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Vaccine ethics have created an unambiguous tradeoff between economics and public health

All lives are equally valuable. That's the strong consensus emerging from the many different countries and organizations that have struggled with the question of who should get first access to the COVID-19 vaccine.

Why it matters: The current scarcity of the vaccine looks like an economics problem — too much demand, and not enough supply. But no one is seriously proposing a market-based solution, where the vaccine goes first to those willing and able to pay to jump to the front of the line.

The big picture: The National Academies of Sciences, Engineering and Medicine have constructed an ethical framework based on three considerations.

  • Maximum Benefit means that the vaccine rollout should be designed to save the most lives, care first for those most in need, and prevent new infections. It does not include any economic considerations.
  • Equal Concern is the principle that "every person has equal dignity, worth, and value." This principle makes it impossible to look at economic concepts like "life-years," which, as the American College of Physicians points out, are "inherently biased against the elderly and the disabled."
  • Mitigation of Health Inequities means that populations experiencing the greatest burden from the disease should receive priority.

Details: No vaccination program will manage to abide perfectly by these ethical standards. If individual states receive vaccine allocations according to their overall population, for instance, that would violate the third principle. Maine's population is much older than Utah's, and Montana's population is much whiter than Mississippi's. But age and race are highly correlated with vulnerability to COVID-19.

  • There is universal agreement, however, that health workers and people in nursing homes should get the vaccine first, and that there should be no formal mechanism whereby individuals can buy early access to the vaccine.

What to watch: Rich people will get early access to the vaccine, just as they are currently getting access to antibody therapies. By the time the World Economic Forum holds its annual meeting in Singapore in May, it's a safe bet that many delegates will have managed to get themselves vaccinated somehow. (Which will surely come as a relief to Singapore's public-health agencies.)

  • Such vaccinations will probably be accompanied by sheepishness, however, since they will clearly be unfair.

Between the lines: Ethical considerations seemingly stop at national borders. Vaccine allocation according to ability to pay is shameful within countries — but has already largely determined vaccine distribution between countries.

  • Of note: The opportunity cost — measured in dollars — of taking the ethical path is impossible to calculate with specificity, but is certainly enormous. A GDP-maximizing algorithm would give large early allocations to healthy high-earners and would place little comparative value on the lives of the elderly.

The bottom line: We've finally reached a point at which there is an unambiguous tradeoff between economic activity and public health. To our credit, we've chosen the latter.

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