When I heard that Illinois was giving covid-vaccine priority to all “essential workers” over the aged, I was puzzled. Not because “essential” workers should all queue up behind older people, but because some “essential workers” weren’t really essential in a sense that should give them priority over older people whose chance of dying from the infection was much higher. “Essential workers” include, according to Yascha Mounk, bankers, liquor-store employees, hardware-store employees, and movie crews. On what grounds, especially considering the differential risk of death or serious illness, should these “essential workers” be given vaccination priority over adults with high-risk medical conditions or older folks (over 65, 70, or 75, depending on the state and the ordering)?
Yet that is what the CDC decided not long ago, realizing, even by their own accounting, that such a decision would cause more people to die than if the order was reversed. The decision to let people die was apparently based on social-justice considerations, as older people were deemed to be more white than were essential workers.
In this article from Persuasion, Yascha Mounk, Associate Professor of Practice at Johns Hopkins University’s School of Advanced International Studies, argues that such a decision is unethical. Click to read:
Mounk begins with some premises that he thinks people will agree on about what what is just and unjust:
. . . there are also some bedrock principles on which virtually all moral philosophers have long agreed.
The first is that we should avoid “leveling down” everyone’s quality of life for the purpose of achieving equality. It is unjust when some people have plenty of food while others are starving. But alleviating that inequality by making sure that an even greater number of people starve is clearly wrong. The second is that we should not use ascriptive characteristics like race or ethnicity to allocate medical resources. To save one patient rather than another based on the color of their skin rightly strikes most philosophers—and most Americans—as barbaric. The Centers for Disease Control have just thrown both of these principles overboard in the name of social justice.
In one of the most shocking moral misjudgments by a public body I have ever seen, the CDC invoked considerations of “social justice” to recommend providing vaccinations to essential workers before older Americans even though this would, according to its own models, lead to a much greater death toll. After a massive public outcry, the agency has adopted revised recommendations. But though these are a clear improvement, they still violate the two bedrock principles of allocative justice—and are likely to cause unnecessary suffering on a significant scale.
He then recounts a talk that Kathleen Dooling, a public-health official, gave at the CDC, a talk that wound up undergirding the initial order of non-healthcare-essential workers > older adults that the organization mandated for vaccination. The decision was based on “feasibility [ease of implementing vaccination in an identified population], science, and ethics.” Dooling presented a chart, below, purporting to show that implementation was easier in a group based solely on age (true: it’s substantially harder to identify “essential non-healthcare workers” as well as define whether someone has a “high-risk medical condition”), and the science itself, she said, showed no difference in outcomes based on priority. (The “+” signs are indices of priority, and are somehow combined to create the order of vaccination.)
The “science” bit is especially wonky. Although older adults without comorbidities are given the same science rating as essential non-healthcare workers (column 1 versus 3), Mounk says this:
According to the CDC’s model, prioritizing essential workers over the elderly would therefore increase the overall number of deaths by between 0.5% and 6.5%. In other words, it would likely result in the preventable deaths of thousands of Americans.
Remember, that is a model that supposedly takes into account all scenarios for mortality, including deaths produced by non-vaccinated “essential non-healthcare workers” who spread the virus to others:
Thus, deciding to prioritize non-healthcare essential workers over adults over 65 rested on grounds of “ethics” is deciding to prioritize “ethical considerations” over life (as if differential death was not an ethical matter!) Mounk says the “ethics” came down to race:
And yet, the presentation concluded that science does not provide a reason to prioritize the elderly. For, as Kathleen Dooling wrote in one of the most jaw-dropping sentences I have ever seen in a document written by a public official, differences in expected consequences that could amount to thousands of additional deaths are “minimal.”
This allowed Dooling to focus on “ethical” principles in selecting the best course of action. Highlighting the most important consideration in red, Dooling emphasized that “racial and ethnic minority groups are underrepresented among adults > 65.” In other words, America’s elderly are too white to be considered a top priority for the distribution of the vaccine against Covid. It is on this basis that ACIP awarded three times as many points to prioritizing the more racially diverse group of essential workers, making the crucial difference in the overall determination. Astonishingly, the higher overall death toll that would have resulted from this course of action does not feature as an ethical reason to prioritize older Americans.
As far as I know, Mounck is correct is stating that this is the basis of the decision. It is based on social-justice optics. Now nobody would want to take a path in which one could foresee a worse outcome—in terms of death or anything else—for members of different races. If one could predict that the death rate among such groups would differ as a result of such a policy decision, that would violate the ethical principles above. But that’s not the outcome here. In fact, as Mounck notes, the proportion of people of color among essential non-healthcare workers isn’t much different from their proportion among the elderly, and it’s in fact conceivable that prioritizing column 1 over column 3 could lead to the deaths of more people of color than the other way around!
The difference in the percentage of white people across age groups is comparatively small. The difference in the percentage of infected people who succumb to Covid across all age groups is massive. Giving the vaccine to African-American essential workers before elderly African-Americans would likely raise the overall death toll of African-Americans even if a somewhat greater number of African-Americans were to receive the vaccine as a result.
Indeed, a few people noticed and objected to this order:
In the days after ACIP published its preliminary recommendations, barely any epidemiologists or health officials publicly criticized its findings or its reasoning. But thankfully, prominent journalists like Zeynep Tufecki, Matt Yglesias and Nate Silver publicly made the case against them. (So did I.)
You might look at the data in Silver’s tweet, since many people seem to trust him.
Age needs to be a higher priority than pre-existing conditions in vaccine rollout plans. Or a lot of people are going to die, unnecessarily. It really is that sample.
— Nate Silver (@NateSilver538) December 19, 2020
Finally, as the controversy grew, the CDC changed its recommendations, putting (after medical workers) Americans over 74 AND essential frontline workers in the second phase. Mounk sees this as an improvement, but one that could still lead to higher deaths (for example, prioritizing frontline workers over those 65-74 could still lead to overall higher mortality).
Although I’m over 65, I don’t really have a dog in this fight. I will patiently wait my turn to be vaccinated whatever and whenever the state of Illinois decides. But what the CDC was trying to do originally—and may be doing to a lesser extent now—smacks of prioritizing the appearance of equity above the lives of Americans—and that includes black lives. I see no other explanation once you realize that the CDC is supposed to have done the math about overall deaths caused by their different strategies—and then opted for a ranking that would increase the number of dead. We all know the importance of optics (Glenn Loury calls it “ass covering”) over substantive and meaningful progress these days, especially when it comes to alleviating inequalities among groups. To use one example, optics rather than achievement is the basis of land acknowledgments.
In the end, Mounk uses this ranking as an example of why we shouldn’t even trust government institutions like the CDC, which is supposed to be using science to make its decisions. Although ethics has to figure in somewhere, if you can’t trust the CDC’s science, what can you trust? And I agree that there was a misstep in the CDC which only public scrutiny prevented. Mounk is especially exercised by the failure of the press to notice and call out the CDC’s priorities, unlike Nate Silver:
Until a few years ago, it was obvious to me that I can trust what is written in the newspaper or what I am told by public health authorities.
Now, I am losing that trust. I still believe that most people, including the journalists who write for established newspapers and the civil servants who staff federal agencies, are the heroes in their own stories. They genuinely mean well. And yet, I no longer trust any institution in American life to such an extent that I am willing to rely on its account of the world without looking into important matters on my own.
The reasons for this mistrust are perfectly encapsulated in the reports that mainstream newspapers published about the CDC’s recommendation. The write-up in the New York Times, for example, barely mentions the committee’s last-minute change of heart. A faithful reader of the newspaper of record would not even know that an important public body was, until it received massive criticism from the public, about to sacrifice thousands of American lives on the altar of a dangerous and deeply illiberal ideology.
Weigh in below; is Mounk’s take right or wrong?