A host of ethical issues surround the design, production, and funding of Covid-19 vaccines, but none as crucial as their end-stage distribution: who get the shots first? Despite the consensus that vaccinations are supposed to diminish deaths and disease as efficiently and quickly as possible, thus effectively ending the pandemic, there is no single route to this goal. Hence, a complex distributive justice problem arises for both national governments and multilateral institutions.

A first proposal comes from the WHO (World Health Organization) with a nod from the COVAX facility (a global initiative of governments and pharmaceuticals), establishing that each participating country first receive vaccines for 3% of its population, followed by rounds of population-proportional allocation until 20% of its people have been immunized. Another suggests distributing vaccines according to the number of front-line healthcare workers, the proportion of the population over 65, and the number of people with comorbidities.

An international group of academics behind the “Fair Priority Model” (FPM), however, criticizes both as very blunt instruments for the task at hand. Regarding the first, providing vaccines exclusively in proportion to population would be unethical, tantamount to allocating HIV retrovirals, for instance, without regard for the actual HIV burden, which varies from country to country.

Similarly, the fairness of the second is questioned, as it fails to consider that healthcare workers in high-income countries, for example, have greater access to personal protective equipment, thereby diminishing their risks of spreading, getting infected, and developing Covid-19, compared to other groups.

Above all, the two previous models further compound the disadvantages of low-income countries, with fewer health care personnel and a smaller proportion of people over 65, besides more fragile health systems. Instead of treating countries and populations equally, a just or equitable vaccine distribution should pay attention to their different needs, represented by the variable severity with which they suffer the pandemic. 

FPM begins by inquiring about the gravity and urgency of harm. “Harm” is understood in terms of death, permanent organ damage, a collapse of the health system, and a devastated economy accompanied by starvation, poverty, unemployment, and so forth. Most importantly, “harm” is measured through the “Standard Expected Years of Life Lost” (SEYLL, based on the lowest, age-specific mortality rates worldwide) which could be averted per vaccine dose. 

FPM analyzes whether such harms are irreversible, their degree of destructiveness, and the extent to which they can be compensated. All of these factors together determine the number of vaccines to be allocated per country and the order of receipt. Accordingly, the top priority consists of reducing premature deaths and irreversible diseases (phase 1); followed by the reduction of economic and social deprivations due to closed schools and businesses, for example (phase 2); and the lowering of community transmission which favors the restoration of freedoms and other socioeconomic activities, with those with highest rates going first (phase 3).

FPM differs from other vaccine distribution strategies by prioritizing the worst off in deaths and disease from the pandemic, poverty, and the reduction of life expectancy (early deaths as a proxy for overall deprivation are most frequent in low-income countries). Also, it promotes equal moral concern for similar individuals, without discriminating on the basis of irrelevant characteristics such as sex, race, or religion: a life saved at a given age is valued equally across countries.

Not that FPM is perfect; no procedure is. Some may dispute that to prevent wastage, only countries with an infrastructure capable of delivering vaccines to end-users should receive them. This is a realistic, albeit cruel conditionality which calls for extra help precisely in developing such a logistical capacity. Others claim that FPM unduly punishes countries which curtailed community transmission without the vaccine, while rewarding those remiss with their social measures. But vaccines are not meant to remedy past wrongs; analogously, treatments aren’t denied to smokers who develop lung cancer or to diabetics who failed to watch their diets.

Still others may argue that proposed metrics are too difficult and uncertain, or may even give rise to perverse incentives, such as exaggerating a country’s Covid-19 burden. Yet all metrics are subject to manipulation, and what’s crucial is the focus on deprivation and vulnerability. Moreover, the tendency to magnify a country’s Covid-19 burden will have to be compensated by the need to reassure tourists and investors of its safety.

Although more and more vaccine options become available, they will not be sufficient to cover current demand. Wealthy countries in a shameless display of vaccine nationalism have already pre-ordered 3.8 billion doses, enough to inoculate their populations several times over, while others are left with very few. FPM provides a fighting chance for morals to prevail over markets in our global pandemic response.

Republished with permission from Alejo José G. Sison’s blog, Work, Virtues, and Flourishing

Alejo José G. Sison teaches ethics at the University of Navarre and Georgetown. His research focuses on issues at the juncture of ethics, economics and politics from the perspective of the virtues and...