With multiple COVID-19 vaccines approved for emergency use in the United States, one of the biggest challenges of 2021 will be ethically and equitably allocating them to the public.
In what order should people get potentially life-saving vaccines? And once a vaccine is available to everyone, would it be unethical not to take it, for the safety of others around you? University of Chicago ethicist Laurie Zoloth has been debating questions like these for a long time.
“A year ago, as the first cases were being reported, I was having students in my class on theories of justice do hypotheticals with tiny plush toys,” said Zoloth, the Margaret E. Burton Professor of Religion and Ethics at the Divinity School. “By the end of class, we were talking about vaccine allocation. Since then, justice has become very real, very quickly.”
As a leading bioethicist and scholar of Jewish studies, Zoloth serves on ethical advisory boards for the American Heart Association, NASA, the CDC, Merck and the National Institutes of Health. She has given Congressional testimony about the ethics of stem cell research and engineering biology, evaluated the efficacy of drugs—including hydroxychloroquine—and made difficult choices about which patients should get organ transplants or new treatments first.
Ethicists like Zoloth will help guide the vaccine allocation process over the next few months. But officials will not be the only ones making decisions that can save lives: According to Zoloth, a just, transparent process needs to be paired with solidarity and goodwill from ordinary people. We’ll need to be aware of our own positionality—allowing others with more urgent needs to be vaccinated first—while also getting vaccinated as soon as we can to boost herd immunity.
Zoloth said the philosophy of Emmanuel Levinas, a French scholar of Lithuanian-Jewish ancestry who survived World War II as a German prisoner of war, is especially relevant to beating COVID-19. Levinas emphasized the other, as opposed to the self, in his approach to ethics.
“Both vaccines and masks are a perfect instantiation of the ethics of responsibility,” Zoloth said. “The golden rule, in the case of COVID-19, comes down to a very basic physical act: I get vaccinated—or wear a mask—to protect you, and you do so to protect me.”
The challenge of vaccine allocation
The task of allocating inoculations to millions of people might seem overwhelming, but this isn’t the first time that a new vaccine, drug or therapy has been available in limited supply. Ethicists are used to thinking through these problems, Zoloth said, and their theories can offer guidance.
The first principle Zoloth cites is the Aristotelian idea that equal cases should be treated equally, while different cases should be considered according to their differences. That means a lottery system is a good solution for determining the order in which people like frontline health care workers—who meet the same criteria and have equal claims to treatment—will get vaccinated.
But many groups of people are considered high-priority, and determining their relative priority can get tricky, especially in a pandemic where timing is key. These kinds of decisions can be guided by utilitarianism, Zoloth said, because the goal should be to achieve the greatest good—or avoid as much harm as possible—for the greatest number of people.
According to Zoloth, decision makers need to reduce the risk of illness and death among elderly Americans (80 percent of COVID deaths so far have been in people over 65) and those with comorbidities, while acknowledging our moral duty to take care of those who have kept society running throughout the pandemic. Because essential workers have served others at great risk to themselves, they need to be vaccinated sooner.
Vaccinating essential workers also helps keep other people safe. But Zoloth said utility is not the only relevant measure of justice: Disparities are also an important consideration.
“One of the tragedies of the pandemic has been the way it has revealed stark inequities, including higher death rates for Black and Latinx Americans,” she said. “Even if we can’t remedy decades of oppression, we have a chance to be intentional about equity as we distribute the vaccine.”
While details of vaccine rollouts are still being worked out, Zoloth said transparency will be key to maintaining public trust once that timeline has been determined. She agrees that leaders in high-visibility roles—like Anthony Fauci, the nation’s leading infectious disease expert—can get vaccinated early to build public confidence. But after that, people will need to wait their turn.
“I believe in a fully transparent, rational process, based on science,” she said. “In a moment like this, there can’t appear to be special benefits for people that have wealth or privilege. Anything that makes our society feel more unfair will only worsen the deep division and mistrust that have already been such a problem in this pandemic.”
Getting vaccinated for your neighbor
Even as COVID-19 vaccines begin to roll out, many Americans remain ambivalent about taking them. To break through such skepticism, Zoloth suggests arguing for the use of both vaccines and masks as part of our ethical duty to one another.
“Social solidarity is the most precious tenet of our democracy,” Zoloth said. “It begins with the notion that you should care about others, even strangers. And the idea that you should love your neighbor as profoundly as you love yourself—even placing their concerns and needs ahead of your own—is the great moral lesson and the core of justice in many religions.”
Our individual actions, she added, should affirm this extraordinary moral claim. She believes small sacrifices, like wearing a mask and receiving an immunization, should be easy to justify, especially when those actions protect the individual as well as those around them. That some Americans consider masks or vaccines to be personal impositions reflects a constrained notion of freedom—a word Zoloth believes once held a grander connotation.
“Freedom should not come at the expense of justice,” Zoloth said. “In America, we once had a vision of freedom in which sacrifice was inherent: People sacrificed their very lives for the freedom of others. We’ve let that vision devolve into one of mere personal preference.”
Recalling her experiences as a child before the discovery of the polio vaccine and as a nurse during the AIDS crisis, Zoloth said that Americans should be celebrating the vaccine as a scientific triumph.
“Because I saw it happen with polio in my own lifetime, I know it’s possible for a vaccine to be developed, distributed and accepted by families,” Zoloth said. “Attitudes can change, and suddenly a terrible disease that constrained your life—as polio constrained my own childhood—doesn’t anymore.”
In addition to thanking the researchers who brought the vaccine into existence, we also need to acknowledge the devotion of the health care workers who saved lives before it was available. Their heroic actions should not be taken for granted.
“One of the most ennobling things about this moment in American health care is that doctors, nurses, health care staff and social workers have unflinchingly gone forward and served,” she said. “They’ve acted ethically and courageously at all levels.”
The challenge for ordinary Americans over the next few months will be acknowledging those levels of compassion and duty and reciprocating them. Such actions underscore the relationship between freedom and responsibility.
“We had a Zoom birthday party for my mother recently,” Zoloth said. “She just turned 100. And the other day she said to me on the phone, ‘You know Laurie, I’m not sure it’s fair that I’m about to get the vaccine—there are a lot of old and sick people out there!’”
—Prof. Jacqueline Stewart
