Public Health

Overview

This section will discuss public health ethics, which explores the tension between individual rights and the public good. During a public health crisis, there is typically a shift between care of individuals and care of the entire population. The new moral calculus introduces many issues, including: how do we weigh the interests of the few against those of the many? What do we owe each other, and what can our government ask of us?

To learn more about legal authority during a pandemic to enforce isolation and quarantine, please read the supplemental materials here.

What are Public Health Ethics?

Public Health Scholar John Last defines public health as “an organized activity of society to promote, protect, improve and when necessary, restore the health of individuals, specified groups, or the entire population” [1]. However, no consensus exists about the precise scope and meaning of public health [2]. In general, we can consider the primary focus of public health is the well-being of the whole population, rather than the individual patient, and often involves a government that develops or carries out public health tasks. As a result, individuals are treated as a member of a larger population impacted by the health care system, as opposed to the individual implicated in a clinical setting.

When it comes to guiding public health officials in decision-making, the bioethics principles developed Beauchamp and Childress might not be as instructive. This is due to the fact that bioethics emerged as a field of study in the 20th century with a focus on the doctor-patient relationship, rather than the “doctor-population” relationship, the focus of public health. Beauchamp and Childress’s four principles of autonomy, beneficence, non-maleficence and justice were taken from values considered important in the interaction between patients and physicians. The idea was that these principles represented a wide consensus about important values and driving forces for clinical interactions. The physician could use the principles as a framework and consider which prima facie obligation outweighs another in a situation. These principles are often useful for guiding clinical interactions, but, as we will see below, they often become insufficient when guiding choices in public health measures.

Public health focuses on creating the conditions in society that allow all persons to be healthy. Hence, principles cannot exclusively focus on the consequences of action for one individual, but rather must consider the consequences for many individuals. Policies or actions may also impact individuals in different ways, since each individual has unique characteristics and needs. In this way, the potential harm and benefit of actions must be considered not just in terms of the four principles, but also in terms of the overall needs of a society. Some ethicists therefore propose that consequentialism or utilitarianism is well-suited to public health. At the same time, other justice considerations such as ensuring equal opportunity to achieve health or rescuing those worse off—such as those with handicaps or severe illness—may outweigh the maximization of overall benefit.

References:

  • [1] Last, J. M. (2007). A dictionary of public health. Oxford University Press.

  • [2] Lee, L. M. (2012). Public Health Ethics Theory: Review and Path to Convergence. The Journal of Law, Medicine & Ethics, 40(1), 85–98. https://doi.org/10.1111/j.1748-720X.2012.00648.x

Overview of Selected Public Health Frameworks

In what follows, we present a few ethical theories that are particularly relevant to modern public health frameworks. Although the overarching theories are more complex and nuanced than can be explored here, the overview below may help frame the key elements of the debate in public health. For instance how do we balance respecting individual good and rights versus public interest? How should public health act in the face of scientific uncertainty? What constitutes appropriate government intervention? After explaining the underlying theories, we will illustrate how they are relevant to public health matters in the COVID-19 pandemic.

  • Paternalism: The main principle of paternalism holds that those in charge of governing—whether it be at the local, state, national, or international level—are thought to know what is best for individual citizens. The paternalistic governing body then sets rules that serve to either protect the individuals, make them better off, or protect the public good of many individuals [1]. Although paternalism commonly carries a negative connotation, proponents have justified the restriction of an individual or group’s liberty with the intent of promoting their good and the good of the many. Common paternalistic policies include laws that require those to wear seatbelts in order to protect individuals. Policies that seek to prevent individuals from driving while intoxicated protect both the individuals themselves and those that may be harmed by an intoxicated driver. In paternalistic systems, the government subverts individual freedoms in making rules that govern its individuals, sometimes in ways that those individuals may not consent to directly or may not prefer [1]. In some cases, a level of deception, and often coercion, is used to prevent individuals from knowing or experiencing truths that may harm them. For example, a governing body may prevent the entry or exit from a hospital unit with a meningitis outbreak to prevent its spread to other individuals and communities. While infringing on the individuals’ rights to free movement through the unit within the unit, it protects the public from potential harm.

  • Libertarianism (Liberalism): In contrast to paternalism, libertarianism (used interchangeably with liberalism here) holds that governing bodies ought to respect individual and personal freedoms. Therefore, policies must be made in such a way as to avoid subverting those individual freedoms. Libertarians assert that individual rights should supersede potential intervening policies from the government. However, individuals are required to not violate the rights of others, despite the lack of defined policies from a government as seen in paternalism [2]. At the same time, individuals cannot be forced to serve the good of all of society, or even serve their own prudential good [2]. This implies that the government must have an underlying trust that individuals will naturally tend to act in ways that benefit society. Importantly, individuals are seen as “right-holders” with “self-ownership,” and those rights are not to be infringed upon unless the individual is using freedoms under said rights to directly harm others in meaningful ways without retribution for the harm [2]. For example, consider a painter who pours her excess paint thinner into a brook to avoid driving to the waste disposal plant, which incidentally poisons children playing in the water. To avoid harming the children, the painter could choose to pay the children’s family to take the paint thinner into the town when they go to buy groceries each week. By doing so, the two individual parties come to a mutual agreement in preventing harm without the need for governmental regulations that constrain their individual rights.

  • Libertarian Paternalism (“Nudging Theory”): Libertarian Paternalism represents a combination of the two above frameworks, serving to assuage the negative connotations ascribed to pure paternalism and, to a lesser extent, libertarianism. As described by Thaler and Sunstein, this theory holds that in many cases individuals make choices that are irrational or against their own interests, and which they would not have made if they “had complete information, unlimited cognitive abilities, and no lack of willpower [3].” Libertarian paternalism may rely on “opt-out” systems rather than “opt-in” ones; that is, the default is for an automatic agreement to a set of beneficial paternalistic policies by individuals, unless they actively choose to opt-out of being constrained by those rules [3]. In the context of healthcare, vaccine administration for children in schools was proposed in 2019 as an application of the theory. Children were to be vaccinated by default without parental authorization (automatic “opt-in”), but parents had the right to complete paperwork that allowed them to “opt-out” their children [4]. Filling out the paperwork to remove a child from the program may deter parents without significant anti-vaccination sentiments from removing their child, ultimately increasing the number of vaccinated children in the community.

Acting in Uncertainty

A feature of the epidemic is its dynamicity, with new, delayed and sometimes dubious information from journals and media outlets every day. An ideal decision tool would be based on probability-weighted models of outcome distributions, with commonly agreed upon thresholds of risk-tolerance. But given the lack of evidence for interventions, how can decision-makers make choices about actions (or inactions) to best promote public health?

The oft-mentioned precautionary principle may provide guidance. One of its earliest formulations states that ”where there are threats of serious or irreversible damage, lack of full scientific certainty shall not be used as a reason for postponing cost-effective measures.” However, how this translates into policies is unclear. Some interpret the principle as a decision-making algorithm (akin to Rawl’s minimax principle, where the policy that risks leading to the worst outcome should be avoided). Others invoke the principle in determining what we admit as evidence to favor the safer option, for example, by accepting less statistically significant results.

The strongest versions of the principle, however, are prone to suffer from over-allocation of resources to prevent low-probability harms and decision paralysis due to risks inherently incurred by all options. Additionally, alterations of our threshold for admitting studies as evidence for one conclusion but not another may fall prey to our biases as we selectively overlook outcomes.

Limited Sympathies

The issues become more complex when evaluating how communities may interact with another. This is perhaps most obvious when countries hoard resources for the benefits of citizens. But the analysis need not be restricted to a mere matter of relations between nations, as humans tend to identify with communities at sub-national and international levels.

Some question whether we should make distinctions between communities at all. Consider this thought experiment: if a child is at risk of death and saving him would require little effort, would your choice of whether to save him differ if he belonged to a different community? If you answer no, perhaps it implies that all humans ought to be treated as members of a single community, what some would call cosmopolitanism.

However, the hypothetical assumes that saving “strangers” requires little effort. Whereas a firm subscriber of cosmopolitanism would argue the effort required is irrelevant, many would struggle to answer the same question if saving strangers leads to risks to friends and families. While we typically assume that all individuals ought to be given equal moral consideration, it is perhaps unrealistic to expect us to be equally emotionally invested in all individuals. Here is where we hit the limitations of certain ethical theories: the idealized “moral saint,” who is never an egoist (who favors those we have personal ties to) and always treats all individuals equally, is likely an unrealistic goal for most of us. Some may propose imagining a ring of concentric circles, where duties are stronger when one is closer to the individuals involved. Under such frameworks, some may modify tiers of responsibilities in relation to the communities we identify with. References:

Case Studies: Public Health Ethics in COVID-19

Face Mask Mandates and Social Distancing

Starting in March of 2020, many states in the United States followed the example of countries around the world and began to implement stay-at-home orders, or social distancing for all individuals, and quarantine for exposed individuals. Historically, quarantines have been contested because of the severe restriction on individual liberty. In the HIV crisis of the 1980s, advocates argued that individuals with HIV should not be forced to isolate from society as it violated their human rights. We can imagine that a libertarian would also defend this position, as individual liberty trumps the public interest.

The debate regarding the necessity of social distancing and face masks can be framed as a tension between those who believe the policy to be justified paternalism and those who prioritize individual rights. The defenders of face masks believe the government should impose these restrictions as it is in the individual and collective best interest. In many political theories, individual liberty is not absolute. As famously advanced by Rousseau, individuals accept the social contract, giving up individual liberties to the government to benefit from a stable social order. For example, in the U.S. constitution, the right to free speech is curtailed, as individuals are not allowed to endanger the public by shouting fire in a crowd. By contrast, the opponents of face masks and social distancing believe that governments and states do not have this authority—it infringes too much upon individual rights, and is therefore an illegitimate policy.

However, when we frame this debate as a dichotomy between individual rights and paternalism, we may miss an important dimension—the mutual vulnerability of individuals and the right not to be harmed by others. Amy Fairchild, Lawrence O. Gostin and Ronald Bayer suggested that social distancing has not been opposed as fiercely as in the AIDS epidemic because of the severe contagiousness of COVID-19 [1]. Since individuals who are asymptomatic or pre-symptomatic may spread COVID-19 to others, we depend on the actions of others in our community to keep us safe. Hence, some defenders of face masks and social distancing have started to argue that social distancing is a right itself [1]. That is to say, individuals have a right to be protected against COVID-19 and not be harmed by others who put them at high risk by not social distancing. In this way, others have a duty to social distance to protect those who are vulnerable. This argument has been made especially for individuals in communities facing higher rates of COVID, as otherwise these communities will disproportionately bear the burden of disease (see module on Health Disparities).

Still, considering what constitutes justified paternalism is important when defining the boundaries of social distancing and face masks. For instance, questions remain about the proper punishment for not following social distancing rules and the level of risk that is acceptable for businesses to re-open.

Reopening Measures

The dilemma of whether or not to reopen primary schools tests the extent to which we accept risks. A survey found that the majority of parents believed that “schools should remain closed until they are certain there is no health risk.” It is, however, unlikely that the statement is chosen following careful reflection. Risks represent a mere probability of a harm occurring; risks are inevitable in daily lives, even without epidemics. A more defensible version of the statement, therefore, is perhaps that a “minimal risk” is acceptable, where the risk is not in excess of what is encountered in daily lives. Even in considering the acceptance of a “minimal risk” threshold, we are no longer playing a game of minimax according to which even the infinitesimally small risk of the worst outcome is unacceptable.

As opposed to using the precautionary principle as an algorithm for making decisions, perhaps it should be utilized as a consideration for appraising scientific evidence. In other words, we need more robust, statistically significant evidence to warrant the reopening of schools than evidence to warrant continued closures, because we presume the harm potentially associated with reopening is greater than that of closure. Even if other countries have successfully reopened schools, the precautionary principle urges us to err on the side of avoiding risks and harms.

One counterargument is that such stances are based on our implicit biases. When we err on the side of precaution, which side are we talking about? When discussing the impact of reopening schools given the epidemic, many will jump to the conclusion that an increased number of interactions may facilitate transmission of the virus, which has frightening consequences of economic harm and longer periods of social distancing. Few will intuitively consider the other side of the equation—that of reduced social-emotional learning for children, inability for students from lower--class families to access free or reduced-price meals, reduced provision of therapeutic services by schools, limited physical activities, etc. All of these variables may even exacerbate inequalities in our society, leading some to the conclusion that the reopening of school is essential, and that the “precautionary action” is to reopen schools.

It is also important to consider that consequences of policies interact with one another. If we are willing only to accept a small amount of risk, it may make policies mutually exclusive—it would, perhaps, go above the tolerable risk threshold to simultaneously open schools and restaurants, leaving us only the options of reopening one or the other.

The question is therefore misframed when we consider closure of schools to be “precautionary”, whereas reopening to be “risky”. All options have a risk, regardless of how small, to lead to the “worst outcome”. Both action and inaction entail risks of harm and potential for benefit. Instead, we should consider the maximal tolerable cumulative risk that we are willing to accept, and given risk tradeoffs, what we are willing to sacrifice for the reopening of schools.

Herd Immunity and Vaccines

In recent years, there has been resistance to mandatory vaccinations. While many of their concerns have little to no scientific credibility, these apprehensions are important to respond to in a global health crisis as they will affect public health outcomes. In many cases, unease over vaccinations may emerge from vaccine hesitancy rather than complete refusal (“anti-vaccination”) [2]. Healthcare providers and physicians can play a critical role in supporting public health by reassuring, educating, and building trust with their patients.

It has been incorrectly suggested that those who voluntarily get vaccinated represent a large enough fraction of the population to protect the remainder from infection, referred to as herd immunity. This status becomes incredibly important for protecting those that are unable to be vaccinated, such as the immunocompromised, newborns, etc. Unfortunately, herd immunity requires a much higher percentage of the population to be vaccinated. There is currently no consensus on the percentage required to achieve herd immunity against SARS-CoV-2, but other infectious diseases require vaccination rates upwards of 85% and 90% [3]. These statistics do not consider isolated communities that choose not to be vaccinated, which would not be protected. Thus, determining how to set ethically sound policies for vaccination are critical for infectious disease containment.

Perhaps we should support a paternalistic policy in which all individuals that immunologically qualify are required to receive the vaccination. Or, instead, a libertarian framework may be more appropriate, where individuals should be able to decide whether they would like to get the vaccine. Yet, we may feel obligated to support a “nudging” stance, similar to that in the California school example, where everyone is required to be vaccinated unless they go through an “opt-out” process. This final framework may find the balance between the two more extreme stances.

However, in a time of global health crisis, some may feel more obligated to support mandatory vaccination for all instead of a middle ground. For instance, policies may restrict the activities of those who choose not to get vaccinated. Individuals may not be allowed in certain public places (parks, pools, etc.) without proof of vaccination, and children may not be allowed to attend daycares or may have to remain virtual for school. In large part, these paternalistic policies would make a clear point: getting vaccinated is partially about protecting yourself, but also about protecting your community, especially those who are unable to be vaccinated.

This decision illustrates the difficulty in determining what is ethical for the good of the public—should individual rights be curtailed for the good of the many (paternalism) or to protect the rights of others (rights-based argument), upheld for the good of the individuals regardless of the potential outcome (libertarianism), or somewhere in between to make individuals more likely to receive vaccinations (nudging theory)? Of course, these frameworks presuppose a “safe and efficacious” vaccine, which is the goal of the many Phase 3 trials being conducted currently. To protect patients’ bodily autonomy, healthcare providers must never force a patient to be vaccinated against their will—but, for the sake of promoting public health, we are obligated to educate patients and the public about the benefits and risks.

We must state outright: vaccinations are beneficial and, in most circumstances, should be administered to as many individuals as possible in situations where the benefits outweigh the risks. The dilemma lies, as described, in how to achieve that goal.

References:

  • [1] Fairchild, A., Gostin, L., & Bayer, R. (2020). Vexing, Veiled, and Inequitable: Social

    Distancing and the “Rights” Divide in the Age of COVID-19. The American Journal of Bioethics, 20(7), 55–61. https://doi.org/10.1080/15265161.2020.1764142.

  • [2] Schwartz, J. L., & Caplan, A. L. (2011). Vaccination Refusal: Ethics, Individual Rights,

    and the Common Good. Primary Care: Clinics in Office Practice, 38(4), 717–728. https://doi.org/10.1016/j.pop.2011.07.009.

  • [3] Omer, S. B., & Orenstein, W. A. (2009). Vaccine Refusal, Mandatory Immunization, and the Risks of Vaccine-Preventable Diseases. The New England Journal of Medicine, 8.

Public Health Ethics of Quarantine and "Typhoid Mary"

History of Quarantines

Different from isolation, which is the restriction of movements of symptomatic individuals to prevent them from infecting the susceptible general public, quarantine is the restriction of movements of asymptomatic individuals exposed to the contagion but have not experienced symptoms. Individuals exposed to COVID-19 are mandated to quarantine for 14 days at home and monitor their symptoms daily.

The English word quarantine was derived from the Italian words quaranta giorni, meaning 40 days, when ships had to anchor for 40 days upon arrival in Venice due to concerns with the Black Death. Before germ theory was widely accepted in the late 1800s, quarantine practices were adopted worldwide to contain the spread of infectious diseases. The first recorded quarantine was mandated in the Byzantine Empire to handle the bubonic plague in A.D. 549. The earliest quarantine law was established by Massachusetts in 1647 to prevent the transmission of the plague from the West Indies. The Pan American Sanitary Bureau was created in 1902 as the first international effort to bring global collaboration of infectious disease control, which later led to the formation of the World Health Organization in 1948. The Public Health Services Act in 1944 founded and authorized the Communicable Disease Center (CDC), which later became the Centers for Disease Control and Prevention, to detain, examine, and quarantine individuals suspected of transmitting infectious diseases.

(Source: https://www.who.int/whr/2007/07_chap1_en.pdf)

In the US, quarantine restrictions are mostly regulated at the state level, but a federal court could overrule a state's decision, as evidenced by the case of Jew Ho v. Williamson in 1900. In addition, tribal lands could impose reservation-wide restrictions, which are also subject to Congress modification via the Indian-commerce clause. However, tribal autonomy has been well preserved historically.

Rothstein’s Quarantine Justification Framework

Quarantine is a public health measure used to slow down the spread and alleviate the negative consequences of a disease when uncertainties are abundant and therapeutics lacking. However, it can also lead to social harm, such as economic disruptions, social inequalities, and unrest. It infringes on individual liberty, and, if used too strictly, could erode public trust and be counter-productive. When discussing the ethics of quarantine, Rothstein proposed a framework where these four aspects should be considered:

  1. Necessity, effectiveness, and scientific rationale. Does an asymptomatic individual pose a threat to the public? Is separating them from the public efficacious enough to contain the spread? For example, during the Ebola outbreak, villagers in Sierra Leone were told to care for family members at home. Lack of proper training and limited resources led to more infections to caregivers. Quarantine is one public health measure, but it is only useful if it is part of a comprehensive and effective plan.

  2. Proportionality and least infringement. Proportionality assesses whether the level of restrictions is proportional to the severity and transmissibility of the infectious diseases of interest. During the early days of the Ebola outbreak in West Africa, a voluntary lockdown was enforced but was shown to be not effective at containing the spread. Least infringement discusses invasion of personal freedom. During the SARS outbreak, Singaporeans were monitored with video cameras at home to enforce quarantine. In addition, they would be electronically tagged if they violated their quarantine. Wuhan closed off travel of the entire city in the early days of COVID-19 outbreak. Depending on the prevailing culture in a region, the level of acceptable infringement on individual rights varies widely.

  3. Humane supportive services. Quarantine limits social and economic activities, placing financial burden on the individuals in quarantine. For quarantines to be effective, supportive services need to be put in place to ensure the basic needs and dignity of quarantined individuals are met. If such services do not exist, families are forced to break quarantine and work to meet their basic needs, rendering the practice ineffective.

  4. Public justification. Public compliance of quarantine and other public health measures relies on effective scientific communication and justification (See Module 5 for more information). Historically, xenophobia and panic have led to discrimination against specific groups. Scientific communication and public health measures cannot be isolated from other current events, political or otherwise. For example, the 1918 Spanish flu occurred during World War I. Trying to boost wartime morale, President Woodrow Wilson downplayed its risks and disregarded quarantine as an essential disease prevention measure, leading to 675,000 deaths.

Quarantine Example: “Typhoid Mary”

In this section, we will examine a highly controversial case of quarantine, “Typhoid Mary,” and use the framework proposed by Rothstein to discuss its relevant ethical considerations.

Mary Mallon, commonly known as “Typhoid Mary,” was an immigrant and cook in New York in the early 1900s. She unknowingly spread typhoid to her clients as she switched jobs from house to house, leading to 22 illnesses and 1 death of a young girl in the families for which she worked. She was also reported to serve ice cream in public on Sundays. In 1906, a sanitary engineer, George Soper, traced the infections back to Mary, who was somehow asymptomatic, uncommon in people with the ability to transmit typhoid. During a time when germ theory was not widely accepted and hand hygiene was not emphasized, Mary did not see the need to wash her hands before cooking. She was the first identified asymptomatic carrier, though it was not known how she could infect others while being symptom-free. When asked by Soper to be tested, she did not see the need and resisted vehemently. Against her will, she was sent by the New York Department of Health to quarantine in a cottage on North Brother Island for two years. During that time, she was reported to be treated like a laboratory pet and repeatedly tested and medically treated without her consent. Having found high levels of Salmonella typhi in her gallbladder from the samples, authorities advised her to remove her gallbladder, to which she refused. After an unsuccessful lawsuit against the health department, she was released but told never to be a cook again.Upon her departure, Mary took a low paying job as a laundress. Seeing she could not make a living with that salary, and still not convinced she could infect others, Mary found her way back into cooking under a different name, leading to even more infections. She was eventually forced to quarantine again on North Brother Island for 26 years until she died in isolation. It was reported that her autopsy showed high levels of bacterial infection in her gallstones, lending credence to the proposed medical procedure to remove her gallbladder. However, some questioned such a report and suspected it was used to calm the public amid controversial ethical debates. At the time of Mary’s death, 400 other asymptomatic carriers of typhoid were found, but none were forced into solitary confinement.

Thought questions using Rothstein's framework:

  • Was Mary’s quarantine necessary, effective, and scientifically sound? Keep in mind this was in the early 1900s, when many modern scientific discoveries were absent.

  • Is Mary’s quarantine proportional to the threat she posed to the public? How was this infringing on her personal freedom?

  • Was Mary provided with the necessary supportive services during her quarantine? What about after her first quarantine when the authorities told her not to be a cook again?

  • How was Mary’s quarantine justified to her and to the public?

Additional thought questions:

  • What ethical and legal responsibilities do the departments of public health, or other organizations have?

  • What moral responsibilities and rights do germ carriers, symptomatic or asymptomatic, have?

  • How would you weigh personal liberty against public health?

  • What medical ethics principles are violated in Mary’s case?

Vaccine Distribution for Public Health

Generally, resource allocation itself falls into two broad categories: micro allocation and macro allocation. Examples of macro allocation in medicine include widely used guidelines at the population level. Generally speaking, macro allocation principles are considered acceptable and ethical in the realms of public health ethics and policy [1]. When considering the public health ethics informing vaccine allocation, it is necessary to consider the global distribution process as well as the national vaccine allocation protocol in the US.

Recently, a partnership between 156 countries and The World Health Organization (known as COVAX) formed the "COVID-19 vaccine allocation plan" to express the rules, regulations, and distribution plans to deliver "2 billion vaccine doses by the end of 2021" [2]. The rationale of COVAX is to encourage collaboration rather than competition and prevent hoarding among member countries [2]. According to the World Health Organization (WHO), there are two phases of vaccine allocation. Phase one will give each country an amount of vaccine proportional to their population. For instance, India, which has a population of 1 billion, will receive 30 million doses. In contrast, Australia, which has a population of 26 million, is allocated 780,000 doses. In both cases, the countries receive enough vaccine doses to cover 3% of their population. Later into phase one, the percentage may continue to rise to a 20% threshold.

Lastly, if the supply continues to remain limited after a 20% threshold is reached, COVAX will prioritize countries with higher incidences of infection. Regardless, the individual countries' policy on vaccine allocation within their population remains in the hands of their public health departments and governments [2]. The USA is currently not part of COVAX. It is attempting to privately fund, develop, and distribute vaccines to its population.

Like the WHO, the American Center for Disease Control (CDC) has stated that the COVID-19 vaccine administration will require a phased approach. If the FDA approves a safe and effective vaccine, there are numerous considerations in the logistics and supply chain [3]. Mass vaccination clinics are considered difficult centers for vaccine administration due to social distancing restrictions. Healthcare homes, PCP offices, and pharmacies are under consideration as potential sites for vaccine administration. It will be challenging to equitably distribute vaccines to low socioeconomic communities, racial and ethnic minorities, and rural populations in not just the US, but the world.

Because healthcare professionals working in hospitals are at the highest risk of contracting COVID-19, the CDC suggests administering vaccine doses to healthcare workers first. Specifically, healthcare workers who work in long-term healthcare facilities are the highest priority among other healthcare workers in the current CDC framework [4]. Healthcare workers number 17 million to 20 million individuals within the overall US population.

Next, the CDC plans to distribute the vaccine to those classified as essential workers in non-clinical settings [4]. Within this next group, some occupations' prioritization may have precedence over other essential occupations; however, this is up to local jurisdictions to decide. Population models indicate that the US has 60-80 million people in the essential worker category.

The next level of prioritization for the COVID-19 vaccine is for adults with medical conditions such as cancer, chronic kidney disease, chronic obstructive pulmonary disease (COPD), immunocompromised state from solid organ transplant, obesity (BMI of 30 or greater), severe heart conditions (heart failure, coronary artery disease or cardiomyopathies), sickle cell disease and diabetes [4]. There are over 100 million adults with these underlying conditions and are considered high risk.

COVID-19 is also a disease that has had more severe consequences in older adults, so the next priority group is adults over 65. The US has 53 million adults over the age of 65 [4]. Once these four priority groups receive the vaccine, the government aims to distribute the vaccine to the remainder of the population as more doses become available.

The CDC's vaccine allocation checklist protects those most at risk of contracting COVID-19 first and foremost, followed by protecting the sickest and most vulnerable. Once these two populations (often, but not always overlapped) are vaccinated, the CDC plans mass distribution to the remaining population [2,4]. As vaccine trials are ongoing, national and worldwide governments are working on storage and distribution protocols to ensure equitable vaccine allocation and distribution. The NIH and CDC recently refer to definite overlap within the four top priority groups [4]. They suggest that the next steps towards a more equitable distribution plan are to create sub-groups within the priority groups for a more detailed allocation protocol. Therefore, the next steps are to overview epidemiological data and assess COVID-19 risk by demographic variables such as gender, race, and ethnicity.

References

COVID-19 Immunity-Based Licenses

Immunity-Based Licenses

Chile, Germany, China, the UK, and the US have indicated varying levels of interest in “immunity passports”, or more broadly “immunity-based licenses” – certifications that a person has contracted and recovered from COVID-19 or (foreseeably) has received a COVID-19 vaccine.[1,2] Such licenses have mostly been proposed as an avenue to reopen international travel. However it has also been suggested as a checkpoint for employment (especially for essential work), housing, school, domestic travel, and entry into public spaces – including banks, government offices, or voting booths. This proposal has been met with controversy from scientists and ethicists alike.

First, the long-term immunity to COVID-19 is itself unclear. Reports of COVID-19 reinfection have been confirmed in Hong Kong, Belgium, the Netherlands, and even Nevada (USA).[3] Even if the presence of detectable antibodies might be used as a proxy for immunity, there is not yet a consensus on what amount of antibody is sufficient for protection and how long this protection is conferred for.[4] Data from seroprevalence studies will be needed to accurately inform policy based on key metrics such as sensitivity, specificity, precision, and false discovery rate.[5] Thus, certifications of functional “immunity”, especially if deployed too early in the pandemic, may give false reassurance regarding the safety of public interaction and might even propagate more infection.

However, even if antibody testing is validated as a viable proxy for establishing immunity, immunity-based licenses raise several ethical concerns as to potential infringement on autonomy and civil liberty. A widely-circulated paper by medical ethicists Persad and Emanuel explored the ethical rationalization behind such licenses based on the public health principle of the “least restrictive alternative”, which forbids any measures more restrictive than necessary to achieve public health objectives.[6] They argued that current liberty-limiting restrictions on social gathering, work, and travel are justified while COVID-19 poses significant harm; however, immunity-based licenses afford individuals a chance to demonstrate little to no risk of infection, deeming the aforementioned restrictions unjustified for licensed individuals. Persad and Emanuel compare immunity-based licenses to driver’s licenses (rather than passports), which do not entirely ban risky activities but instead licenses individuals to participate only after individual evidence of safety. The term “license” is intended to restrict the dichotomy of immune status is only relevant to the risky activities to which the license is applied - unlike that of “passport” which may create a stronger separation between groups.

Biological Citizenship

“Biological citizenship” (roughly equivalent to “biocitizenship” and “genetic citizenship”) is rooted in Foucaldian “biopower”, which asserts that the control and management of people is an innate aim of political governance. Petryna coined the term “biological citizenship” to apply to public movements of patient advocacy and civic engagement seeking welfare, reform, and remuneration among individuals who had been exposed to radiation from Chernobyl.[7] Petryna’s definition of biological citizenship may be understood as a neoliberal expansion of patient rights that harnesses the political power of shared genetic status or disease state. Subsequent sociologists and anthropologists – notably Rose and Novas – have expanded “biological citizenship” to mean an active form of citizenship that produces new claims on belonging, expertise, and access to resources based on biological claims, entailing risk of surveillance, exclusion, and discrimination stemming from biological and genetic identities.[8-10] Examples include the genetic burden of proof for immigrant family reunification (which foregrounds Western biological constructs of the family)[11] and the lobbying power of disability rights movements for legislative accommodations and protections to ensure equal rights for people with disabilities.[12] Essentially, biological information may be used by political entities to empower, affirm, disenfranchise, racialize, discriminate, stratify, and/or surveil citizens along with existing socioeconomic divisions as well as novel hierarchies based on biological condition or disease state.

We might use biological citizenship to understand the implications of immunity-based licenses on sociopolitical identity and civil liberties more broadly. We can imagine that the state-sanctioned utilization of immunity as a proxy for participation in civil activities might create two distinct classes of individuals: the immunolicensed and the immunorestricted. The former are those who are “immune” or vaccinated, and have been given full license to participate in civil life without restriction. The latter are those who have not yet contracted COVID-19 or do not have access to the vaccine, and thus continue to operate with restrictions on their civil liberties on the basis of protection given latent vulnerability. We will use these classes to explore a few of the emerging ethical dilemmas concerning immunity-based licenses:

  • Unfair access: We can predict that separation into immunolicensed and immunorestricted subpopulations might track with existing socioeconomic stratifications in society. With a shortage of testing in several states, those who are wealthy and powerful in society have greater access to rapid COVID-19 testing at their convenience.[13] On the other hand, those who would need licenses most urgently – such as those who are unemployed, uninsured, and financially underprivileged – might encounter the greatest difficulty in finding nearby testing centers and obtaining timely results. Similarly, driver’s license fees have been shown to unfairly burden low-income individuals.[6] Disparities in access to testing and additional out-of-pocket costs of licensing may exacerbate existing inequalities. Depending on early vaccine administration procedures, it is possible that the wealthy may find ways to jump the line and ensure vaccination before other needy subpopulations, entrenching existing social powers in the immunity-based hierarchy.

  • Incentivizing infection: Deploying immunity-based licenses as a restriction to work, travel, and civil participation may create a perverse incentive for individuals to willfully seek out infection.[14] With prior efforts of willful infection in service of herd immunity having been unsuccessful,[15] such efforts would pose a risk not only to individuals, but also those with whom they come into contact. Willful infection is especially a concern among those who are unable or hesitant to seek medical care due to out-of-pocket cost, inadequate insurance status, or discriminatory access. Often, these characteristics track with minority and immigrant communities, which also display elevated susceptibility and mortality to COVID-19 due to higher prevalence of comorbidities.[16] Those who are most in need of licensing and a pathway to civil re-engagement may be deprioritized in access to medical care, serological testing, and (eventually) vaccine administration; they may be left with little practical alternative to actively seek infection. Without significant logistical amendments, immunity-based licenses may very well perpetuate existing racial and socioeconomic disparities in COVID-19 morbidity.

  • Potential for discrimination: Linking immunity status to civil participation raises serious concerns as to the ability of citizens to exercise their constitutional rights. For example, the immunolicensed would be first in line to receive emerging offers of employment, especially in positions with high rates of interaction.[2] While there are protections against discrimination based on medical condition, it is unclear as to whether COVID-19 immunity would fall under this category for the following few reasons. First, the population prone to discrimination are those without evidence of infection. Second, the transmissibility of COVID-19 might invoke restriction of anti-discriminatory clauses due to potential harm to others.[17] The potential for discrimination is all the more troubling in relation to public rights such as suffrage. Let us imagine that prospective voters are barred from entering the voting booth without presenting a formal, state-approved immunity-based license (similar to current voter identification requirements) and are otherwise only left with mail-in ballots (the accessibility for which varies between states). This could result in a disenfranchised immunorestricted class, potentially compounding existing racial and socioeconomic disparities in voter participation.

  • Threats to privacy: Immunity-based licensing does not only run the risk for discrimination along COVID-19 immunity status. Some Chinese provinces have utilized smartphone QR codes conveying COVID-19 exposure status to control entry into public spaces. First, these technologies may pose a barrier to older and poorer populations, who may not have the experience with or access to smartphone platforms. A more insidious concern is that apps have been found to track people’s locations, travel history, and other health information – providing a platform right for citizen surveillance.[18] The convenience of electronic immunity-based licenses aside, increasing law enforcement encroachment into genetic databanks raises serious concerns as to long-term access to biological information.[19] This sets an uneasy precedent of state-sanctioned collection of private health information, which may be expanded to mental health, chronic conditions, and genetic information from health records. States should exercise caution before deploying electronic immunity-based licenses to ensure encryption and/or destruction from access by private entities and law enforcement beyond the duration of the COVID-19 pandemic.

References:

  • [1] Bartlett J. Chile’s ‘immunity passport’ will allow recovered coronavirus patients to break free from lockdown, get back to work. The Washington Post. 2020. Published April 20, 2020. Accessed October 2, 2020.

  • [2] Phelan AL. COVID-19 immunity passports and vaccination certificates: scientific, equitable, and legal challenges. The Lancet. 2020;395(10237):1595-1598.

  • [3] Joseph A. Scientists are reporting several cases of Covid-19 reinfection — but the implications are complicated. STAT. 2020. Published August 28, 2020. Accessed October 2, 2020.

  • [4] Long Q-X, Liu B-Z, Deng H-J, et al. Antibody responses to SARS-CoV-2 in patients with COVID-19. Nature Medicine. 2020;26(6):845-848.

  • [5] Winter AK, Hegde ST. The important role of serology for COVID-19 control. The Lancet Infectious Diseases. 2020;20(7):758-759.

  • [6] Persad G, Emanuel EJ. The Ethics of COVID-19 Immunity-Based Licenses (“Immunity Passports”). JAMA. 2020.

  • [7] Petryna A. Biological Citizenship: The Science and Politics of Chernobyl-Exposed Populations. OSIRIS. 2004;19:250-265.

  • [8] Rose N, Novas C. Biological Citizenship. In: Ong A, Collier S, eds. Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems. Oxford, UK: Blackwell; 2005.

  • [9] Raman S, Tutton R. Life, science, and biopower. Science, Technology, & Human Values. 2010;35(5):711-734.

  • [10] Wehling P. Biology, citizenship and the government of biomedicine: exploring the concept of biological citizenship. In: Brockling U, Krasmann S, Lemke T, eds. Governmentality: Current Issues and Future Challenges. New York: Routledge; 2010.

  • [11] Heinemann T, Lemke T. Biological citizenship reconsidered: the use of DNA analysis by immigration authorities in Germany. Science, Technology, & Human Values. 2014;39(4):488-510.

  • [12] Fitzgerald R. Biological citizenship at the periphery: parenting children with genetic disorders. New Genetics & Society. 2008;27(3):251-266.

  • [13] Lieberman-Cribbin W, Tuminello S, Flores RM, Taioli E. Disparities in COVID-19 Testing and Positivity in New York City. American Journal of Preventive Medicine. 2020;59(3):326-332.

  • [14] Kofler N, Baylis F. Ten reasons why immunity passports are a bad idea. Nature. 2020;581:379-381.

  • [15] Orlowski EJW, Goldsmith DJA. Four months into the COVID-19 pandemic, Sweden’s prized herd immunity is nowhere in sight. Journal of the Royal Society of Medicine. 2020;113(8):292-298.

  • [16] Evans MK. Covid’s Color Line — Infectious Disease, Inequity, and Racial Justice. New England Journal of Medicine. 2020;383(5):408-410.

  • [17] Mello MM, Persad G, White DB. Respecting Disability Rights — Toward Improved Crisis Standards of Care. New England Journal of Medicine. 2020;383(5):e26.

  • [18] Mozur P, Zhong R, Krolik A. In Coronavirus Fight, China Gives Citizens a Color Code, With Red Flags. The New York Times. 2020. Published March 1, 2020. Accessed October 2, 2020.

  • [19] Rothstein MA, Talbott MK. The Expanding Use of DNA in Law Enforcement: What Role for Privacy? Journal of Law, Medicine, and Ethics. 2006;34(2):153-164.

Is the Cure Worse Than the Disease?

Some have suggested that we must be careful that the "cure" for COVID-19 is not worse than the disease itself. By this, they suggest that public health measures, including social distancing, are taking a dramatic toll on our economy, increasing unemployment, and bringing sectors of the economy to a halt. Many people fear that we are at the beginning of a serious recession that will cause untold hardship for millions of Americans over the course of months to years.

Considering the alternative, if we stop social distancing and allow viral spread, a large number of Americans are projected to die, primarily people older than 60 with pre-existing medical conditions, but also many younger people. In the process, hospitals around the country will be forced to make tragic choices regarding who should receive a ventilator, whether patients with COVID-19 should automatically be made DNR, and many other rationing issues raised earlier. Most likely, we will all know someone who has died of the virus if it continues to spread. However, Americans may develop herd immunity soon and be able to return to work and socialize as before. At the same time, it is important to remember that we do not know how long immunity lasts and if people can get re-infected.

It is hard to carefully consider such catastrophic consequences. Most individuals have never experienced a pandemic this severe, but perhaps the subsequent recession will be greater than any recession in American history. With a large portion of the population unemployed, suicide rates could increase, crime could rise, and many people could develop food insecurity. It is improbable that millions of Americans would die of suicide or starvation, but almost everyone’s lives will be affected for the worse, and those of us who are already the most vulnerable may find ourselves in dire straits.

We have to ask ourselves, are the lives of a smaller group of people, in this case, those who may die from COVID-19, worth immense hardship for a larger group of people? Do we value life above all other goods, or is it possible for quality of life considerations to outweigh life? A utilitarian, who values utility or happiness and aims to achieve the greatest utility for the greatest number of people, may prefer to end social distancing and open the economy. A deontologist, who supports the morally correct option over the option with the best results, may prefer to avoid allowing millions of Americans to die. Now approach the problem the other way: how could a utilitarian prefer social distancing and a deontologist prefer allowing viral spread?

References:

What Do We Owe Each Other?

While much of the debate surrounding the COVID-19 public health response centers on the use of government power, we can consider what we owe each other in a time of crisis. In particular, what do the healthiest among us owe to the most vulnerable?

The U.S. has broken into two camps: those that are observant of social distancing and hopeful of flattening the curve and those that have pushed back against public officials’ pleas to stay home. In China, social distancing policies were harder to evade, as officials closed off apartment complexes and screened millions for elevated temperatures. Yet, in the U.S., there is a strong sense of letting individual liberties prevail in some parts of the country and “carrying on” despite the ongoing crisis. For example, the Washington Metro issued statements asking that people not take the Metro to see the cherry blossoms this year, however, the cherry blossoms continued to draw crowds of people. There are countless examples in the news and media of people, including business owners and government officials, defying social distancing policies. These opposing views bring up a common debate in American politics: When do we sacrifice personal liberties to protect the safety of communities?

How we react to this crisis depends on our understanding of when individual rights must be limited in favor of supporting more vulnerable populations. We are social creatures that thrive in groups, meaning we must make certain sacrifices to be a part of that group. Thomas Hobbes, for example, argues that we intentionally surrender some of our rights to the government for security and other benefits. T.M. Scanlon, a moral philosopher, states, “The idea is that actions are wrong if a principle that permitted the action couldn’t be justified to the affected people in the right way.” In other words, people that defy social distancing rules would have to justify their decisions to the community, particularly older and sicker individuals. Communitarianism is a emphasizes the connection between individuals and the community. The principle of “solidarity” asks that we act in a way that supports the most vulnerable members of our community and that we not abandon those in need in a time of crisis. A more personal perspective: we all have a friend or loved one who is vulnerable to COVID-19 - what would we want others to do to protect them?

Thought questions:

  • What arguments do you see in favor of social distancing? What arguments do you see against those measures? What do we owe each other as members of a community during a crisis?