Receiving the COVID-19 vaccine in Vienna, Austria, December 2020
Lisi Niesner / TPX Images of the Day / Reuters

The global supply of authorized COVID-19 vaccines will likely remain scarce for months, if not years, and governments worldwide face tremendous political pressure to secure enough doses to immunize their populations. Approximately 190 countries, including about 64 high-income countries, have joined the COVID-19 Vaccine Global Access (COVAX) Facility, a World Health Organization–supported initiative that aims to distribute vaccines equitably. But to avoid being left at the back of the queue, many governments have hedged their bets by signing bilateral agreements with pharmaceutical companies that grant them preferential access to vaccines.

Some countries have used these agreements to secure access to more doses than they have people—sometimes many times over. Canada, for instance, has signed deals with multiple companies for vaccine purchase options totaling nearly nine times its population of 37 million people. Deals like these have enabled high-income countries to mitigate the risk that any one manufacturer’s vaccine might fail. But they will also limit low- and middle-income countries’ access to vaccines until producers are able to meet global demand.

Many governments defend their bilateral agreements with pharmaceutical companies by claiming that they are merely securing enough doses to vaccinate their residents. Other governments argue that because they funded COVID-19 vaccine development, they are entitled to a share of the early production. But as long as vaccines remain a scarce, lifesaving resource, a fundamental ethical question will remain: How many vaccine doses are countries permitted to secure for the purpose of immunizing their own residents before they are obligated to relinquish doses to other countries?

We propose a novel framework to answer that question—the Fair Priority for Residents (FPR) framework—which sets the obligatory threshold for sharing vaccine doses at the point where deaths directly and indirectly caused by COVID-19 begin to resemble those from influenza. Tens of thousands of Americans die every year from the flu, but the U.S. government treats these deaths as normal background risk. The government takes modest measures to provide vaccines but does not mandate vaccination or mask wearing, even though doing so would save lives. We propose that governments have a duty to give “fair priority” to their residents when distributing vaccines in order to reduce COVID-19-related mortality to pre-crisis, or “flu risk,” levels. Once they have reached that point, however, their duty to assist people threatened by COVID-19 abroad outweighs their duty to further reduce mortality in their own countries.

 FAIR PRIORITY FOR RESIDENTS

Two competing philosophical outlooks frame any discussion of resource allocation during global health emergencies: cosmopolitanism and nationalism. Cosmopolitans hold that national borders are arbitrary and of limited moral significance. Where individuals are born is wholly out of their control and therefore should not affect their access to lifesaving interventions. Nationalists, by contrast, hold that governments have a responsibility to protect and promote the rights and well-being of their citizens. As a result, governments are permitted—even required—to accord exclusive priority to the interests of their people.   

In their extreme forms, neither vaccine nationalism nor vaccine cosmopolitanism is ethically defensible. Extreme nationalism ignores the basic moral claims of human beings beyond a country’s borders, while extreme cosmopolitanism overlooks a government’s obligations to its citizens and residents. On a practical level, cosmopolitanism seems utopian, since there is presently no political will to create, fund, and abide by a single global platform that could fairly distribute vaccines without regard for national borders. COVAX remains underfunded, and bilateral deals continue to proliferate. Extreme nationalism, though not utopian, is shortsighted, both because unusually high mortality in some countries can have harmful economic effects on all countries and because it ignores the importance of the soft-power advantage in helping other countries out of a health crisis.

One potential compromise between the cosmopolitan and nationalist positions would be to allow countries to secure enough doses for their populations to reach herd immunity but require them to donate any excess doses to COVAX for redistribution to countries where the virus is still circulating. Some experts place the threshold for herd immunity at around 70 percent of a given population, although the precise share will depend on a number of empirical factors, including transmission rates and the extent to which vaccines prevent infection rather than merely limit the virus’s ability to cause medically serious symptoms. This suggests that from an ethical standpoint, countries should not retain more doses than would be required to achieve roughly 70 percent immunization. But do countries have an ethical obligation to share vaccines even before they reach herd immunity?

Consider the usual government response to the flu. Like COVID-19, the flu is a respiratory virus that tends to affect older patients and those with comorbidities. In a particularly harsh flu season, such as the winter of 2017–18, about 60,000 people, or 20 per 100,000, die from the flu in the United States. Yet the federal government does not declare the flu a public health emergency or take extraordinary measures to vaccinate enough people to attain herd immunity. Like other governments, the U.S. government tolerates this level of mortality as normal flu risk.

Do countries have an ethical obligation to share vaccines even before they reach herd immunity?

Our FPR framework uses flu risk as a baseline. Under FPR, governments can ethically retain as many COVID-19 vaccine doses as they need to maintain a noncrisis level of mortality (which includes both direct and indirect deaths, such as those that result when people with cancer or heart attacks avoid medical services or receive lower-quality care), a functioning health system, and economic activity. By controlling excess mortality, countries could ease lockdowns and return to near normality, with the safe resumption of primary and secondary schooling, retail shopping, and some travel, indoor dining, and the like.

FPR assumes that governments will continue to implement reasonable public health mitigation measures aimed at reducing infection alongside their vaccination campaigns, so as to limit the number of doses required to control mortality. Examples of such mitigation efforts include requiring masks and installing high-efficiency particulate air filtration systems in public buildings, schools, and housing for the elderly. These measures are effective at limiting transmission and do not impose unreasonably significant individual costs or restrictions, although the emergence of more infectious strains of the virus may require heightening them. After all, it is difficult to justify vaccinating more residents of a country in order to relax these reasonable measures if doing so means depriving citizens of other countries of vaccines that will save many lives.

How many people would countries be permitted to vaccinate under FPR? The answer will vary depending upon the epidemiology of the virus, the transmissibility and lethality of variants, and the effectiveness and durability of vaccines. In some countries, such as Taiwan, New Zealand, and Australia, public health efforts have controlled mortality without vaccines. These countries would receive little permission to retain vaccines beyond what is required to relax stringent public health restrictions. Other countries, such as the United States and the United Kingdom, have seen their death rates increase significantly. According to one simple model developed by Bryan Grenfell and his research group at Princeton University that assumes vaccines confer immunity for one year, these harder-hit countries would need to vaccinate about 25 percent of their populations and maintain an ongoing vaccination rate of about one percent of their populations per week (50 percent per year) in order to reach pre-crisis flu-risk mortality levels. After that, FPR would require them to share vaccines with COVAX for redistribution in lower- and middle-income countries. Importantly, the FPR framework sets no absolute threshold for population vaccination levels. The moral position must be responsive to the empirical situation of COVID-19 spread and burden and therefore must be constantly revisited.

ENTERTAINING THE OBJECTIONS

High-income and some middle-income countries might object to the FPR framework on the grounds that they funded and undertook much of the basic science, clinical research, and manufacturing that allowed for the rapid development and distribution of vaccines. Shouldn’t the governments that made these advances possible be allowed to secure preferential access for their citizens?

This objection ignores the important contributions of scientists, researchers, and technicians from other countries to the global COVID-19 response. But even if one concedes that wealthier countries have done more to speed the development, testing, and manufacture of vaccines, one cannot justify giving excessive priority to their residents. These countries were able to contribute disproportionately to vaccine research and development only because of their wealth. And wealth should not determine whether a country has access to lifesaving resources, especially not against a background of extreme global inequality. After all, it would be unethical to allocate livers for transplantation based on patients’ ability to pay or donate to liver disease research programs. Indeed, most people believe that ability to pay should not determine access to lifesaving medical care of any sort. 

High-income countries might also object to the FPR framework on the grounds that their citizens and residents have already paid taxes, the proceeds from which were used to acquire vaccines. The governments of these countries may even have cut other important services in order to reallocate financial resources to vaccine purchases. In giving priority to their taxpayers, governments might argue that they are merely providing a service for which their residents have already paid.  

But taxpaying residents are no more deserving of preferential access to vaccines than the residents of rich nations that drove vaccine development. The capacity to raise taxes is largely dependent on a country’s wealth, and as we have argued, wealth does not justify exclusive possession of a lifesaving medical resource.

Most people believe that ability to pay should not determine access to lifesaving medical care of any sort. 

But what of the sacrifices that many countries have made in order to suppress the spread of the virus? Shouldn’t the severe lockdowns endured by citizens of Australia, Norway, and South Korea entitle them to greater vaccine allocations? After all, they have endured substantial social and economic deprivations in order to reduce deaths directly and indirectly related to COVID-19.

The FPR framework does not require that these countries continue to bear the costs of severe restrictions. It requires only that they impose reasonable public health measures, such as masks and air filtration systems. And it permits countries currently imposing severe restrictions to vaccinate enough people that they can shift to reasonable public health measures without incurring excessive levels of mortality.  

Related to the question of sacrifice is the question of competence when it comes to COVID-19 response. Governments that have impressive track records in containing the virus might reasonably object to sending excess doses to governments that have failed to slow the disease’s spread, because of either politics or mismanagement. Why should Australia, which has managed the pandemic responsibly, refrain from procuring vaccines so that Brazil, which currently faces a bad outbreak because of government incompetence, can have more?

Vaccine distribution should not be about rewarding or punishing past behavior. It should be forward-looking, aiming to reduce the COVID-19 burden to a tolerable level.  Moreover, as Israel, the United Kingdom, and the United States have shown, there appears to be little correlation—and for mysterious reasons, there may in fact be an inverse correlation—between the ability of governments to manage COVID-19 effectively and their ability to effectively manage the rollout of vaccines. And the performance of countries is likely to improve as institutions learn lessons and political leadership changes. Poor handling of the pandemic may accelerate this learning process in countries that have free elections.

THE ETHICAL WAY FORWARD

The FPR framework—and the flu-risk standard for determining when to share vaccines—is our answer to the central ethical dilemma of the pandemic. Agreement on the FPR proposal could form the basis of an international agreement through which countries commit to a morally defensible vaccine distribution plan. A binding agreement by all countries—but especially by rich countries—to adhere to the framework would establish a principled norm that builds trust between nations. Such an agreement would also make it easier for civil society, nongovernmental organizations, and activists to name and shame defecting countries and pressure them to adhere to their moral obligations. And it would give governments a powerful counterargument to those demanding that they prioritize vaccinating all of their residents over sharing doses with other countries.

An important lesson of the COVID-19 pandemic is that the world urgently needs strong international institutions that can effectively and ethically respond to global health emergencies. Absent such institutions, high- and middle-income countries will scramble to buy up the medical resources they need, while low-income countries are left to rely on limited donations and charity. The result is an international response that is not only unjust but ineffective. The establishment of COVAX was a step in the right direction, but it must be improved upon. Governments have a collective responsibility to establish a global institution empowered to deal with future global health emergencies. They owe this not just to their own citizens but to the citizens of every other country around the world.

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  • EZEKIEL J. EMANUEL is Vice Provost of Global Initiatives and University Professor at the University of Pennsylvania.
  • CÉCILE FABRE is a Fellow at All Souls College, University of Oxford.
  • DANIEL HALLIDAY is Senior Lecturer in Political Philosophy at the University of Melbourne, Australia.
  • R. J. LELAND is Assistant Professor of Philosophy at the University of Manitoba, Canada.
  • ALLEN BUCHANAN is Professor of Philosophy at the University of Arizona.
  • KOK-CHOR TAN is Associate Professor of Philosophy at the University of Pennsylvania.
  • SHUK YING CHAN is a Ph.D. candidate in the Department of Politics at Princeton University.
  • This essay is adapted from a forthcoming paper co-authored by the above authors and Joseph Heath, Lisa Herzog, Florencia Luna, Matthew S. McCoy, Ole F. Norheim, G. Owen Schaefer, Christopher Heath Wellman, and Jonathan Wolff.
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