What’s the order of vaccination?: A discussion featuring ethicists, scientists and epidemiologists

December 28, 2020 • 1:15 pm

Last week we had a little “accident” at my university. Due to a misstep somewhere, some biology graduate students got their Covid-19 vaccinations before healthcare workers at the hospital. These students had nothing to do with clinical research, but apparently got their jab tickets because they are, like me, part of the Biological Science Division, which includes the University hospital that is currently scheduling shots for its own workers. I suspect that someone messed up the scheduling.

This distressed me quite a bit, as I’m waiting patiently in line for my jab, and feel that healthcare workers should certainly get the first shots (they haven’t finished yet). But some of the students, surely knowing this was an error, ran over immediately and got their shots. (Others realized the potential error and made inquiries.) That, of course, means that a second dose had to be reserved for their second shot, and that some essential healthcare workers had to wait.  I’ve let the powers-that-be know about the error so this won’t happen again. (It was surely a mistake, and these things will happen.)

In fact, this kind of error happened in another U.S. hospital last week (it was on the news; I can’t remember where), and caused a huge furor. Those people who want the shots—and thankfully their numbers are growing—are rightfully incensed by “line jumping”. I suspect that if rich people could pay to get vaccinated early, it would create huge turmoil, and rightly so. After all, is a rich person’s life worth more than a poor one’s? Not in my book. But according to LA Magazine, the wealthy are already angling to get early jabs.

But regardless of existing ordering, the question of whose lives are worth more is the real topic of this discussion, moderated by the New York Times‘s Emily Bazelon with a good lineup of participants. As I discussed the other day, the CDC originally wanted to vaccinate essential non-healthcare workers before older people—even though their models showed that this ordering would lead to more deaths than the reverse ordering—because the second group was “whiter”. That’s been changed, but race is also a central issue in this discussion. Click on the screenshot to read it:

Here’s the lineup, which is a good group:

The Panelists

Ngozi Ezike, an internist and pediatrician, is the director of the Illinois Department of Public Health. She previously worked for 15 years in the Cook County health system, where she delivered inpatient and outpatient care and directed medical services at the Cook County Juvenile Detention Center.

Gregg Gonsalves is a professor of epidemiology at the Yale School of Public Health and an AIDS and global health activist. He is also a 2018 MacArthur Fellow.

Juliette Kayyem is a professor at the Harvard Kennedy School, where she is the faculty chairwoman of the Security and Global Health program, and a former assistant secretary at the Department of Homeland Security. She is advising a number of public and private entities on pandemic response and vaccine distribution.

Siddhartha Mukherjee is a professor of medicine at Columbia University and a cancer physician and researcher. He is the author of “The Emperor of All Maladies: A Biography of Cancer,” which was the winner of the 2011 Pulitzer Prize in general nonfiction. He is a founder of a vaccine-delivery platform called Othena.

Peter Singer is a bioethics professor at Princeton, author of “The Life You Can Save” and founder of the charity of the same name. His most recent book is “Why Vegan?”

Emily Bazelon, a staff writer for The New York Times Magazine, moderated the discussion, which has been edited and condensed for clarity, with material added from follow-up interviews.

I’m not going to reprise the whole long exchange, but just mention a few high points.

What surprised me is that race, though the first thing Bazelon brought up (this is, of course, the NYT), wasn’t an element of dissent. Everyone agreed that since people of color have a higher risk of dying from the virus, they should, as Singer said get the first jabs, though he notes the unethicality of the CDC’s original recommendation:

Peter Singer: It makes sense to protect those who are most vulnerable, whether the vulnerability is social or health-related. So if the evidence indicates that Black, Latino or Native American people have a higher risk of dying from the virus, they should be offered the vaccine ahead of others of the same age who are at lower risk because they are white or Asian. But a document that was circulated in November to A.C.I.P., the C.D.C. panel, suggested that the fact that racial and ethnic minorities are underrepresented among those older than 65 is a reason for giving lower priority to that age group as a whole and instead vaccinating more than 100 million “essential workers” ahead of them. The effect would be that more people over all would die — and also that more members of racial and ethnic minorities would die, because the higher fatality rate in older people would outweigh their lower share of representation in that age group. That’s absurd. Equity for disadvantaged minorities can’t tell us to distribute vaccines in a manner that will mean more deaths in those communities themselves.

In fact, I found the whole discussion much less engaging than I thought it would be—except for Singer’s comments. He’s always provocative, and though I’m initially shocked by some of his views about ethics, like recommending euthanasia for terminally deformed or sick newborns, I usually come around to his way of thinking. And so he makes a statement that may shock people, but has some merit:

Singer: The objective that we should aim for is to reduce years of life lost. I know a lot of people are talking just about saving lives. But I do think that it’s different whether somebody dies at 90 or 50 or a younger age still. So, in my view, that’s what we should be looking at.

. . . The basis for the British government’s plan is, of course, to treat those who are at the highest risk of dying and thus to minimize the number of deaths. But it is also important to consider what your life would be like if you don’t die.

It might still be that we should protect 90-year-olds first, based on data suggesting that 90-plus are at eight times the risk of dying from the virus as people around 70, whereas their life-expectancy difference is roughly something like four and a half years as against 15 years for 70-year-olds. If that’s correct, then the higher risk to the 90-year-olds outweighs the difference in life expectancy.

He also suggests that older people without the ability to give consent, like those with dementia, might not be vaccinated, arguing that “many doctors tell me that when patients have severe dementia, they do not treat conditions like pneumonia. Even though you could treat it with antibiotics relatively simply, they say, there’s a time to let a patient go.” (He also says that families should of course be consulted.)

Mukherjee seems to spend a fair amount of his discussion promoting his vaccine-delivery platform (see description above). If he doesn’t profit from the platform, that’s fine, but if he does (and the platform’s website and this interview suggest that it’s part of his own company, Cura), statements like the following seem self-promoting:

Mukherjee: When you talk about trucks breaking down, that’s one problem. There’s a second, equally important but I think neglected logistical problem, which a company I co-founded, Othena, is trying to solve. The Pfizer and the Moderna vaccines require booster shots. They need to be tracked, and they need monitoring and auditing. What’s the reminder system for telling you to come back for your second dose and for tracking which populations are getting the vaccine? This is a data-management challenge. We are piloting Othena software to address this issue in Orange County and other places in the country.

Current software systems are not patient-based, and vaccination will only be scalable if patients can manage their own vaccination.

He repeats this emphasis, but I’ll move on.

Two other matters in the exchange are worth considering. First, there’s the fact that areas like the U.S., Australia, New Zealand, and Europe are clearly getting priority for the vaccines, even though places like Brazil are severely afflicted, and African countries might soon be in the same situation. (I heard on the news last night that New Zealand has ordered enough vaccine to do its entire population more than four times over!) Is that ethical? Why should any countries get priority over others, much less reserve excess vaccine? I haven’t thought much about this, but offer it for your consideration.

And there’s the issue of patent-breaking—of poorer countries stealing the patents on vaccines to help their residents, as (says Mukherjee) India did with anti-retroviral drugs during the AIDS crisis. To me, if it saves lives, it’s worth considering, and perhaps companies shouldn’t go after patent-breakers so long as the stolen vaccines are good ones.

As for the ordering, I’m happy with where it is, and if they decide to vaccinate bartenders or truck drivers before me, well, so be it. This is a complicated process, and different states will have different priorities. It turns out that American states do have considerable leeway about the order of vaccination, and I haven’t paid much attention to the variation: I just watch the news and have registered at the hospital here to be informed when my number is up.

And about jumping the queue with money, here’s part of that discussion:

Mukherjee: Peter, what if you could jump the queue, and get 10 doses of vaccine for your friends and family, if you contribute 5,000 or 10,000 or 500,000 doses for the Global South. Would you be open to such an option?

Singer: Yes, I would be, I think. Clearly, for a utilitarian like me, the benefits greatly outweigh the costs.

Gonsalves: It won’t happen. But there will be huge numbers of rich people who will jump the line for the vaccine and not give anything back.

I don’t see how rich people can jump the line given the guidelines, but Gonsalves is sure that will happen. If it does, it will really piss people off. After all, this isn’t a queue to get into the movies or buy toilet paper, but one that can affect your chance of dying.

45 thoughts on “What’s the order of vaccination?: A discussion featuring ethicists, scientists and epidemiologists

  1. Did y’all see that weasel Marco Rubio cut to the front of the line ???

    Seriously, anybody that dismissed the severity of the pandemic, told people not to wear masks, etc, should be LAST in ANY LINE !!!

    1. Marco’s one of my senators, unfortunately. I’ve taken to sending him scabrous emails through his US senate website whenever he says or does something idiotic or evil (which is pretty much all the time these days).

      All it ever gets me in return is a form email thanking me for my support (like I’m some kinda freakin’ campaign donor or something) and an automatic subscription to his newsletter (which I promptly cancel as soon as the first one arrives in my inbox). But it helps me blow off steam.

      1. well, at least he wasn’t prosecuted for Medicare fraud like our other senator, Rick Scott. And he doesn’t look like a reptile…

  2. the U.S., Australia, New Zealand, and Europe are clearly getting priority for the vaccines, even though places like Brazil are severely afflicted, …

    Because those countries have paid lots of money to obtain the vaccines, and the companies making them are commercial enterprises? It’s no different from first-world healthcare in general being much superior to what’s available in third-world countries.

    (I heard on the news last night that New Zealand has ordered enough vaccine to do its entire population more than four times over!) Is that ethical?

    They ordered large batches of all the different vaccines under development, because they did not know which ones would be effective and safe and on what timescale. Similarly, the UK has ordered way more doses than its population for that reason. It does not mean that they are sitting on stocks of vaccine that others need.

      1. The UK has ordered 357 million doses from 7 different vaccines, but that number of doses depends on all 7 being effective and safe and passing the regulators. It was a sensible strategy to hedge the bets this way at a time when no vaccine had proven effective. If they end up with a surplus I don’t know what they’ll do, but I expect they’ll be happy to pass it on to other countries (they’d have a financial incentive to sell it on) — but so far we’re far from having a surplus, only around 1 million of those 357 million have been delivered.

        1. I should hope at least some of it would be donated to the impoverished in third-world nations.

          I never had much use for Dubya (even if he seems like Pericles compared to our departing POTUS), but I do give him props for his initiative on HIV/AIDS in Africa.

        2. but that number of doses depends on all 7 being effective and safe and passing the regulators

          Also, nobody (and I mean nobody) knows which vaccine type will have a longer-lasting effect. If they only have effect for 18 months, that apparent “surplus” isn’t going to look so big. even more so if the vaccines for the pre-2020/11 strains are not so effective against the strains in circulation in 2022 (because those pesky hoomins have been selecting against the first strains of the virus to emerge and so tilting the evolutionary pool table in favour of new strains emerging ; hoominz also provide abundant vectors for long-distance transmission, including hoomins on snow-play-planks).
          I would suspect that by the time that those doses (NZ, UK, CA …) can be clearly flagged as “surplus”, the vaccine factories of India and Brazil are going to be churning out third- or fourth- generation vaccines. Well into 2022?
          Or, in the words of Bill Gates on a programme I was listening to this morning, the next “surprise infection” has come along. Because hoominz don’t learn easily.

      2. The hospital that messed up scheduling was Stanford. They used a sophisticated but stupid model (actually it was not clear the model would be bad, the parameters were not well thought out, and special cases — like interns do not “belong” to a department — were not included.)



      3. New Zealand has ordered quantities of several different vaccines, and its order (which will be fully funded by the NZ Government) includes stocks for a number of Pacific Island nations, who will be supplied free.

    1. My understanding is that Canada has done the same but has promised to give the excess to poor countries who can’t afford much on their own.

  3. I am pretty sure that NZ is also supplying vaccine for the islands eg Samoa etc for free so they do technically need more than their population. It makes sense for them to do so since people regularly migrate back and forth to the islands so it does provide protection to the New Zealanders. Sort of a ring of confidence

    1. I heard on that report that NZ was planning on giving lots of the vaccine to poor countries or area. NZ handled the virus so much better than damn near every country. They sure made us look stupid.

  4. Peter Singer thinks it’s immoral to kill a fish but not an infant. He wouldn’t be my go to guy in a discussion on ethics.

    1. I think Singer’s reasoning is that the infant is going to die anyway, whereas the fish will lead a long and healthy life and die quietly of old age.

      In his view, predation only happens at the hands of humans.


      1. I am not sure that “severely disabled” necessarily means “doomed to early death”. In fact, among all autosomal trisomies, we are most interested in the prenatal diagnosis of Down syndrome exactly because children born with it tend to live.
        Besides, in the broad sense, we are all going to die anyway.

  5. The grad students who were vaccinated either knew they not amongst those who should be vaccinated at this time and did it anyway because they could get away with it, or they didn’t know and thus were showing they are not keeping up with one of the most important topics in biology at this moment. Regardless of which of the two is true, is the department or university going to sanction them for doing this?

    1. For what, exactly, will they be sanctioned?
      In fact, if my experience with bureaucracy is any clue, I’d recommend everyone to go and get his dose at the moment when it is available. Because I find it quite likely that, if you “refuse” to vaccinate, you will just fall out of the lists, and will never be called again. And even if you are ready to pay for the vaccine, it is not currently on the market for private individuals.

      1. In fact, if my experience with bureaucracy is any clue, I’d recommend everyone to go and get his dose at the moment when it is available.

        Yeah, as much as I would be happy to wait, I also do know how easily mistakes can be made. And that the distribution process is already difficult without adding another layer to the problem.

  6. I’m surprised to see Singer say “for a utilitarian like me” as I’m pretty sure that in the past he has backed Popper’s concept of Negative Utilitarianism, of which Popper wrote:

    [T]here is, from the ethical point of view, no symmetry between suffering and happiness, or between pain and pleasure… In my opinion human suffering makes a direct moral appeal, namely, the appeal for help, while there is no similar call to increase the happiness of a man who is doing well anyway. A further criticism of the Utilitarian formula “Maximize pleasure” is that it assumes a continuous pleasure-pain scale that lets us treat degrees of pain as negative degrees of pleasure. But, from the moral point of view, pain cannot be outweighed by pleasure, and especially not one man’s pain by another man’s pleasure. Instead of the greatest happiness for the greatest number, one should demand, more modestly, the least amount of avoidable suffering for all.

    1. Did not know Popper said that – I certainly agree that there is no pleasure pain continuum, but they are separate categories, likewise good & bad or ‘evil’ – separate things.

      Did you study philosophy? I forget…

  7. In a country which doesn’t have universal health care, isn’t it an implicit principle that healthcare is available to the highest bidder?
    (I am a supporter of universal healthcare by the way).

    As far as I know, the companies manufacturing vaccines can sell on the open market if the vaccine is legally approved.
    Bribing your way to a vaccination in the public sector is a different issue.

    There are also a wide range of prices on offer for Covid19 tests (live infection or antibody): between about £38 and £380.

    If the government produced these tests itself, they could be produced at cost (something of the order of £20 each) and the technical knowhow would also be a state asset.

    There has also been one case of a UK MP taking a £100,000 annual salary for unspecified services to a British drug testing company which gained a £300,000,000+ uncontested contract with the government for supplying Covid test kits. Conflict of interest or cronyism seems obvious but there is no investigation as yet. No names, no pack drill!

  8. I will soon be 91, so my expiration date could be several years away or yet this afternoon.

    I surmise I will not be terribly inconvenienced being dead. What concerns me is the manner of dying and COVID seems to be an especially odious way of departing.

    Were I to be infected and given an injection that made me unconscious or even facilitated my death, I would be less concerned. No human would be allowed to do that for me. But humans would be allowed to permit the virus to finish me off in perhaps a most gruesome fashion.

    As for my place on the Enjoyment of Life Index, I may well be way ahead of many who are 70. Or even 30 for that matter. I thoroughly enjoy my life and generally good health allows me to do so. So, yes, I am hoping I can get vaccinated even at my advanced age.

    1. Indeed. Although I am a couple of decades behind you (and therefore my reasoning may be influenced by that) an extra consideration is that ‘allowing’ more lower qualy people to die will also tie up hospital and other health resources. Which may negatively affect higher qualy people who also need those services.

      You could make an argument for pragmatic reasons that you should deal with the ‘lower hanging fruit’ first (older people and healthcare workers, easier to identify and vaccinate) to gain a quicker return to normality for everybody

    2. @Barry
      I am pretty much locked in with my father(92) and mother(87).
      The doctors have supplied us with palliative care prescriptions for severe pain (morphine), anti-spasmolytics and strong sedation.
      Covid is not a particularly “nice” way to go,as you say, but pneumonia is also fairly common as a final complication in other conditions, and is similar in many ways to Covid.
      In those cases, the health carers cannot “facilitate” someone’s death, but they should ensure that the person’s pain is reduced and/or that they are in a state of controlled unconsciousness/sedation.
      My mother gets vaccination in two days from now.
      Good luck with your Enjoyment of Life Index.

  9. “It makes sense to protect those who are most vulnerable, whether the vulnerability is social or health-related. So if the evidence indicates that Black, Latino or Native American people have a higher risk of dying from the virus, they should be offered the vaccine ahead of others of the same age who are at lower risk because they are white or Asian.”

    But if the factors are social or health-related, why not use those factors to identify at-risk individuals, regardless of race, and prioritize them? If you don’t, you’ll needlessly penalize a huge number of vulnerable white Americans with health issues or are poorer and/or underserved by health resources. The National Academy of Sciences has done a geographical analysis of such vulnerable groups that could be used for this.

  10. We will have local responsibility at the regional level, but the initial priority is fixed:

    The primary purpose of the vaccination in the first stage is to protect at an early stage the groups that are most at risk of becoming seriously ill or dying in covid-19, which is considered to be people who live in special housing for the elderly or have home care.

    The Swedish Public Health Agency recommends that the following groups be vaccinated first:
    – People who live in special housing for the elderly or have home care.
    – Personnel in elderly care, health and medical care and other care personnel who work close to people as above.
    – Close household contacts to people who have home care.

    None of that “years left” calculus, by pushing down death rates fast it will sort itself out.

    But FWIW on the non-treatment of critical conditions, I found that advanced dementia victims have a median survival of 1.3 years [ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2778850/ ]. Still, if you prick them, do they not suffer?

    areas like the U.S., Australia, New Zealand, and Europe are clearly getting priority for the vaccines, even though places like Brazil are severely afflicted,

    There is some fine print friend corruption in this, for instance Scandinavian nations that are not EU members and part of the common ordering, licensing and distribution is provided their share by the rest. Sweden distribute part of the (hence embiggened) vaccine share to Norway.

    Russia is, according to their own statistical agencies, the third worst afflicted nation. It is notable how authoritarian led states, apart from China, has fared ill in this. Luckily [?] Russia have their famed, untested own vaccine.

    The poor ethics of unregulated markets is not a new situation (c.f. “tragedy of the commons”). But happily I read projections that Sweden can start supply other area nations with surplus starting from March.

  11. Covid patients in hospitals tend to be older so vaccinating them will relieve pressure on the overburdened health care system.

  12. Surely the only factor to be considered is which approach saves the most lives? So yes, the especially vulnerable should be near the top, and there is a good case for immunising health care workers who are involved in Covid care, as they may save lives of others. Only then would I consider other workers like those in grocery stores (liquor stores and hardware stores, not so much). The rationale for that is that we all need to be able to eat, and we don’t want starvation or civil unrest.
    But seeing politicians jumping to the front of the queue, even with the thin excuse that they are encouraging the rest of us to get the vaccine, is disgraceful.

    1. “Surely the only factor to be considered is which approach saves the most lives?”
      No, it makes just as much (or as little) sense to maximize “additional years lived”, as the article says.

  13. Chrism, I think Singers point is that it is not just what saves most lives, but that we should consider what saves most ‘life-years’.
    Like four injections will save two 90 year old’s but they die of other causes in 2 and 5 years = 7 life-years, while injecting two 60 year old’s with a life expectancy of 20 more years, say 9 and 24 = 33 life-years. Of course one should also include the probability of dying when contracting the virus. That balances it. I’m sure some whizz-kid can design a good algorithm.
    However, to complicate matters, we also should take into account what the chances are to actually be exposed to the virus, as well as their chance to expose others, and which others. Our whizz-kid must be sweating by now.
    I’d definitely not only give health care workers involved in Covid care priority, but I would add all carers (Drs, nurses, cooks and cleaners, the lot) that work in old age homes, retirement villages, hospices and hospitals. Not just to protect these unsung heroes, but also because they can spread the virus among a highly vulnerable population. (And dentists, dentist assistants and ENT health workers too).
    I agree about these politicians, especially if they called the whole thing a hoax or otherwise minimized the seriousness of the epidemic.

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