This week we discuss the COVID-19 vaccine rollout with Arthur L. Caplan, PhD, the director of the division of medical ethics at the New York University Grossman School of Medicine. Listen and subscribe on Apple, Stitcher, Spotify, or Google so you don’t miss the next episode. And if you like what you hear, a five-star rating goes a long way in helping us Track the Vax! That was a big ethical question and undertaking. As a medical ethicist, tell us, how are those decisions made? Dr. Arthur Caplan: Well, it’s been complex as to how allocation and rationing have been handled for vaccines. Some guidance has come from top-level organizations like the CDC; there have been states that have, almost uniformly, created advisory panels and tried to come up with criteria. And then we have guidance coming even from international organizations like the World Health Organization [WHO]. The guidance is fairly consistent, but not a hundred percent. Serena Marshall: How do medical ethicists determine who should get the vaccine first? Because without fail, someone’s going to feel left out or discriminated against. Arthur Caplan: Well, let me be clear that in some states, the decisions about how to proceed did not involve medical ethicists or bioethicists. They weren’t on the committees. Their input was not sought. In other states, their input was actively sought. So when it is a situation where the ethicists weigh in, they ask first: What’s the goal? What do you want to achieve with vaccination? Do you want to protect people who are most at risk of getting sick? Or do you want to maintain your workforce in healthcare, or do you have other goals? Keep the economy moving, try and vaccinate people who can do that. And then there are certainly goals that might involve making sure that the people who make vaccines and distribute them are vaccinated. That seems pretty self-evident. You don’t want to have them shutting down. So the major question is, what goal? And we’ve got some consensus, most ethicists would say, [we should] protect those most at risk. And if you agree with that, then you get to nursing home residents and staff, and then you get to healthcare workers with high exposure risk. And then probably if you’re being ethical, you get to prisons and other congregate settings where people can’t be distanced and are on top of one another. I think those jump out, given that goal. Serena Marshall: The two goals of stopping the disease spread versus disease impact and deaths seem not always aligned with each other. Arthur Caplan: I think that’s right. So if you had a group that was really at risk, but living in a setting where they don’t go out much, [let’s say] nursing home residents. They’re not huge risk factors for spread, right? Maybe the staff has to wear protective gear. Maybe they have to keep distance. Serena Marshall: What about when you include the things that we don’t know about the virus, like the long-term impact on those who have been infected, the “long haulers” as they’re called? Do we protect folks with a longer life span, the quality of life for those individuals, versus the elder population, who might have a shorter number of years? Arthur Caplan: I think ethically, most ethicists have argued that even if you’re old — 80, 90 — if you’re at risk of dying, you should still have access to vaccination. You shouldn’t lose those remaining years. Others have pointed out, does that apply to people even in palliative care who are going to die imminently? Do we vaccinate them? Some have argued that at that point in time, days are precious in ways that might not be true for others. So, yes, personally, I find the palliative care argument not that persuasive. I think that is a place where we would forgo, and ought to forgo, vaccination. There’s just not much time left for those people, and others could benefit far more. I think in the nursing home case, you have to do it almost case by case. If someone’s 104, frail, and has six underlying diseases, they may be dying, basically. And that may not make sense. Whereas someone in a nursing home who’s 68 and in relatively good shape may have many years of active life yet. The other tough question is, what if they’re cognitively impaired? What if they’re demented, what if they have Alzheimer’s, Lewy body syndrome? I’ve still argued that we have to treat them fairly. And unless someone is completely comatose and can’t enjoy life in any way, they too should receive vaccination as priority. But others, I think, hesitate and are not as convinced. So that’s been a close call. Serena Marshall: Mandating the COVID-19 vaccine is a perfectly legal route for some businesses, and it’s one schools may take, but is it ethical to require people to get the vaccine? It’s a question, you know — “my body, my choice” — that we’ve heard when it comes to vaccines that are already in the market, like the MMR [measles, mumps, rubella], for example. Arthur Caplan: It’s harder to mandate, I think, something that’s out on an experimental use authorization [EUA], because you are saying it’s important, it looks good, but we’re not definitive. And I think people who didn’t want to get vaccinated, it would be hard to stand up to a legal challenge if they challenge a mandate on using something with an EUA. But once vaccines get licensed, we will see mandates within the next week. [Vaccines for] healthcare workers and nursing home staff absolutely are going to get mandated.
