;

Who should get the COVID-19 vaccine first? A look at the ethics of priority-setting using Norway as a case study

Gry Wester

Lecturer in Bioethics and Global Health Ethics

11 June 2021

Since the beginning of 2020, the COVID-19 pandemic has posed significant challenges worldwide. The comprehensive infection control measures that have been adopted in response, such as social distancing, quarantine, school closures and travel restrictions, are not sustainable in the long term. The use of effective SARS-CoV-2 vaccines will probably constitute the best strategy for a return to normality. However, initially demand will exceed supply of vaccines, which means that it will be necessary to prioritise. That raises difficult questions about which groups should gain access to potentially life-saving vaccines first.

In September 2020, I was invited to join an expert ethics group to advise the Norwegian government about the planned coronavirus immunisation programme. This group was set up by the Norwegian Institute of Public Health, which had been commissioned by the Norwegian Ministry of Health and Care Services to organise the national coronavirus immunisation programme.

The group’s mandate was, first, to establish what the goals of the vaccination programme should be, and second, to decide on which groups should be given priority in the first phase of the vaccination programme.

First consideration: Values

We followed a process whereby we first established a set of core values to guide our recommendations, before deciding on the goals of the vaccination programme, and lastly the vaccine allocation priority order. This is in line with the World Health Organisation (WHO) guidelines, which emphasise the importance of a values framework, because decisions about vaccine allocation can’t be driven by scientific considerations alone. In deciding on who should get the vaccine first, some interests will necessarily be put before others – this is ultimately an ethical question, a question of distributive justice and fairness. A values framework provides a fundament from which to develop our key recommendations, and helps to make explicit the trade-offs between different values that may be held.

We adopted five core values to guide our recommendations:

Equal respect: All human beings have equal moral status and their interests are deserving of equal moral consideration. Vaccina allocation should not be based on invidious discrimination, such as religion, sex, income or social status.

Welfare: We should benefit people and reduce harm. Where possible, without conflicting with other important values, there is an implication to maximise the benefits from vaccination.

Equity: Vaccine allocation should seek to reduce, and avoid exacerbating, inequity in health and welfare. One implication is that vaccines should be free. Furthermore, additional efforts may be required in order to ensure access for certain groups who are more at risk, and to overcome vaccine hesitancy.

Trust: The immunisation programme should be based on trust. Trust must be earned through the adherence to the values framework. Insofar as possible, vaccinations should be voluntary.

Legitimacy: The legitimacy of the vaccine allocation priority order must be ensured through a decision process based on best evidence, shared values, transparency of the process and appropriate input from affected parties, and public deliberation.

Second consideration: Goals

Establishing the overarching goals of the vaccination programme is important, because many different, and potentially conflicting, interests are at stake at the same time.

We proposed five goals for the vaccination programme:

Reduce the risk of death
Reduce the risk of severe illness
Maintain essential services and critical infrastructure
Protect employment and the economy
Re-open society

The goals are ranked in order of importance. Where possible, we should strive to achieve all five goals at the same time, but if there is conflict between any of them, then we should prioritise the highest ranked goal. It is also important to emphasise that goal achievement can be direct or indirect – there is a direct benefit for the vaccinated individuals, and indirect benefits to other individuals. The value of the objective to reduce the risk of death is based both on the direct benefit of saving lives and the indirect benefit of re-opening society.

Should saving lives have absolute priority in the vaccination programme?

The answer to this question is less obvious than it may seem at first glance. As a society, we don’t always give absolute priority to saving lives. In certain contexts, it is a common and accepted practice to limit how much we as a society are willing to pay to save lives. In the discussion that followed the publication of our recommendations, some economists argued that we ought to have given greater weight to reducing the broader economic and societal consequences of the pandemic response. Norway has fared relatively well in containing the pandemic, and we have seen very low numbers of death and severe illness from COVID-19. On the other hand, the costs of the enduring restrictions have been very high, in terms of economic losses for society as a whole and individually, social isolation and reduced personal liberty. The economists argued that given that these costs are so high, and the numbers of deaths relatively low, it would be wrong to give absolute priority to saving lives. Rather, we should prioritise reducing the overall societal costs.

In the ethics group we agree that the objectives for the vaccine programme should be broader than just reducing the risk of death and severe illness – and this is why we outlined five objectives, emphasising that all five should be pursued simultaneously, where possible. Our key assumption was that if we start in the right order, the goals are less likely to come into conflict with each other. At the time when we made our recommendations there were many uncertainties about the vaccine. It was expected that vaccines would, first and foremost,be effective in reducing risk of death and severe illness, whereas we didn’t know much about their effect on transmission rates. - That was much less certain. For as long as we don’t have enough knowledge about the best strategy to reduce transmission rates it is reasonable to assume that protecting the group with the highest risk of death first will be the most effective strategy for achieving the defined goals of the vaccine programme. It is important to acknowledge that this is an empirical assumption and as our knowledge of the vaccines evolve, things may change. But in our recommendations, we gave high priority to reducing the risk of death.

Recommendations for vaccine allocation priority order

In line with the values framework and the goals of the vaccination programme we recommended that, in a scenario where societal infection levels were low to moderate, we should initially prioritise risk groups - defined by risk factors for death and severe illness such as age and underlying health conditions - and secondly, healthcare personnel. In the event of more widespread infection, we recommended prioritising healthcare personnel, followed by risk groups and then workers in critical societal functions.

Why did we not give higher priority to healthcare personnel also in the scenario with low to moderate infection levels? The priority order we have outlined follows from the defined goals of the vaccination programme: giving the highest priority to older people and risk groups first saves the greatest number of lives. A key argument for prioritising healthcare personnel first is to ensure that they are able to continue their essential work and to maintain health services capacity to protect and treat others who become ill. However, as long as infection levels in Norway remained low to moderate, the capacity of the health care system was not considered to be under threat. This changed just before the end of the year, when infection rates were on the rise, and thus the Public Health Institute changed the priority order in line with our recommendations.

These recommendations are in accordance with the values and goals that we proposed. These are preliminary recommendations for the order of priority for coronavirus vaccines in Norway, and we have taken into account that the recommendations may need to be revised if there are significant changes to the empirical evidence. Our recommendations have been largely followed by the Norwegian government. We welcome continued public debate on who should be prioritised for the corona vaccine.