An Ethical Analysis of Vaccine Rationing

These comments refer to the case study Influenza Vaccine Shortage: The Ethics of Rationing

As an asthmatic university student, Alison brings to light many of the difficulties of distributing influenza vaccines in a shortage. A first-come first-served basis is probably the most straightforward method for vaccine distribution, and at first glance it seems somewhat fair. People who really want the vaccine, like Alison, should be able to make the effort to go to a distribution center, be early in line, and ensure that they receive a vaccine. If some medical necessity considerations are taken into account, such as refusing the vaccine to people who are not in any of the at-risk populations, the first-come first-served approach is a reasonably fair method of distribution.

On the other hand, there are significant problems with this method. It does not take into consideration people like the elderly man's daughter who could not come to the clinic. What if one of her children were severely asthmatic and therefore desperately needed the vaccine, but the child could not get to the clinic because her mother could not get time off from work? In such a situation, it is not a lack of effort or interest on the mother's part that prevents her from getting the vaccine for herself and her children; it is the fault of the system which requires that she be in line at four in the morning to have any hope of receiving the vaccine. This demonstrates a distinct unfairness in a first-come first-served approach. Few alternative approaches are followed, however, due to their impracticality. A clinic would have to reserve its vaccine supply for specific patients if it were not going to employ a first-come first-served approach.

Another stumbling block is the vaccine distribution to the supplying clinics. The clinic that Alison visits is the only one within 50 miles to receive a vaccine supply, so anyone without a car or other mode of transportation is excluded from any possibility of receiving a vaccine. This is a significant problem for many seniors, who are homebound or unable to drive themselves that far. If the clinic were closer, then maybe a family member could drop them off or something else could be arranged; for many people, however, 50 miles eliminates the possibility of getting the vaccine. The first-come first-served approach has a bias to vaccinate people who have flexible jobs that allow them to take time off, who can drive long distances, and get up early to make the trip. In many cases, this will mean it naturally favors the middle and upper classes.

To avoid making this bias worse, people should not be able to buy the vaccine if they are not part of an at-risk population. Indeed, if there is already a shortage, one can argue that justice requires that the limited supply should go to those who need it most. Justice is often defined as a form of fairness, or as Aristotle described it, "giving to each that which is his due." ¹What a person is due can be determined based on need, merit, societal contribution, or many other factors, but in this case it seems clear that the criterion of medical need should be more heavily weighed; it is certainly unfair in a shortage to let a healthy person buy a vaccine when it could mean life or death for someone else.

From a utilitarian perspective, policies should be in place to ensure that the vaccines are going to those who need them most to allow the vaccine to do the most good. According to utilitarian theory, "the morally right action is the action that produces the most good". ² A healthy person is unlikely to die from the flu and therefore does not need the vaccine as much as a senior, an asthmatic, or others who are at-risk of serious complications. It would be an ineffective use of the limited vaccine supply to allow vaccine to be distributed to people not in the at-risk populations.

Similarly, people who cannot pay should still be allowed to get the vaccine if they are at-risk. This goes against the principles of free-market economics, which would let anyone buy a vaccine for a high enough price and refuse to give it away for free. In a free market economy, "both parties undertake the exchange because each expects to gain from it." ³ Since the companies that manufacture the vaccine gain nothing from giving it away and therefore cannot afford to do so, the government should pay for many vaccines. Indeed, it should be the government's moral responsibility to take care of the most basic needs of its people. If the government has failed to ensure that there are an appropriate number of vaccines available, then it should be responsible for ensuring that the limited supply is distributed in the fairest way possible. If the government worked harder to ensure that there was an adequate supply, then there would not be a crisis of distribution to begin with. The government is in a unique position to be able to manage the production and distribution of the vaccines, which no one else can do--so it should be the government's responsibility to ensure it is done right.

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Sarah Ludwig created these case studies on seasonal influenza when she was a senior at Santa Clara University as her Honzel Fellowship project at the Markkula Center for Applied Ethics.