Vaccine ethics: An ethical framework for global distribution of COVID-19 vaccines

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. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

Rhetoric, Persuasion, Compulsion, and the Stubborn Problem of Vaccine Hesitancy.

Despite the impact of vaccination on the control and prevention of many infectious diseases, vaccine opposition and hesitancy remain significant barriers to fully protecting individuals and communities against serious disease. The primary response to the problem of vaccine hesitancy includes persuasion and some degree of compulsion, usually in the form of vaccine mandates. Persuasion, if it can be successfully leveraged to provide sufficient control of disease spread, is the ethically preferred approach. Yet persuasion has proven less than adequate, leading to increasing calls for vaccination mandates and the elimination of nonmedical exemptions to those mandates. Four scholars have recently examined the underlying causes of vaccine hesitancy in the interest of improving rhetoric surrounding vaccination. This article reviews those books and offers suggestions for optimizing the strategy of persuasion in the interest of reducing the need for compulsion.

Should Health Care Institutions Mandate SARS-CoV-2 Vaccination for Staff?

Health care workers have been prioritized for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination, but vaccine hesitancy among workers may limit uptake. Institutions may wish to consider SARS-CoV-2 vaccine mandates for health care workers, but such proposals raise important ethical questions. Arguments supporting mandates emphasize the proposed favorable balance of harms and benefits for both individuals and communities, as well as moral duties of health care workers and organizations. Arguments in opposition seek to challenge some claims about utility and raise additional concerns about infringement on autonomy, damage to organizational relationships, and injustice. While available SARS-CoV-2 vaccines remain under an experimental designation, mandates may be excessively problematic, but following approval by the Food and Drug Administration mandates may be reconsidered. The authors summarize ethical arguments and practical considerations, concluding that mandates may be ethically permissible in select circumstances.

Staffing crisis capacity: a different approach to healthcare resource allocation for a different type of scarce resource.

Severe staffing shortages have emerged as a prominent threat to maintaining usual standards of care during the COVID-2019 pandemic. In dire settings of crisis capacity, healthcare systems assume the ethical duty to maximise aggregate population-level benefit of existing resources. To this end, existing plans for rationing mechanical ventilators and intensive care unit beds in crisis capacity focus on selecting individual patients who are most likely to survive and prioritising these patients to receive scarce resources. However, staffing capacity is conceptually different from availability of these types of discrete resources, and the existing strategy of identifying and prioritising patients with the best prognosis cannot be readily adapted to fit this real-world scenario. We propose that two alternative approaches to staffing resource allocation offer a better conceptual fit: (1) prioritise the worst off: restrict access to acute care services and hospital admission for patients at relatively low clinical risk and (2) prioritise staff interventions with high near-term value: universally restrict selected interventions and treatments that require substantial staff time and/or energy but offer minimal near-term patient benefit. These strategies-while potentially resulting in care that deviates from usual standards-support the goal of maximising the aggregate benefit of scarce resources in crisis capacity settings triggered by staffing shortages. This ethical framework offers a foundation to support institutional leaders in developing operationalisable crisis capacity policies that promote fairness and support healthcare workers.

Caregiver COVID-19 vaccination for solid organ transplant candidates.

An increasing proportion of transplant centers have implemented a mandate for vaccination against COVID-19 for solid organ transplant candidates. There has been comparatively little exploration of the ethical considerations of mandating vaccination of a candidate's primary caregiver, despite a high risk of transmission given the close nature of contact between the candidate and caregiver. We examine how a caregiver mandate can improve overall utility in organ allocation, particularly in circumstances where vaccine effectiveness at preventing transmission and serious disease is low among recipients but high in caregivers. Our analysis reveals how sensitive such mandates must be to the evolving circumstances of disease severity, transmissibility, and vaccine effectiveness: as the facts change, the degree of benefit gained and therefore the degree of infringement on access to transplant and caregiver choice that is tolerated will likewise change.

Perspectives of Triage Team Members Participating in Statewide Triage Simulations for Scarce Resource Allocation During the COVID-19 Pandemic in Washington State.

Importance: The COVID-19 pandemic prompted health care institutions worldwide to develop plans for allocation of scarce resources in crisis capacity settings. These plans frequently rely on rapid deployment of institutional triage teams that would be responsible for prioritizing patients to receive scarce resources; however, little is known about how these teams function or how to support team members participating in this unique task. Objective: To identify themes illuminating triage team members' perspectives and experiences pertaining to the triage process. Design, Setting, and Participants: This qualitative study was conducted using inductive thematic analysis of observations of Washington state triage team simulations and semistructured interviews with participants during the COVID-19 pandemic from December 2020 to February 2021. Participants included clinician and ethicist triage team members. Data were analyzed from December 2020 through November 2021. Main Outcomes and Measures: Emergent themes describing the triage process and experience of triage team members. Results: Among 41 triage team members (mean [SD] age, 50.3 [11.4] years; 21 [51.2%] women) who participated in 12 simulations and 21 follow-up interviews, there were 5 Asian individuals (12.2%) and 35 White individuals (85.4%); most participants worked in urban hospital settings (32 individuals [78.0%]). Three interrelated themes emerged from qualitative analysis: (1) understanding the broader approach to resource allocation: participants strove to understand operational and ethical foundations of the triage process, which was necessary to appreciate their team's specific role; (2) contending with uncertainty: team members could find it difficult or feel irresponsible making consequential decisions based on limited clinical and contextual patient information, and they grappled with ethically ambiguous features of individual cases and of the triage process as a whole; and (3) transforming mindset: participants struggled to disentangle narrow determinations about patients' likelihood of survival to discharge from implicit biases and other ethically relevant factors, such as quality of life. They cited the team's open deliberative process, as well as practice and personal experience with triage as important in helping to reshape their usual cognitive approach to align with this unique task. Conclusions and Relevance: This study found that there were challenges in adapting clinical intuition and training to a distinctive role in the process of scarce resource allocation. These findings suggest that clinical experience, education in ethical and operational foundations of triage, and experiential training, such as triage simulations, may help prepare clinicians for this difficult role.

Patient Information Items Needed to Guide the Allocation of Scarce Life-Sustaining Resources: A Delphi Study of Multidisciplinary Experts.

OBJECTIVE: Plans for allocation of scarce life-sustaining resources during the coronavirus disease 2019 (COVID-19) pandemic often include triage teams, but operational details are lacking, including what patient information is needed to make triage decisions. METHODS: A Delphi study among Washington state disaster preparedness experts was performed to develop a list of patient information items needed for triage team decision-making during the COVID-19 pandemic. Experts proposed and rated their agreement with candidate information items during asynchronous Delphi rounds. Consensus was defined as ≥80% agreement. Qualitative analysis was used to describe considerations arising in this deliberation. A timed simulation was performed to evaluate feasibility of data collection from the electronic health record. RESULTS: Over 3 asynchronous Delphi rounds, 50 experts reached consensus on 24 patient information items, including patients' age, severe or end-stage comorbidities, the reason for and timing of admission, measures of acute respiratory failure, and clinical trajectory. Experts weighed complex considerations around how information items could support effective prognostication, consistency, accuracy, minimizing bias, and operationalizability of the triage process. Data collection took a median of 227 seconds (interquartile range = 205, 298) per patient. CONCLUSIONS: Experts achieved consensus on patient information items that were necessary and appropriate for informing triage teams during the COVID-19 pandemic.

Vaccine ethics: an ethical framework for global distribution of COVID-19 vaccines.

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.

Ventilator Triage Policies During the COVID-19 Pandemic at U.S. Hospitals Associated With Members of the Association of Bioethics Program Directors.

BACKGROUND: The coronavirus disease 2019 pandemic has or threatens to overwhelm health care systems. Many institutions are developing ventilator triage policies. OBJECTIVE: To characterize the development of ventilator triage policies and compare policy content. DESIGN: Survey and mixed-methods content analysis. SETTING: North American hospitals associated with members of the Association of Bioethics Program Directors. PARTICIPANTS: Program directors. MEASUREMENTS: Characteristics of institutions and policies, including triage criteria and triage committee membership. RESULTS: Sixty-seven program directors responded (response rate, 91.8%); 36 (53.7%) hospitals did not yet have a policy, and 7 (10.4%) hospitals' policies could not be shared. The 29 institutions providing policies were relatively evenly distributed among the 4 U.S. geographic regions (range, 5 to 9 policies per region). Among the 26 unique policies analyzed, 3 (11.3%) were produced by state health departments. The most frequently cited triage criteria were benefit (25 policies [96.2%]), need (14 [53.8%]), age (13 [50.0%]), conservation of resources (10 [38.5%]), and lottery (9 [34.6%]). Twenty-one (80.8%) policies use scoring systems, and 20 of these (95.2%) use a version of the Sequential Organ Failure Assessment score. Among the policies that specify the triage team's composition (23 [88.5%]), all require or recommend a physician member, 20 (87.0%) a nurse, 16 (69.6%) an ethicist, 8 (34.8%) a chaplain, and 8 (34.8%) a respiratory therapist. Thirteen (50.0% of all policies) require or recommend that those making triage decisions not be involved in direct patient care, but only 2 (7.7%) require that their decisions be blinded to ethically irrelevant considerations. LIMITATION: The results may not be generalizable to institutions without academic bioethics programs. CONCLUSION: Over one half of respondents did not have ventilator triage policies. Policies have substantial heterogeneity, and many omit guidance on fair implementation. PRIMARY FUNDING SOURCE: None.