COVID-19 Vaccination Raises Ethical Questions

[MUSIC PLAYING] Welcome, everyone. I'm Dr. John Whyte, chief medical officer at WebMD, and you're watching Coronavirus in Context. We've been watching videos of vaccine distribution, and you might be having some questions. Is it fair who's getting it first in terms of age and other risk factors?

So to help talk about all things ethics around COVID-19, I've asked back the world's leading bioethicist, Dr. Arthur Caplan from NYU Langone Health. Dr. Caplan, welcome back.

Hey. Thank you for having me, John.

Let's get right to it. Some states, some jurisdictions, it's people over 75. Others, it's 65. We're hearing other stories about there could be vaccine that's leftover at the end of the day, and people's family members are getting it. Where's the fairness, Dr. Caplan? Do we need to have a centralized process?

Well, look. We don't have consistency in the states, or for that matter, in localities about who can get vaccinated. I've heard-- I haven't seen it-- but I've heard that in Florida, in some communities, you just get in line, or get in your car and get in line.

And they'll vaccinate you whether you're a native, a snowbird, or even Canadian. They don't much care. It's just kind of line up. In New York near where I am in Richfield, Connecticut, the governor's saber rattling and saying, if you don't follow our standards, we're going to penalize you. There'll be big institutional penalties.

You need consistency, I think, in order to get compliance. We sometimes say in ethics, there's a difference between fairness and justice. Justice is what you just described, John. Over 65, over 75, health care worker, high-risk, a nursing home resident, somebody with comorbidities. Fairness is, does everybody get the same chance? Are we being treated equally?

We don't have fairness, and that undermines people's willingness to go along with justice, meaning if I think you're getting ahead of me because you have some money or you're just in a state that doesn't care or doesn't enforce it, I get angry. And then I start to say well, then I'm going to start to see if I can push to the head of the line one way or another.

One other source of trouble in a broad policy sense, you know what the biggest scandal is. There's too much vaccine in warehouses. While we're arguing about who goes first and who's the priority, you look state to state and say, you gave out 9% of what you were sent. You gave out 11% of what you were sent.

This is a scandal. We need vaccine in arms, not in warehouses. So I worry if we're trying to follow, if you will, standards and criteria about who goes first too tightly, if it becomes too burdensome, is that hindering us from giving out the vaccines at all?

It's really an issue of distribution, not right [INAUDIBLE] supply.

It is.

I want to ask you about health professionals. And some health professionals are choosing not to get vaccinated, even those that are involved in clinical care. Is it unethical for health providers not to get vaccinated?

I'm going to answer that with a mild yes. I don't mean to be critical of those who are trying to help others and trying to put someone else's interests ahead of their own. But the way the system is now, if you pass on a vaccine, it doesn't mean it's going to go to someone who's needier. It just means it's going to someone further down the line at the institution-- say a hospital or a nursing home-- where they have a supply.

So the way this has worked is states roll out, in most cases, a supply of vaccine to let's say a hospital. The hospital then looks at it and says, huh. We got to track it, two doses. We got to refrigerate it. We're going to work our way through our employees because we can keep tabs on them.

So if I say, don't vaccinate me. I stay home. I'm not patient-facing. I'm not that big a risk. I don't need it for disease reasons, then all that's going to happen is it's going to go to the it guy who's next on the line. It's not going to a nursing home.

So I think you have to think hard. You don't want to pass a vaccine. If you are patient-facing I think even minimally, that becomes important to protect yourself, to protect them. You don't want to miss work, and you don't hopefully want to make others sick, although our evidence on transmission is still weak. I think there's a duty to get vaccinated by nurses, doctors, cleaning people to keep the system going.

We don't really know, does it prevent me from infecting you? I mean, we think. We hope. But when it really does is it keeps the workforce intact, keeps the place running. And here's the thing that I think people have to be a little generous about.

The states have said health care workers who are in clinical settings, nursing home residents, because they're high-risk, nursing home staff. OK. If you went to many hospitals, what they'd say is, we can't run this place without IT people. We need the billing department. We have to have security.

We need people to greet people at the door and send them on to the right parts of the facility. They're essential. Now, they're not in the list that ethicists, or committees, or governors, or whoever made up. But the hospital often will say, if I don't have my management team, this place isn't going to run.

So if the goal is to keep the system going-- and that's what we hear the point is of these priority classifications, keep the health care system working-- then I think you have to give some discretion to the hospital, to the nursing home, even to the prison, in those states where they're vaccinating there, about what they consider essential. Because I'm not sure the criteria that have been promulgated do a good job.

All right, you opened it up with mentioning prisons, so I'm going to ask you about that. Some states are choosing to vaccinate prisoners before they're vaccinating people that are over the age of 65. And some people are outraged, saying it's wrong. Is it wrong? Is it unethical? How do we factor that into the distribution?

Yeah. It's a tough one, because obviously people think prisoners, they lose rights, they lose their liberty.

That's why I'm asking Dr. Caplan.

They lose their freedom. But I'm going to say the goal of public health is not to get into who's good and who's bad. It's to try and make sure that you control the spread of the epidemic. So prisons are notorious places for not only infecting prisoners, but infecting guards, food handlers, people who visit, people who come in and out.

So you don't want to do what they do in Russia, which is they have tuberculosis in the prisons, and it spreads out all over the community because they ignore the prisoners. I think we have an image, partly from Hollywood, that everybody in prison is working out in the yard, is a musclebound 30-year-old who's waiting to get in a gang war. A lot of them are old. A lot of them are sick. A lot of them are there for let's call it not super serious crimes.

And that makes me also start to say, you know, it's not one-size-fits-all when we think about prisons. But more to the point, you want to get a bang for the buck. You want to stop outbreaks. Prisons we know from a public health point of view are trouble spots. Anything where there's conjugal living.

Another group-- not as controversial but gets ignored-- psychiatric facilities and people in homes for those with intellectual disabilities. I keep looking for them on this. A couple of states list them. Most don't.

But if you have Down syndrome, you know the death rate from the virus is four times what it is for others, probably due to immune disorders and people with Down? You don't want to ignore them either. So what we need to be paying attention to is not that I want to save murderers and rapists, but what I want to do is not have infection outbreaks that are going to really spread back out to the community.

You're taking it from the perspective of public health, and who's most at risk, and really trying to cut down on infection spread, so OK. Now, as you know, I'm an avid reader of your writings, so I want to pursue this.

By the way, there's nothing worse than actually having somebody read what you wrote and them ask you about it.

[LAUGHTER]

That's what I'm going to do, Dr. Caplan. And you talked about recently on Medscape, we shouldn't be sharing the vaccine with other countries, that we're just going to put it out there. You're saying America first.

Is this the problem here, this mentality, that look, the developing world is not going to have the resources? But you're suggesting, let's take care of our own people first, not the same time. What's the ethical issue there?

So you can describe this as vaccine nationalism. Should countries try to take care of their own-- the US, or Britain, or whoever it is-- before they move to help others? I sometimes think of the airline analogy, put on your own face mask before you try and help your child or your neighbor. If you're in trouble, you're not going to do much good for anybody else.

But the reason I argue for this is I think we have to take care of those in need in our own country first. There may be people who are relatively healthy, not super high-risk. OK. But if you have a health care workforce that's broken here, I don't see the point of giving vaccine away to anybody else until you get our health care system up and running, able to take care of COVID patients, able to take care of people who are seriously ill or injured.

I feel the same way about protecting our most at-risk populations-- comorbidity, age, and whatever. The point is if I'm a citizen, I expect my government to look out for me, not look out for the world. The point is if I'm trying to decide morally, I have some food. I know there's kids starving in other countries, but my kids are hungry, too. I don't flip a coin. I feed my kids first.

Then once they're taken care of, I start to think, and now what do I owe others? So I'm not against considering the needs of others, but I want to treat equal needs equally. I don't want to just vaccine every American and then get to foreign assistance, but I do want to get through the at-risk populations, the most likely to die populations here. Then we should start to think about, what are we going to do for the rest of the world?

And by the way, the rest of the world has no money. There are some initiatives to do this through COVAX, and the WHO, and the Gates Foundation, but it's not really going to make much of a dent. If we are going to do something for other countries, our government is going to have to buy vaccine and send it elsewhere. There's no other way I can see that happening.

It's a global economy, a global world. If you don't vaccinate other countries, it's just going to come back and impact those that aren't.

Right. So do we get it to our groups in need first? Then we can't ignore elsewhere. You don't want outbreaks in Italy coming back, or an outbreak in Brazil, or South Africa with a new strain coming back. I get that, and I take it seriously.

But let's be ready to understand they're not going to be able to pay. It's going to be us or other rich countries who are going to have to throw some resources in that direction. Sometimes, Americans get mad about that. They don't want to spend money on foreign aid or helping others. I think they should. But they should also be reassured we didn't try to take care of the neediest here first. That far, I'll go.

Vaccine nationalism, I have not heard it. We've heard it here first. Let me ask you about whether it's ethical to make vaccination mandatory. I'm going to parse it out a little. Right now, technically, as you and I know, it's authorized. It's not fully approved and a licensed product.

It's probably not until April or May that Pfizer and Moderna will submit for full approval. Some employers are currently saying it is legal to require to make it mandatory. And the EEOC actually put out an advisory that says employers can mandate COVID-19 vaccination right now while it's authorized. Is it ethical?

Yeah. Well, another tough one, and I'm going to not duck it. I think--

I only ask you tough questions.

[LAUGHTER]

That's all right. That's all right.

And I don't tell you ahead of time, just so people know.

I respect it and I also like the fact that you actually get ready and you've read through controversial things I've said, and said, really? Do want to believe that? Tell me why. So that's good. We're all for that. That's part of what ethics is all about is pushing to make sure the arguments and the reasoning holds up, so absolutely fair and good to do.

I think it's going to be tough to mandate emergency use. While the data is there and the FDA is convinced that it's safe enough in effectiveness to get it out there, it's partly because it's an emergency and it's a terrible plague that they're going to let early approvals take place.

I have a feeling if you went to court and said they mandated that I have to get this vaccine, but it's not licensed, it's not yet fully approved, I'm doing it on partial evidence, I think you might win that court fight. Having said that, I think there are settings where I would try to mandate and take on the legal battle.

Nursing home staffs-- I just had a friend of mine told me in the Cleveland, Ohio area refusals by both patients and staff, 60%. Now, you got a 60% refusal rate, you're killing the elderly, and the staff is going to get sick.

We know already I think 100,000 or more people have died in nursing home settings or nursing home staff. They've been decimated by this outbreak. I'd try to mandate. I can't put up with a 60% refusal rate in the worst danger zones that we've got.

Would you mandate on the health professionals? You said it's their professional responsibility.

Yeah, I do. And I think I might also push into the ICUs. I'm hearing refusal rates, even at hospitals-- some nurses 30%, some doctors 15%. You're putting yourself and others at risk in a terrible way. [INAUDIBLE]

We don't force influenza. We don't mandate-- well, we do in the medical community.

Right.

But we don't mandate influenza, shingles, pneumonia, Pneumovax.

Right. So shingles, I don't mandate because if you get shingles, it's not fun, and I would tell you to get the shingles vaccine, but you're not going to make anybody else sick. I pushed hard for flu mandates for health care workers. I'm the guy who originated that idea along with Paul Offit from the Children's Hospital in Philly.

And we pushed it in at Penn and CHOP, brought it to NYU, and pushed it all around the country, and people do it. And we fired people for not doing it. I think there's a special obligation to take vaccines when you're putting others at risk and when you yourself might not be available to work. So that's why I'm tough on the nursing home setting, on the hospital setting, actually on the home care setting for that matter, too. I think those groups are different and I would try to mandate.

But I'll say, John, if I got pushback, the Nurse's Union sued, I don't know if I'm going to win that one, because it's still a tentative approval. I'd try it.

[INAUDIBLE] approval. What about the role of vaccination in children? We know the risk is lower.

Yeah.

[INAUDIBLE] trials yet? Should we be--

No studies yet. I can't do kids quite yet. You've got to get some data on kids. It's going to be hard, by the way. I think once vaccines get licensed and approved, we're going to see some creep.

People are going to start to say, I don't know. You're 17. You're 16. We don't have data on that, but maybe it'd be better. I think you're also going to see some other countries just say, well, we don't care about the data. We're going to start vaccinating kids.

But 17 is different than 10.

It is, and different than five, to get into nursery school. Still, I hope that we can launch some studies once we're convinced that adults seem to be doing OK in kids. I don't think you're going to see mandates pushed as fast there until this data comes in for approval.

Will they eventually make it to the mandated vaccine list? Yeah, I think so. And by the way, I also think once vaccines get approved, we're going to see something else happen. Airlines, cruise ships, trains, hotels, they're going to say you need--

You need a passport.

You're going to have to show something on your iPhone, or a tattoo on your forehead-- I don't know, something that says I got vaccinated. Those industries are ruined because people rightly are afraid that they're going to get infected if they head to the airport and so on.

So I think the private sector, particularly those, again, with big public interactions, are going to say, you have to vaccinate in order to use our service. And I know some people are going to say, you can't make me do that. True. But they don't have to let you on the airline, either. I mean, you have right to be there. It's a private service.

I think we'll see athletes starting to vaccinate so they can carry out their sports activities. Maybe to get into the stadiums, you're going to have to show that you've got a vaccination passport, or certificate, or proof. And I think you'll start to see other businesses say, if you want to come back to work here, we can't easily accommodate you in terms of social distance or masking options. Either stay home and work, or you've got to vaccinate.

So the future, I think, is health care workers, yeah, wants approved. Private employees, and then probably kids as data comes in and it looks safe.

Your level of optimism that we'll reach 70% to 80% immunity-- recognizing that we want people to take personal responsibility, but at the same time, you also need to have a perspective of community. Not just to protect yourself, but protect your family, protect your immediate community, and broader national and world community. Is that where we are currently? Do you think we'll get there?

We're not there. We have too many people who put personal liberty and personal choice in front of the consideration of others. Also, there was just plain fatigue. I think people just said, I can't stay in anymore. I'm going out.

I talked to some young people who said, I have no social life. I can't meet anybody. I want to go to a bar. I want to get out there. Partly, I don't excuse it because it puts others at risk, including when they go home or see their relatives who may be medically compromised or older.

But I do kind of understand it. I get what leads people. It's tough to follow for a year, quarantine and all the restrictions on behavior that we ask, and also loss of job, and mental stress, and the rest of it. But I think we're starting to get a little better. I think we're starting to understand.

I see less vocal opposition about the mask issue than we were seeing back six months ago. I think the vaccine helps give us some hope that if we can do that, maybe we could get back to some semblance of normal by the end of this year.

So I'm going to say I am a little more optimistic that both offering people some hope of getting out of fatigue, of quarantine fatigue, of COVID lockdown fatigue plus realizing, you know, the people who were telling us about mask weren't crazy. Look at California. Look at the crunch in the ICUs in many parts of the country. Look at the escalation of COVID post motorcycle rallies, political rallies.

Look at what happened in the Trump White House as the virus spread through all of the staff and many, many of the leading politicians. It wasn't made up. It wasn't a hoax. Mask behavior, more and more studies keep showing, does help. So I think if you really establish that it works and it matters, add in more concern about others as the thing gets worse and affects more and more people, yeah, I'm more optimistic.

That's a good note to leave it on, optimism. Dr. Caplan, I want to thank you.

We haven't had a lot of that with COVID.

No, we have not. I want to thank you again for sharing your optimism, sharing your insights as well as helping us to think through some of these difficult ethical issues as we think about immunizing ourselves as well as loved ones. Thanks, Dr. Caplan.

I very much appreciate the opportunity. Thank you.

And if you have questions about COVID, drop me a line. You can email it to me at [email protected]. Thanks for watching.

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