge the importance of choosing a testing strategy that contributes efficiently to stopping the overall spread of the disease. Commercial direct-to-consumer test services: Except in cases of acute scarcity, such services will in practice have to be allowed. We propose that they should be subject to regulation that ensures test quality and adequate information to users. Testing of unauthorized immigrants, their children and other people with unclear legal status: Like everyone else, these individuals may be in need of testing, and it is in society's interest to reach them with testing in order to stop the spread of the disease. A society that offers comprehensive medical services to unauthorized immigrants is in a much better position to reach them in a pandemic than a society that previously excluded them from healthcare. Obligatory testing: While there are often strong reasons for universal testing in residential areas or on workplaces, there are in most cases better ways to achieve testing coverage than to make testing mandatory.

CONCLUSION

In summary, we propose (1) decision-making primarily based on needs-based criteria, (2) strict regulation but not prohibition of direct-to-consumer test services, (3) test services offered to unauthorized immigrants, preferably as part of comprehensive medical services, and (4) broad outreach of testing services whenever possible, but in general not obligatory testing.

Who's Getting Shots First? Dealing With the Ethical Responsibility for Prioritizing Population Groups in Vaccination

BACKGROUND

The current pandemic has raised several ethical dilemmas, related to conducting real-time trials for new treatments or vaccines or with decisions such as accessibility to vaccines.

STUDY QUESTION

Should there be a prioritization of access to the vaccine based on ethical and objective criteria or should the access be done at random?

STUDY DESIGN

To determine the ethics and reality of rationing the accessibility to anti-COVID vaccine according to the official strategies.

DATA SOURCES

The study is based on the consultation of (1) scientific articles from international databases (Google Scholar, PubMed, ProQuest, and Clarivate), (2) public health documents, and (3) official information of various governments.

RESULTS

The analyzed documents revealed that a few similarities can be observed in European countries when it comes to the first categories of people who have received the vaccine: people living in care facilities and medical staff; it can also be seen that the vaccination plan was adopted by each country for the needs and characteristics of its population, the prioritization being done in 2-14 stages; some of them divided, in their turn, into subsequent substages. Most of the states subject to the analysis assigned the medical staff in the first stage, followed by those in the sectors ensuring the maintenance of essential services, afterward by the elderly or people with comorbidities, only later to expand to other social categories.

CONCLUSIONS

Prioritization of vaccine administration is not only necessary, unavoidable, but also problematic both ethically and logistically, which should involve leaders in the field of public health, but also medical staff, regardless of their specialization. Prioritization of vaccination can not only have an impact on individual health (physical and emotional) but also on society from public health, economic, and sociocultural point of view.

Vaccine ethics: an ethical framework for global distribution of COVID-19 vaccines

This paper addresses the just distribution of vaccines against the SARS-CoV-2 virus and sets forth an ethical framework that prioritises frontline and essential workers, people at high risk of severe disease or death, and people at high risk of infection. Section I makes the case that vaccine distribution should occur at a global level in order to accelerate development and fair, efficient vaccine allocation. Section II puts forth ethical values to guide vaccine distribution including helping people with the greatest need, reducing health disparity, saving the most lives and promoting narrow social utility. It also responds to objections which claim that earlier years have more value than later years. Section III puts forth a practical ethical framework to aid decision-makers and compares it with alternatives.

How should we conduct pandemic vaccination?

Vaccination plays an important role in pandemic planning and response. The possibility of developing an effective vaccine for a novel pandemic virus is not assured. However, as we have seen with SARS-CoV-2 vaccine development, with sufficient resources and global focus, successful outcomes can be achieved in a relatively short period. However even when vaccine is available it will initially be scarce. When one becomes available, how should it be distributed?

In this paper we explicate how ethical thinking that is carefully attuned to context is essential to decisions about how we should conduct vaccination in a pandemic where demand exceeds supply. We focus on two key issues. First, setting the aims for a pandemic vaccination programme. Second, thinking about the means of delivering a chosen aim. We outline how pandemic vaccine distribution strategies can be implemented with distinct aims, e.g. protecting groups at greater risk of harm, saving the most lives, or ensuring societal benefit. Each aim will result in a focus on a different priority population and each strategy will have a different benefit-harm profile. Once we have decided our aim, we still have choices to make about delivery. We may achieve at least some ends via direct or indirect strategies. Such policy decisions are not merely technical, but necessarily involve ethics. One important general issue is that such planning decisions about distribution will always be made under conditions of uncertainty about vaccine safety and effectiveness. However, planning how to distribute vaccine for SARS-CoV-2 is even harder because we understand relatively little about the virus, transmission, and its immunological impact in the short and long term.

Constructing an ethical framework for priority allocation of pandemic vaccines

Background

Allocation of scarce resources during a pandemic extends to the allocation of vaccines when they eventually become available. We describe a framework for priority vaccine allocation that employed a cross-disciplinary approach, guided by ethical considerations and informed by local risk assessment.

Methods

Published and grey literature was reviewed, and augmented by consultation with key informants, to collate past experience, existing guidelines and emerging strategies for pandemic vaccine deployment. Identified ethical issues and decision-making processes were also included. Concurrently, simulation modelling studies estimated the likely impacts of alternative vaccine allocation approaches. Assembled evidence was presented to a workshop of national experts in pandemic preparedness, vaccine strategy, implementation and ethics. All of this evidence was then used to generate a proposed ethical framework for vaccine priorities best suited to the Australian context.

Findings

Published and emerging guidance for priority pandemic vaccine distribution differed widely with respect to strategic objectives, specification of target groups, and explicit discussion of ethical considerations and decision-making processes. Flexibility in response was universally emphasised, informed by real-time assessment of the pandemic impact level, and identification of disproportionately affected groups. Model outputs aided identification of vaccine approaches most likely to achieve overarching goals in pandemics of varying transmissibility and severity. Pandemic response aims deemed most relevant for an Australian framework were: creating and maintaining trust, promoting equity, and reducing harmful outcomes.

Interpretation

Defining clear and ethically-defendable objectives for pandemic response in context aids development of flexible and adaptive decision support frameworks and facilitates clear communication and engagement activities.

The role of IS in the covid-19 pandemic: A liquid-modern perspective

History shows that pandemics can catalyse enormous change, fundamentally transforming the way people make sense of the world. Technologies can also be catalysts of change. While digital technologies are playing a vital role in tackling the covid-19 pandemic, the pandemic also presents a significant opportunity for digital technologies. Some experts believe the pandemic may permanently normalise the comprehensive societal use of digital technologies. This article casts a critical eye over the potential implications of this opportunity in the context of information systems (IS) research and development. We introduce and outline selected principles of Zygmunt Bauman's theory of liquid modernity. We then apply the liquid-modern principles to illustrative examples drawn from the covid-19 literature by focussing on three areas of established information systems interest: control, big data and information privacy. We show that traditional conceptualisations of scientific and societal order and control need to be reassessed; that big data alone cannot order clear and safe paths out of the current crisis and that information privacy regulations are irrelevant when undermined or circumvented by public and private actors. We conclude by making four recommendations for IS pandemic researchers and five practical recommendations in the context of the pandemic.

The Advisory Committee on Immunization Practices' Ethical Principles for Allocating Initial Supplies of COVID-19 Vaccine - United States, 2020

To reduce the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) and its associated impacts on health and society, COVID-19 vaccines are essential. The U.S. government is working to produce and deliver safe and effective COVID-19 vaccines for the entire U.S. population. The Advisory Committee on Immunization Practices (ACIP)* has broadly outlined its approach for developing recommendations for the use of each COVID-19 vaccine authorized or approved by the Food and Drug Administration (FDA) for Emergency Use Authorization or licensure (1). ACIP's recommendation process includes an explicit and transparent evidence-based method for assessing a vaccine's safety and efficacy as well as consideration of other factors, including implementation (2). Because the initial supply of vaccine will likely be limited, ACIP will also recommend which groups should receive the earliest allocations of vaccine. The ACIP COVID-19 Vaccines Work Group and consultants with expertise in ethics and health equity considered external expert committee reports and published literature and deliberated the ethical issues associated with COVID-19 vaccine allocation decisions. The purpose of this report is to describe the four ethical principles that will assist ACIP in formulating recommendations for the allocation of COVID-19 vaccine while supply is limited, in addition to scientific data and implementation feasibility: 1) maximize benefits and minimize harms; 2) promote justice; 3) mitigate health inequities; and 4) promote transparency. These principles can also aid state, tribal, local, and territorial public health authorities as they develop vaccine implementation strategies within their own communities based on ACIP recommendations.