The manner in which limited vaccines are distributed during a pandemic is an ethical issue. The utility principle has been used to argue priority be given to certain individuals based on factors such as the epidemiology of the spread of disease and maintaining the functioning of society. The equity principle has been used to encourage fair practices that account for the economic and social costs of all decisions made. We argue that both principles are met through priority vaccination of homeless (...) individuals, as this strategy protects a medically vulnerable population while reducing the chances of transmission to others as they move through populated urban spaces. We begin by reviewing debates around ethical vaccine distribution. We then argue the homeless are a medically high-risk population who may contribute to the spread of disease through their mobility. As immunization rates are generally lower among the homeless and many do not access mainstream health care, we argue that community vaccine clinics must be used to reach these individuals. We provide support by analyzing Toronto Public Health’s operation of vaccine clinics in shelters and drop-in centres during pH1N1 and conclude that this strategy is effective for immunizing homeless individuals, bringing together the equity and utility principles. (shrink)

While COVID-19 vaccines provide light at the end of the tunnel in a difficult time, they also bring forth the complex ethical issue of global vaccine distribution. The current unequal global distribution of vaccines is unjust towards the vulnerable living in low-income countries. A vaccine tax should be introduced to remedy this. Under such a scheme, a small fraction of the money spent by a country on vaccines for its own population would go into a fund, (...) such as COVAX, dedicated to buying vaccines and distributing them to the world’s poorest. A vaccine tax would provide a much-needed injection of funds to remedy the unequal distribution of vaccines. The tax allows for a distribution that, to a lesser degree, reflects the ability to pay and is superior to a donation-based model because it minimises the opportunity for free-riding. (shrink)

Applying the Roman Catholic Church's set of moral principles on social concerns called Catholic social teaching (CST) on charity, distributive justice, private property and the common good, and utilising some secondary data and scientific literature, this article argues that establishing distributive justice for the global distribution of the COVID-19 vaccines must be a priority than donating millions of doses in the name of charity to address vaccine scarcity. Catholic social teaching teaches that the right to private property is (...) a basic right but has moral limits and is subordinated to the moral principles on the universal destination of earth's goods and the common good. CONTRIBUTION: The current COVID-19 vaccines are developed by people and organisations outside the pharmaceutical companies and largely funded using taxpayers' money. Thus, by virtue of justice, these vaccines must belong to all nations as global public health goods. Patents are to be suspended to allow poor countries to reproduce the popular vaccines and address the current vaccine shortage. (shrink)

This paper addresses the just distribution of vaccines against the SARS-CoV-2 virus and sets forth an ethical framework that prioritises frontline and essential workers, people at high risk of severe disease or death, and people at high risk of infection. Section I makes the case that vaccine distribution should occur at a global level in order to accelerate development and fair, efficient vaccine allocation. Section II puts forth ethical values to guide vaccine distribution including (...) helping people with the greatest need, reducing health disparity, saving the most lives and promoting narrow social utility. It also responds to objections which claim that earlier years have more value than later years. Section III puts forth a practical ethical framework to aid decision-makers and compares it with alternatives. (shrink)

In this article, we aim to map out the complexities which characterise debates about the ethics of vaccine distribution, particularly those surrounding the distribution of the COVID-19 vaccine. In doing so, we distinguish three general principles which might be used to distribute goods and two ambiguities in how one might wish to spell them out. We then argue that we can understand actual debates around the COVID-19 vaccine – including those over prioritising vaccinating the most (...) vulnerable – as reflecting disagreements over these principles. Finally, we shift our attention away from traditional discussions of distributive justice, highlighting the importance of concerns about risk imposition, special duties, and social roles in explaining debates over the COVID-19 vaccine. We conclude that the normative complexity this article highlights deepens the need for decision-making bodies to be sensitive to public input. (shrink)

In the context of the global COVID-19 pandemic, the fast and equitable distribution of effective vaccines worldwide is one of the challenges faced by international institutions in charge, as global equity in vaccine supply has not yet been achieved. Our paper explains the current state of ethical research on equity in global COVID-19 vaccine allocation, focusing on the COVAX Facility established by the WHO, acting as the global vaccine distributor. The article presents a detailed analysis of (...) the first year of COVAX allocation in 2021 identifying problematic aspects of its allocation framework regarding the implementation of COVAX’s fundamental allocation principles. We argue that the COVAX Facility has developed a proper concept to deal with global vaccine allocation—but to address uncovered defaults, we introduce the ‘Prioritized Distribution of Equal Shares’ model—a both ethical and practically feasible alternative allocation framework to protect the value of human lives in both high- and low-income countries through fair and fast global vaccine distribution in health emergencies. Nonetheless, we argue that the COVAX Facility remains the main organization to provide equitable access to vaccines. Yet, the global community has to consider further aspects such as patent protection, vaccine production and the lack of power of global structures to address the inequities that have arisen. Since new wars and further crises have arisen, a shift in public global attention endangers the processing of COVID-19-related issues. That is why now more than ever extensive efforts to achieve vaccine equity are needed. (shrink)

The COVID-19 (SARS-CoV-2) pandemic dealt a severe blow to society as a whole and required countries to confront a situation that exceeded the limits of their borders. In this paper, we analyze how these countries as well as supranational organizations responded to this unprepared global emergency. We also explore what alternative models have been proposed in the wake of this crisis and propose some changes—other ways of acting—so that in future pandemics or global emergencies, we can deal with the situation (...) more effectively. (shrink)

In a recent paper, Hugh McLachlan argues from a deontological perspective that the most ethical means of distributing scarce supplies of an effective vaccine in the context of an influenza pandemic would be via an equal lottery. I argue that, even if one accepts McLachlan's ethical theory, it does not follow that one should accept the vaccine lottery. McLachlan's argument relies upon two suppressed premises which, I maintain, one need not accept; and it misconstrues vaccination programmes as clinical (...) interventions targeted solely at protecting the health of vaccinated individuals, rather than as public health interventions targeted at protecting the health of the population as a whole. (shrink)

Wardrope argues against my proposed non-consequentialist policy for the distribution of scarce influenza vaccine in the face of a pandemic. According to him, even if one accepts what he calls my deontological ethical theory, it does not follow that we are required to agree with my proposed randomised allocation of doses of vaccine by means of a lottery. He argues in particular that I fail to consider fully the prophylactic role of vaccination whereby it serves to protect (...) from infection more people than are vaccinated. He concludes that: ‘The benefits and burdens of vaccination are provided impartially and far more effectively by targeted vaccination than impartial lotteries.’ He has shown convincingly that this conclusion can be established in the case of his particular envisaged scenario. However, Wardrope gives no reason to suppose that, in the circumstances that we actually face, targeted vaccination would constitute impartial treatment of citizens in the UK. I readily agree with Wardrope that if it should treat its citizens justly and impartially, it does not necessarily follow that the state should distribute vaccinations of the basis of a lottery. That will be a reasonable thing to do only if certain assumptions are made. These assumptions will not always be reasonable. However, they are reasonable ones to make in the actual circumstances that currently apply. (shrink)

The complexity and inefficiency of the U.S. health care system complicates the distribution of life-saving medical technologies. When the public health is at stake, however, there are alternatives. The proposal for a national PrEP program published in this issue of the Journal applies some of the lessons of the national COVID vaccine campaign to HIV prevention. In doing so, it draws on other examples of public health approaches to the financing of medical technology, from vaccines for children to (...) hepatitis C treatment. (shrink)

Accelerated COVID-19 vaccine development represents an important accomplishment and a milestone in the history of vaccine evolution. However, the vaccine’s scarcity made its equitable global allocation and distribution ambiguous. Despite the initial pledges from wealthy countries for fairness and inclusivity towards the poorer ones, the policies followed diverged significantly. Wealthy countries have vastly superior access to vaccines in a reality likened to an ethical disaster. This paper calls for the need for fair global vaccine allocation (...) and distribution and examines the barriers that were met along the way, originating from different points, such as the nationalistic approach on the matter that most wealthy countries have adopted or the inability of poor countries to purchase or manufacture vaccines. Further, a suggestion regarding the ethical principles and values that ought to guide global vaccine allocation and distribution is provided with a higher priority given to helping the worst-off, saving the most lives, protecting people in high risk, such as frontline healthcare professionals, and minimising social gaps, along with an ethical theoretical background for each prioritisation. It is not too late for wealthy countries to realise that vaccine inequity prolongs pandemics, so that they change their policies in favour of the global common good that will not only provide immediate universal benefits but will also serve as a guide for future pandemic crises. (shrink)

The implementation of COVID-19 vaccine certificates or passports entails many difficult issues, both technical and ethical. Looking at the ethical issues from a decolonial approach to justice, it i...

The current UK policy for the distribution of scarce vaccination in an influenza pandemic is ethically dubious. It is based on the planned outcome of the maximum health benefit in terms of the saving of lives and the reduction of illness. To that end, the population is classified in terms of particular priority groups. An alternative policy with a non-consequentialist rationale is proposed in the present work. The state should give the vaccination, in the first instance, to those who (...) are at risk of catching the pandemic flu in the line of their duties of public employment. Thereafter, if there is not sufficient vaccine to give all citizens equally an effective dose, the state should give all citizens an equal chance of receiving an effective dose. This would be the just thing to do because the state has a duty to treat each and all of its citizens impartially and they have a corresponding right to such impartial treatment. Although this article specifically refers to the UK, it is considered that the suggested alternative policy would be applicable generally. The duty to act justly is not merely a local one. (shrink)

Effective vaccines for COVID‐19 are already available to humankind. In Peru, 86 million doses were administered to cover the demand for 33 million Peruvian people. Hence, vaccination has been prioritized in groups: health personnel, subjects with pre‐existing health conditions and those over 65 years of age. However, given the social problems and the public health situation in Peru, this work defends that the priority of vaccination should be focused on the population living in extreme poverty. The method used was an (...) ethical argumentation on the distribution of scarce antiSARS‐CoV2 vaccine in Peru. This argument is based on the analysis of the Peruvian population living in extreme poverty, which presents different layers of vulnerability, and that, in the face of an eventual SARS‐CoV2 infection, these would be exacerbated one after the other, through a cascade effect. This scenario would give rise to new vulnerabilities to those already existing, causing greater damage. Vaccination efforts on this key population would give them the opportunity to continue to find ways to bring food to their homes, significantly reducing the risk of contagion in their environment and mitigating the devastating effect of the local diseases to which they are already exposed. Four objections related to this argument are raised with their corresponding responses. Priority access to the vaccine would significantly reduce the humanitarian harm to people living in extreme poverty, prevailing the principles of justice and equity. (shrink)

In 2020, the world faced a new pandemic. The corona infection hit an unprepared world, and there were no medicines and no vaccines against it. Research to develop vaccines started immediately and in a remarkably short time several vaccines became available. However, despite initiatives for global equitable access to COVID-19 vaccines, vaccines have so far become accessible only to a minor part of the world population. In this article, I discuss the global distribution of COVID-19 vaccines from an ethical (...) point of view. I reflect on what ethical principles should guide the global distribution of vaccines and what global justice and international solidarity imply for vaccine distribution and I analyse the reasons for states to prioritize their own citizens. My focus is on ethical reasons for and against ‘vaccine nationalism’ and ‘vaccine cosmopolitanism.’ My point of departure is the appeal for international solidarity from several world leaders, arguing that ‘Where you live should not determine whether you live’. I discuss the COVAX initiative to enable a global vaccination and the proposal from India and South Africa to the World Trade Organization to temporarily waive patent rights for vaccines. In the final section, I argue for global vaccine sufficientarianism, which is a modified version of vaccine cosmopolitanism. (shrink)

Inequity has been a hallmark of the COVID-19 pandemic in the United States, especially in the sharply disproportionate impacts among people of color. Recent studies have confirmed that t...

While rich countries like the USA and UK are starting to vaccinate their populations against COVID-19, poor countries may lack access to a vaccine for years. A global effort to provide vaccines through the COVAX facility Accelerator) aims to distribute 2 billion vaccinations by the end of next year, but the USA has refused to join and even those rich countries that have joined are entering into bilateral deals with pharmaceutical companies to buy up the supply. Canada, for instance, (...) has already secured enough to vaccinate its entire population nine times over, and the USA, European Union, UK, Australia and Japan can vaccinate their populations between 2 and 8 x.1 Vaccine nationalism is neither ethically justified, nor even in rich countries’ long-term self-interest. No one deserves the luck of their birth and few have much control over their country of residence. So, when there are four ventilators per 12 million people in some low-income and middle-income countries, and people are being buried in cardboard boxes in mass graves, it is simply unconscionable to argue that wealthy countries can keep their vaccines to themselves or even help their populations first.2 Vaccine nationalism fails to respect basic human rights and the people who have them. Moreover, many argue that rich countries have contributed to global poverty through a shared and violent history of colonialism and oppression and profit from instituting, upholding and sustaining coercive rules that often exacerbate, rather than alleviate, global poverty.3 Be that as it may, putting basic health systems in place to ensure everyone can get vaccinated, not only against COVID-19 but a host of other terrible diseases, would better protect even the rich from …. (shrink)

Many have argued that human enhancement, in particular bioenhancement via genetic engineering, brain-interventions or preimplantation embryo selection, is problematic even if it can be safely implemented. Various arguments have been put forward focusing on issues such as the undermining of autonomy, uneven distribution and unfairness, and the alteration of one’s identity, amongst others. Nevertheless, few, if any, of these thinkers oppose vaccines. -/- In what follows, I argue for the permissibility of a limited set of cognitive enhancements – in (...) particular, the enhancement of evaluative judgment and self-control – by analogy with the permissibility of vaccines. As a result, it follows that if one accepts the permissibility of vaccines one will also, other things being equal, be committed to the permissibility of these enhancements. I then consider and respond to a number of possible objections in order to defend and clarify my position. (shrink)

The development of some COVID-19 vaccines by private companies like Moderna and Sanofi-GSK has been substantially funded by various governments. While the Sanofi CEO has previously suggested that countries that fund this development ought to be given some priority, this suggestion has not been taken seriously in the literature. Considerations of nationalism, sustainability, need, and equitability have been more extensively discussed with respect to whether and how much a country is entitled to advance purchase orders of the vaccine under (...) conditions of absolute scarcity. Yet, little attention has been paid to whether prior investment into developing a vaccine entitles a country to some priority with respect to these orders. Moreover, while not a majority view, some survey results show that a significant minority of the populace does endorse some view like this. This article argues that the minority have a point: recognizing funder countries some priority is justified by the weak Lockean claim (WLC). According to the WLC, the fact that someone has contributed to the development of something gives them some entitlement to the resultant product. This article will defend the WLC, and address objections to the argument, including those pertaining to questions of historical injustice and medical need. This argument does not imply an unconstrained entitlement. Rather, contribution to development is one morally relevant factor that must be tempered by and weighed against potentially more substantial claims to priority based on need, equity, and other considerations. (shrink)

The development of some COVID-19 vaccines by private companies like Moderna and Sanofi-GSK has been substantially funded by various governments. While the Sanofi CEO has previously suggested that countries that fund this development ought to be given some priority, this suggestion has not been taken seriously in the literature. Considerations of nationalism, sustainability, need, and equitability have been more extensively discussed with respect to whether and how much a country is entitled to advance purchase orders of the vaccine under (...) conditions of absolute scarcity. Yet, little attention has been paid to whether prior investment into developing a vaccine entitles a country to some priority with respect to these orders. Moreover, while not a majority view, some survey results show that a significant minority of the populace does endorse some view like this. This article argues that the minority have a point: recognizing funder countries some priority is justified by the weak Lockean claim (WLC). According to the WLC, the fact that someone has contributed to the development of something gives them some entitlement to the resultant product. This article will defend the WLC, and address objections to the argument, including those pertaining to questions of historical injustice and medical need. This argument does not imply an unconstrained entitlement. Rather, contribution to development is one morally relevant factor that must be tempered by and weighed against potentially more substantial claims to priority based on need, equity, and other considerations. (shrink)

ABSTRACT This paper seeks to critically review a traditional objection to preventive medicine (which I call here the ‘prevention problem’). The prevention problem is a concern about the supposedly inequitable distribution of benefits and risks of harm resulting from preventive medicine's focus on population‐based interventions. This objection is potentially applicable to preventive vaccination programmes and could be used to argue that such programmes are unethical. I explore the structure of the prevention problem by focusing upon two different types of (...) vaccination (therapeutic vaccination and preventive vaccination). I argue that the ‘prevention problem’ cannot be fairly applied to the case of preventive vaccination because such programmes do not just focus upon benefits at the level of populations (as is claimed by the prevention problem). Most such preventive vaccination programmes explicitly seek to create and maintain herd protection. I argue that herd protection is an important public good which is a benefit shared by all individuals in the relevant population. This fact can then be used to block the ‘prevention problem’ argument in relation to preventive vaccination programmes. I conclude by suggesting that whilst the future development and use of therapeutic vaccines does raise some interesting ethical issues, any ethical objections to prophylactic vaccination on the basis of the ‘prevention problem’ will not be overcome through the substitution of therapeutic vaccines for preventive vaccines; indeed, the ‘prevention problem’ fails on its own terms in relation to preventive vaccination programmes. (shrink)

While the unprecedented lockdown measures were at the heart of the debate in the first year of the pandemic, the focus since then has shifted to vaccination issues. The reason, of course, is that vaccines and vaccinations have become available by now. All experts agree: If mankind had failed to develop vaccines against SARS-CoV-2, the death toll would have been much higher. This issue seeks to explore what could be described as a “generational approach to vaccinations”. The question “What can (...) we do to avoid future pandemics?” is related to different aspects of the failures and successes of humanity’s vaccination strategy against SARS-CoV-2. Pathogens are among the existential risks to humanity that could potentially kill a large part of it in a very short time. For all the tragedy and horror it has brought upon the world, the Corona virus has not been lethal on such a large, all-encompassing scale. But it could serve as a wake-up call for more and better prevention in the future, put differently: as a call to build a “preventive society”. When people look back to the year 2022 from the year 2200, will they think of the absence of mandatory vaccination as a dangerous anachronism? And will the unequal global distribution of vaccines be seen as an unbearable vice of our epoch? And will “human infection studies” still be dismissed as unethical if a dangerous new virus boards human bodies? If intergenerational justice means improving the life chances and living conditions of future generations to the largest possible extent, then its link to (the avoidance) of infectious diseases is obvious. We should protect future generations from foreseeable damage if we have the power to do so. “We” is humankind in its entirety. Politically, humanity is divided into many single nations. But biologically, as members of the same species, we share the same vulnerability regardless of ethnicity. The regular reader of this journal might wonder why this issue of IGJR has a different structure. An unprecedented pandemic calls for an unprecedented reaction and therefore IGJR 1/2021 and 2/2021 are special issues that deal with this disruptive event. We have invited several health experts, politicians and scholars alike to share their perspectives in short opinion pieces (instead of regular peer-reviewed articles). And we are exploring something new: the publication of a FRFG policy paper. This policy paper starts off with a historical overview on how pandemics have afflicted humanity in the past. It separates moral from legal duties and formulates “epidemiological imperatives” – the way of thinking of a responsible and solidary individual facing the task of preventing an outbreak of epidemics in a community. With the discovery of vaccines, and their availability, the catalogue of duties is increased by one more: to get the jabs as an act of solidarity with others, including future generations. This would prevent states from being forced to take disease control measures that bring about drastic collateral damage. During the first two years of the Corona pandemic, states have imposed lockdowns. The closure of schools has put a special burden on the youngest members of society. This could have been prevented during the second and the further waves. The policy paper also calls for more government funding for prophylactic vaccine research and for the designation of vaccines as “global public goods”. The issue then moves on to a section dedicated to opinion papers by various different authors. The first paper, written by Agnes Binagwaho and Kedest Mathewos (both from University of Global Health Equity, Rwanda), focuses on the issue of health inequity, a concern which has gained more and more traction during the Covid-19 pandemic. The paper examines how vaccine distribution during the pandemic was mainly focused on the global north and how such actions might affect future generations’ perception of what is just, fair and morally correct. The second paper, by Samantha Vanderslott (University of Oxford), focuses on the right and wrongdoings connected to pandemic preparedness and response. The third paper, authored by Rajeev Sadanandan (Health Systems Transformation Platform, India), talks about the lessons that can and should be drawn from child immunisations. The fourth paper, by Adriano Mannino (LMU and Parmenides Foundation, Munich), delves into the question how future generations will assess our actions and our response to the current pandemic. The fifth and final paper, written by Jörg Tremmel (FRFG and University Tübingen), is centered around the question whether human infection studies could have been implemented during the early stages of the pandemic to minimise deaths and severe infections. The issue concludes with two reviews on recent books by Alberto Giubilini and Katie Wright. In his review of Giubilini’s The Ethics of Vaccination, Marius Kunte notes that it contains a “thought-provoking plea” for individual, collective and institutional obligations to reach high vaccination rates. Judith Kausch-Zongo concludes her review of Wright’s Gender, Migration and the Intergenerational Transfer of Human Wellbeing with a special emphasis on the book’s empirical findings, and praises it in its entirety as “undoubtedly important”. Both books serve as poignant reminders of how sustainable societies can only emerge once the challenges revolving around its most vulnerable members have been properly addressed. (shrink)

Vaccine apartheid is creating conditions that make for premature death, poverty, and disease in racialized ways. Invoking vaccine apartheid as opposed to euphemisms like vaccine nationalism, is necessary to highlight the racialized distributional consequences of vaccine inequities witnessed with COVID-19. This commentary clarifies the concept of vaccine apartheid against the historical and legal usage of apartheid. It reflects on the connections and important disjunctions between the two. It places the intellectual property regime under heightened scrutiny (...) for reform and transformation. This commentary finds that drawing on the intersections between a human rights and health justice approach can provide creative and novel approaches for anti-subordination. It concludes that acknowledging and naming the structural injustice of vaccine apartheid is only the first step towards providing redress. (shrink)

BackgroundFor over 35 years, Africa has continued to host HIV vaccine trials geared towards overturning the HIV/aids pandemic in the continent. However, the methods of sharing the vaccines, when available remain less certain. Therefore, the study aims to explore stakeholders’ perspectives in the global South, in this case, Tanzania, on how HIV vaccines ought to be fairly shared.MethodsThe study deployed a qualitative case study design. Data were collected through in-depth interviews and focus group discussions with a total of 37 (...) purposively selected participants. This included researchers, institutional review board members, a policymaker, HIV/aids advocates, and community advisory board members. The data obtained were inductively and deductively analyzed.Results Findings indicate that HIV vaccines can be shared fairly under the principles of distributive justice (contribution, need and equality). Thus, contribution-based sharing ought to be utilized upon the necessity to prioritize vaccine access or subsidized trial benefits to host communities. Need-based sharing ought to be considered for non-host communities that are at an increased risk of HIV infection. Lastly, equal-based sharing would be useful at later stages of vaccine distribution or when the aforementioned principles are deemed morally inappropriate. However, none of the benefit-sharing approaches is free of limitations and a counterbalancing sense of unfairness.ConclusionFair sharing of HIV vaccines, when available, ought to be informed by the contribution, need and equality principles of distributive justice. Countries in the global south including Tanzania are likely to be prioritized during the distribution of the HIV vaccines due to their participation in HIV vaccine trials and due to the disproportionate HIV burden evident in the region. (shrink)

India, despite being the world's largest vaccine manufacturer is now struggling with various unprecedented social, legal, moral issues with the ongoing Covid-19 vaccination program for 1.3 billion people, the largest democracy in the world. With three major vaccines including Covishield, homemade vaccine Covaxin, and Russia's Sputnik V, India is still facing acute scarcity of vaccines and raw material supply. This is not only unfortunate but also reveals the ethically-triggered facts about the imbalanced healthcare system between public and private (...) sectors, ineffective inequitable healthcare policies, unaccountable data reports that raise mistrust and confusion, and a deeper concern about global unfair distribution. In this paper, I have briefly discussed some unparalleled ethical issues raised from the vaccination program of India. (shrink)

In this article, we propose the Fair Priority Model for COVID-19 vaccine distribution, and emphasize three fundamental values we believe should be considered when distributing a COVID-19 vaccine among countries: Benefiting people and limiting harm, prioritizing the disadvantaged, and equal moral concern for all individuals. The Priority Model addresses these values by focusing on mitigating three types of harms caused by COVID-19: death and permanent organ damage, indirect health consequences, such as health care system strain and stress, (...) as well as economic destruction. It proposes proceeding in three phases: the first addresses premature death, the second long-term health issues and economic harms, and the third aims to contain viral transmission fully and restore pre-pandemic activity. -/- To those who may deem an ethical framework irrelevant because of the belief that many countries will pursue "vaccine nationalism," we argue such a framework still has broad relevance. Reasonable national partiality would permit countries to focus on vaccine distribution within their borders up until the rate of transmission is below 1, at which point there would not be sufficient vaccine-preventable harm to justify retaining a vaccine. When a government reaches the limit of national partiality, it should release vaccines for other countries. -/- We also argue against two other recent proposals. Distributing a vaccine proportional to a country's population mistakenly assumes that equality requires treating differently situated countries identically. Prioritizing countries according to the number of front-line health care workers, the proportion of the population over 65, and the number of people with comorbidities within each country may exacerbate disadvantage and end up giving the vaccine in large part to wealthy nations. (shrink)

This paper considers the forms of vaccine nationalism specific to responses to SARS-CoV-2. First, it considers the initial vaccine responses to SARS-CoV-2 and how the competition unfolded in a broader, global sense. The second part considers the way the European Union adopted its own type of nationalism, despite claiming to distinguish itself as more humanitarian and equitable in approaching COVID-19 vaccine production, supply, and distribution. The creation of the export control mechanism, and the threat of its (...) use, was itself an expression of Euro-nationalism in action. The need to do so was largely a product of the EU’s own making, given its own contractual relationships with the pharmaceutical companies. Finally, this paper contends that the advocacy for vaccine passports, championed by the EU, served to cause parochial ruptures in the bloc for commercial reasons. (shrink)

In June 2020, Gilead agreed to provide the USA with 500 000 doses of remdesivir—an antiviral drug which at that time was percieved to show promise in reducing the recovery time for patients with COVID-19. This quantity represented Gilead’s then full production capacity for July and 90% of its capacity for August and September. Similar deals are evident around access to proposed vaccines for COVID-19, and such deals are only likely to increase. These attempts to secure preferential access to medicines (...) and vaccines, so-called vaccine/treatment nationalism, jeopardise supplies of life-saving treatments and vaccines available elsewhere, and jeopardise global equitable distribution of such vaccines/treatments more generally. Much of the focus to date has been on States’ role in negotiating such deals. However, such developments also demonstrate the power patent holders have in controlling access to life-saving healthcare, determining who obtains access first and at what price. This article argues that the extent of control currently given to patent holders for COVID-19 must be questioned. This article demonstrates that patents have significant implications for healthcare acting as private governance tools over patented inventions. It is only by greater probing of patent holders’ role in delivering access to medicines, diagnostics and vaccines for COVID-19 that equitable global equitable access can be achieved. (shrink)

Although a safe, effective, and licensed coronavirus vaccine does not yet exist, there is already controversy over how it ought to be allocated. Justice is clearly at stake, but it is unclear what justice requires in the international distribution of a scarce vaccine during a pandemic. Many are condemning ‘vaccine nationalism’ as an obstacle to equitable global distribution. We argue that limited national partiality in allocating vaccines will be a component of justice rather than an (...) obstacle to it. For there are role-based and community-embedded responsibilities to take care of one’s own, which constitute legitimate moral reasons for some identity-related prioritisation. Furthermore, a good form of vaccine nationalism prioritises one’s own without denying or ignoring duties derived from a principle of equal worth, according to which all persons, regardless of citizenship or identity, equally deserve vaccine-induced protection from COVID-19. Rather than dismissing nationalism as a tragic obstacle, it is necessary to acknowledge that a limited form of it is valuable and expresses moral commitments. Only then can one understand our world of competing obligations, a world where cosmopolitan duties of benevolence sometimes conflict with special obligations of community membership. Once these competing obligations are recognised as such, we can begin the work of designing sound ethical frameworks for achieving justice in the global distribution of a coronavirus vaccine and developing practical strategies for avoiding, mitigating or resolving conflicts of duty. (shrink)

This paper questions an exclusively state-centred framing of global health justice and proposes a multilateral alternative. Using the distribution of COVID-19 vaccines to illustrate, we bring to light a broad range of global actors up and down the chain of vaccine development who contribute to global vaccine inequities. Section 1 (Background) presents an overview of moments in which diverse global actors, each with their own priorities and aims, shaped subsequent vaccine distribution. Section 2 (Collective action (...) failures) characterises collective action failures at each phase of vaccine development that contributed to global vaccine disparities. It identifies as critical the task of establishing upstream strategies to coordinate collective action at multiple stages across a range of actors. Section 3 (A Multilateral model of global health governance) takes up this task, identifying a convergence of interests among a range of stakeholders and proposing ways to realise them. Appealing to a responsibility to protect (R2P), a doctrine developed in response to human rights atrocities during the 1990s, we show how to operationalise R2P through a principle of subsidiarity and present ethical arguments in support of this approach. (shrink)

The rapid development of vaccines against COVID‐19 represents a huge achievement, and offers hope of ending the global pandemic. At least three COVID‐19 vaccines have been approved or are about to be approved for distribution in many countries. However, with very limited initial availability, only a minority of the population will be able to receive vaccines this winter. Urgent decisions will have to be made about who should receive priority for access. Current policy in the UK appears to take (...) the view that those who are most vulnerable to COVID‐19 should get the vaccine first. While this is intuitively attractive, we argue that there are other possible values and criteria that need to be considered. These include both intrinsic and instrumental values. The former are numbers of lives saved, years of life saved, quality of the lives saved, quality‐adjusted life‐years (QALYs), and possibly others including age. Instrumental values include protecting healthcare systems and other broader societal interests, which might require prioritizing key worker status and having dependants. The challenge from an ethical point of view is to strike the right balance among these values. It also depends on effectiveness of different vaccines on different population groups and on modelling around cost‐effectiveness of different strategies. It is a mistake to simply assume that prioritizing the most vulnerable is the best strategy. Although that could end up being the best approach, whether it is or not requires careful ethical and empirical analysis. (shrink)

Initial vaccine allocations for the coronavirus disease 2019 (COVID-19) will be limited. It is crucial to assess the ethical values associated with different methods of allocation, as well as important scientific and practical questions. This Viewpoint identifies three ethical values, benefiting people and limiting harm; prioritizing disadvantaged populations; and equal concern for all. It then explains why these values support prioritizing three groups: health care workers; other essential workers and people in high-transmission settings; and people with medical vulnerabilities associated (...) with poorer COVID-19 outcomes. In contrast, two other groups, people over 65 without medical vulnerabilities and participants in clinical research, present more complex ethical questions. This prioritization also encompasses valuing direct benefits to vaccinated individuals, indirect benefits to individuals protected from spread of infection, and indirect health and socioeconomic benefits to those protected from harm as health system and societal functioning improve. Vaccine allocation that recognizes important ethical values and avoids arbitrariness, waste, and corruption can ensure that the distribution of a COVID-19 vaccine is both fair and perceived as fair. (shrink)

This article sets forth a solidaristic approach to global distribution of vaccines against the SARS‐CoV‐2 virus. Our approach draws inspiration from African ethics and from the characterization of the Covid‐19 crisis as a syndemic, a convergence of biosocial forces that interact with one another to produce and exacerbate clinical disease and prognosis. The first section elaborates the twin ideas of syndemic and solidarity. The second section argues that these ideas lend support to global health alliances to distribute vaccines beyond (...) national borders. The third section introduces ethical criteria to guide global distribution, emphasizing priority to low‐ and middle‐income countries, which have the least ability to obtain vaccines on their own. It also justifies giving priority to people at high risk of infection and high risk of severe disease and death. (shrink)

For much of 2021, allocating the scarce supply of Covid‐19 vaccines was the world's most pressing bioethical challenge, and similar challenges may recur for novel therapies and future vaccines. In the United States, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) identified three fundamental ethical principles to guide the process: maximize benefits, promote justice, and mitigate health inequities. We argue that critical components of the recommended protocol were internally inconsistent with these principles. Specifically, the ACIP (...) violated its principles by recommending overly broad health care worker priority in phase 1a, using being at least seventy‐five years of age as the only criterion to identify individuals at high risk of death from Covid‐19 during phase 1b, failing to recommend place‐based vaccine distribution, and implicitly endorsing first‐come, first‐served allocation. More rigorous empirical work and the development of a complete ethical framework that recognizes trade‐offs between principles may have prevented these mistakes and saved lives. (shrink)

There are three broad ethical issues related to handling public health emergencies. They are the three R's - rationing, restrictions and responsibilities. Recently, a severe shortage of annual influenza vaccine in the US, combined with the threat of pandemic flu, has provided an opportunity for policy makers to think about rationing in very concrete terms. Some lessons from annual flu vaccination likely will apply to pandemic vaccine distribution, but many preparatory decisions must be based on very rough (...) estimates. What ethical principles should guide rationing decisions, what data should inform these decisions, how to revise decisions as new data emerge, and how to implement rationing decisions on the ground are all important considerations. In addition, ethicists might be able to help policy makers think through the importance of international cooperation in surmounting global rationing dilemmas and to accept the inevitable responsibilities of government in making and implementing rationing decisions. (shrink)

The urgent drive for vaccine development in the midst of the current COVID-19 pandemic has prompted public and private organisations to invest heavily in research and development of a COVID-19 vaccine. Organisations globally have affirmed the commitment of fair global access, but the means by which a successful vaccine can be mass produced and equitably distributed remains notably unanswered. Barriers for low-income countries include the inability to afford vaccines as well as inadequate resources to vaccinate, barriers that (...) are exacerbated during a pandemic. Fair distribution of a pandemic vaccine is unlikely without a solid ethical framework for allocation. This piece analyses four allocation paradigms: ability to develop or purchase; reciprocity; ability to implement; and distributive justice, and synthesises their ethical considerations to develop an allocation model to fit the COVID-19 pandemic. (shrink)

Equal access to vaccines has been one of the key ethical challenges during the COVID-19 pandemic. Most scholars consider the massive purchase and hoarding of vaccines by high-income countries, especially at the beginning of the pandemic, to be unjust towards the vulnerable living in low-income countries. A recent proposal by Andreas Albertsen of a vaccine tax has been put forward to remedy this problem. Under such a scheme, high-income countries would pay a contribution, conceptualised as a vaccine tax, (...) dedicated to buying vaccines and distributing them to low and middle-income countries. Proceeding from this proposal, we critically assess the feasibility of a vaccine tax and suggest how to conceptualise and implement a vaccine tax in practice. We present our ‘VaxTax model’ and explore its comparative advantages and disadvantages while considering other possible measures to address the global vaccine access problem, also in view of future pandemics and disease outbreaks. (shrink)

With evidence of vaccine hesitancy in several jurisdictions, the option of making COVID-19 vaccination mandatory requires consideration. In this paper I argue that it would be ethical to make the COVID-19 vaccination mandatory for older people who are at highest risk of severe disease, but if this were to occur, and while there is limited knowledge of the disease and vaccines, there are not likely to be sufficient grounds to mandate vaccination for those at lower risk. Mandating vaccination for (...) those at high risk of severe disease is justified on the basis of the harm principle, as there is evidence that this would remove the grave public health threat of COVID-19. The risk–benefit profile of vaccination is also more clearly in the interests of those at highest risk, so mandatory vaccination entails a less severe cost to them. Therefore, a selective mandate would create fairness in the distribution of risks. The level of coercion imposed by a mandate would need to be proportionate, and it is likely that multiple approaches will be needed to increase vaccine uptake. However, a selective mandate for COVID-19 vaccines is likely to be an ethical choice and should be considered by policy-makers. (shrink)

The aim of this paper is to introduce the one hundred years of vaccination that has passed since Louis Pasteur first coined this generic term. According to the late Jonas Salk, vaccinology is a science encompassing all aspects of vaccine from its conception in the laboratory to its production by companies and its application and distribution in the field. In this historical survey I explore how vaccination never consisted of a simple and uniform application of a rational model, (...) but rather diverged along various pathways, several of which were discarded in retrospect as being hazardous, and I analyse the ongoing interplay between rational and inventive thinking. (shrink)

BackgroundViral pandemics present a range of ethical challenges for policy makers, not the least among which are difficult decisions about how to allocate scarce healthcare resources. One important question is whether healthcare workers should receive priority access to a vaccine in the event that an effective vaccine becomes available. This question is especially relevant in the coronavirus pandemic with governments and health authorities currently facing questions of distribution of COVID-19 vaccines.Main textIn this article, we critically evaluate the (...) most common ethical arguments for granting healthcare workers priority access to a vaccine. We review the existing literature on this topic, and analyse both deontological and utilitarian arguments in favour of HCW prioritisation. For illustrative purposes, we focus in particular on the distribution of a COVID-19 vaccine. We also explore some practical complexities attendant on arguments in favour of HCW prioritisation.ConclusionsWe argue that there are deontological and utilitarian cases for prioritising HCWs. Indeed, the widely held view that we should prioritise HCWs represents an example of ethical convergence. Complexities arise, however, when considering who should be included in the category of HCW, and who else should receive priority in addition to HCWs. (shrink)

Introduction: There is currently no binding, internationally accepted and successful approach to ensure global equitable access to healthcare during a pandemic. The aim of this ethical analysis is to bring into the discussion a legally regulated vaccine allocation as a possible strategy for equitable global access to vaccines. We focus our analysis on COVAX (COVID-19 Vaccines Global Access) and an existing EU regulation that, after adjustment, could promote global vaccine allocation. -/- Methods: The main documents discussing the two (...) strategies are examined with a qualitative content analysis. The ethical values reasonableness, openness and transparency, inclusiveness, responsiveness and accountability serve as categories for our ethical analysis. -/- Results: We observed that the decision-making processes in a legal solution to expand access to vaccines would be more transparent than in COVAX initiative, would be more inclusive, especially of nation states, and the values responsiveness and accountability could be easily incorporated in the development of a new regulation. -/- Discussion: A legal strategy that offers incentives to the pharmaceutical industry in return for global distribution of vaccines according to the Fair Priority Model is an innovative way to achieve global and equitable access to vaccines. However, in the long term, achieving the Sustainable Development Goals will require from all nations to work in solidarity to find durable solutions for global vaccine research and development. Interim solutions, such as our proposed legal strategy for equitable access to vaccines, and efforts to find long-term solutions must be advanced in parallel. (shrink)

We argue that individuals who have access to vaccines and for whom vaccination is not medically contraindicated have a moral obligation to contribute to the realisation of herd immunity by being vaccinated. Contrary to what some have claimed, we argue that this individual moral obligation exists in spite of the fact that each individual vaccination does not significantly affect vaccination coverage rates and therefore does not significantly contribute to herd immunity. Establishing the existence of a moral obligation to be vaccinated (...) despite the negligible contribution each vaccination can make to the realisation of herd immunity is important because such moral obligation would strengthen the justification for coercive vaccination policies. We show that two types of arguments—namely a utilitarian argument based on Parfit’s Principle of Group Beneficence and a contractualist argument—can ground an individual moral obligation to be vaccinated, in spite of the imperceptible contribution that any single vaccination makes to vaccine coverage rates. We add a further argument for a moral obligation to be vaccinated that does not require embracing problematic comprehensive moral theories such as utilitarianism or contractualism. The argument is based on a “duty of easy rescue” applied to collectives, which grounds a collective moral obligation to realise herd immunity, and on a principle of fairness in the distribution of the burdens that must be borne to realise herd immunity. (shrink)

The COVID-19 pandemic will likely recede only through development and distribution of an effective vaccine. Although there are many unknowns surrounding COVID-19 vaccine development, vaccine demand will likely outstrip early supply, making prospective planning for vaccine allocation critical for ensuring the ethical distribution of COVID-19 vaccines. Here, we propose three central goals for COVID-19 vaccination campaigns: to reduce morbidity and mortality, to minimise additional economic and societal burdens related to the pandemic and to narrow (...) unjust health inequalities. We evaluate five prioritisation approaches, assess their likely impact on advancing the three goals of vaccine allocation and identify open scientific questions that may alter their outcomes. We argue that no single prioritisation approach will advance all three goals. Instead, we propose a multipronged approach that considers the risk of serious COVID-19 illness, instrumental value and the risk of transmission, and is guided by future research on COVID-19-specific clinical and vaccine characteristics. While we focus this assessment on the USA, our analysis can inform allocation in other contexts. (shrink)

Seven COVID-19 vaccines are now being distributed and administered around the world (figure correct at the time of submission), with more on the horizon. It is widely accepted that healthcare workers should have high priority. However, questions have been raised about what we ought to do if members of priority groups refuse vaccination. Using the case of influenza vaccination as a comparison, we know that coercive approaches to vaccination uptake effectively increase vaccination rates among healthcare workers and reduce patient morbidity (...) if properly implemented. Using the principle of least restrictive alternative, we have developed an intervention ladder for COVID-19 vaccination policies among healthcare workers. We argue that healthcare workers refusing vaccination without a medical reason should be temporarily redeployed and, if their refusal persists after the redeployment period, eventually suspended, in order to reduce the risk to their colleagues and patients. This ‘conditional’ policy is a compromise between entirely voluntary or entirely mandatory policies for healthcare workers, and is consistent with healthcare workers’ established professional, legal and ethical obligations to their patients and to society at large. (shrink)

ArgumentIt is well known that the development of a diphtheria anti-toxin serum evolved in a competitive race between two groups of researchers, one affiliated with Emil Behring in Berlin and Marburg, and another affiliated with Émile Roux in Paris. Proceeding on the basis of different theoretical assumptions and experimental practices, the two groups developed a therapeutic serum almost simultaneously. But the standardized substance they developed took on very different forms in the two countries. In Germany the new serum was marketed (...) in the private sphere and subjected to state regulations, becoming a kind of prototype of industrial medications. In France, however, the same substance was marketed as a gift of science to humanity and distributed through the communal health care system. This article demonstrates how a new medication emerged from the efforts to produce, market, regulate, distribute, and apply it in the two respective countries. It attributes the difference to the negotiations between the respective actors (scientists, industrialists, politicians, officers, and the public) and institutions (firms, academies, private and public institutes, legislative bodies, professional corporations). I develop this argument on three different levels: First, I stress the importance of the institutional foundations of serum production; second, I illustrate the decisive role played by existing “ways of regulating” in the rapid development of new legal statutes; and third, I describe the consequences that flowed from the respective administrative organization of marketing and dissemination. In sum, I explore how an experimental object was transformed into an object of the public health system and stabilized by administrative means. (shrink)

ABSTRACTGiven the ethical controversies concerning HIV vaccine trials , we aimed to understand through an exploratory study how members of institutional review boards in the United States and research ethics committees in South Africa view issues concerning the process and content of reviews of these studies. We mailed packets of 20 questionnaires to 12 US IRB chairs and administrators and seven REC chairs to distribute to their members. We received 113 questionnaires . In both countries, members tended to be (...) white males with advanced academic degrees. Compared to the US, SA members called for ‘major changes’ in HVT protocols more frequently , and were less likely to think that HVT participants understood risks and benefits or informed consent forms . In both countries, members were divided on several critical issues , but agreed that they needed more training. Of the SA respondents, 40% reported that they were ‘self‐taught’ in ethics. This study, the first we know of to offer quantitative data comparing US vs. non‐US IRBs/RECs, thus suggests key similarities and differences , along with needs for education. These initial exploratory data in this area have important implications for IRBs, RECs, policy‐makers and scholars concerning future practice, training, policy, and investigations in research ethics, and prevention and treatment of HIV and other diseases in the developing world and elsewhere. (shrink)

Hugh V. Mclachlan Cet article est une réponse à la critique de Saunders de ma proposition de politique non conséquentialiste publiée précédemment concernant l’utilisation d’une loterie pour la distribution de vaccins rares par l’État face à une pandémie de grippe. J’y ai soutenu que, pour des raisons de justice, l’État devrait distribuer une partie du vaccin rare qu’il pourrait détenir à certains de ses employés de la santé et le reste aux citoyens de manière aléatoire et égale sur le (...) principe d’une loterie. Au coeur de la critique de Saunders se trouve l’affirmation selon laquelle j’ai omis à tort de prendre en compte les différences moralement pertinentes dans les besoins et la capacité de production entre les receveurs potentiels du vaccin. Le point central de ma réponse ici est que le fait que le besoin et la capacité de production soient ou non des facteurs moralement pertinents dépend de qui ou de quoi distribue le vaccin, à qui ils le distribuent et pourquoi ils le font. Par exemple, la discrimination entre les personnes dans la distribution de vaccins publics distribués à titre prophylactique sur la base de leur âge est injuste, qu’elle soit ou non moralement justifiable pour d’autres motifs. (shrink)

In a paper recently published in this journal, Navin and Largent argue in favour of a type of policy to regulate non-medical exemptions from childhood vaccination which they call ‘Inconvenience’. This policy makes it burdensome for parents to obtain an exemption to child vaccination, for example, by requiring parents to attend immunization education sessions and to complete an application form to receive a waiver. Navin and Largent argue that this policy is preferable to ‘Eliminationism’, i.e. to policies that do not (...) allow non-medical exemptions, because Inconvenience has been shown to maintain exemption rates low while not harming parents by forcing them to do something that goes against their beliefs. We argue that it is at least doubtful that Inconvenience is ethically preferable to Eliminationism: while the latter disregards the value of liberty, Inconvenience disregards the value of fairness in the distribution of the burdens entailed by the preservation of a public good like herd immunity. We propose a variant of Inconvenience, which we call ‘Contribution’, which we think is preferable to the versions of Inconvenience discussed by Navin and Largent in that it successfully strikes a balance between the values of parents’ liberty, fairness and expected utility. (shrink)