Hello, I'm David Edmonds and this is the Pandemic Ethics Accelerator Podcast.
The UK Pandemic Ethics Accelerator was a project funded by the Arts and Humanities Research
Council in 2021 22 to examine the ethical challenges faced during the COVID pandemic,
it combined expertise from the University of Oxford, Bristol, Edinburgh University College, London and the Nuffield Council on Bioethics.
This six part podcast series covers some of the themes that emerged from the research.
Vaccines to combat COVID were developed in record time.
But policymakers then faced a tricky question. It was impossible to vaccinate everyone immediately.
So who to inoculate first? Jonathan Pugh of Oxford University's U.
Healer Centre for Practical Ethics, says there were complex trade offs.
Jonny Pugh, welcome. Thanks for having me, Dave.
Before we get to the substance of the argument about how to prioritise vaccines, let's remind ourselves of some of the background.
When the virus vaccines were introduced, we knew who the most vulnerable people were.
Mostly risk was correlated with age, and the older you were, the more at risk you were.
But did we have robust data on how effective the vaccines would be with the various age groups?
So that's a really important question. Start thinking about prioritisation.
So we first saw the vaccines being approved in late 2020 on the basis of Phase three trials.
And these trials were effectively designed to tell us how effective the vaccines were going to be in reducing severe disease.
Now, a couple of the trials gave us some limited clues about the effectiveness in different subgroups,
but they didn't have enough participants to give us robust data on that point.
So we didn't know enough about the vaccines to be certain about just how effective they would be in different age groups.
Another thing we didn't know much about is whether they would be effective in preventing onward transmission.
So again, we had some limited clues in some of the studies. We had some data about the vaccines potentially preventing asymptomatic cases.
But again, this was in very small numbers. The key takeaway from the phase three trials from which the vaccines were approved
was that they were effective at reducing severe disease across all age groups.
So there was obviously a fair amount of uncertainty. Can you just remind us how the UK ran its program?
There was a phase one and a phase two. Start with phase one. Yes, that's right.
Phase one was initiated almost as soon as the vaccines were approved.
And the idea here was that the prioritisation was aiming to prevent 99% of COVID related mortality.
So to that end, the UK outlined nine prioritisation groups with groups one and two representing those at greatest risk.
So these included those in aged care, home facilities and frontline care home staff.
Second group, those aged over 85 and frontline healthcare workers.
And each group went down in age bands of about five years, all the way down to age 50, about halfway down that prioritisation group.
There were other individuals included, such as those suffering from immuno compressed conditions.
So that was phase one. Phase two. So phase two started once all those had been offered a vaccine in the first phase, right down to those over age 50.
Now, there's a lot more debate when we started phase two because we'd already aim to prevent 99% of COVID related mortality in the first phase.
How the UK decided to press on with this age based prioritisation.
So essentially the first age group offered vaccinations in phase two where those aged over 45 and we continue right down to those aged over 18.
It's worth pointing out at this stage an unspoken assumption in the debate,
and that is that practically we couldn't vaccinate everyone immediately and spontaneously.
We had to choose. We had to privatise for logistical reasons.
There was a limited supply of people qualified to administer the vaccine and also because there was a limited availability of vaccines themselves.
Yeah, and that's absolutely essential to thinking about prioritisation, because if it was possible to vaccinate everyone immediately,
we wouldn't really be faced with these difficult ethical questions because we could
simply make the vaccine available to everyone who wanted it at the same time.
But as you mentioned, there are significant logistical challenges in manufacturing,
that vast number of vaccines, doses that we needed, as well as delivering those vaccines in good time.
So this is the reason why we face such pressing challenges.
So that's some of the background. Those are the facts. Let's talk about the normative issues, the issues of morality.
Now, Britain chose to start by vaccinating the oldest, as you've mentioned, and certainly one can see the rationale behind that.
But I guess another way of distributing vaccines would have been at random.
You might think that that was a fair way of dealing with vaccine distribution.
That's absolutely true.
And some scholars have defended this idea that in a pandemic situation, we should be adopting a lottery, if you like, in allocating vaccines.
The rationale for a lottery would be that it is one way in which to ensure equality.
Everyone has an equal chance of accessing this scarce medical good.
It would also have the virtue of being easy and quick to implement.
The problem with that overall system, though, is that it is very inefficient.
It would have led to many preventable deaths. So.
Given what we knew about the virus at that stage, we knew that unvaccinated eight year old is a far,
far higher risk of death from COVID than an 18 year old.
So if we simply allocated in accordance with the lottery procedure,
we would have a system where the 18 year old has an equal chance to an eight year old, despite that vastly different risk.
You draw a distinction, in other words, between fairness and benefit.
I mean, the benefit is pretty obvious. The benefit is that you get to live.
Yes, that's absolutely right. And that's one useful way of framing the debate.
We're likely to face trade-offs in prioritisation between ensuring that people have an equal chance
to access this scarce good and achieving certain kinds of benefit with our allocation in this case,
perhaps saving as many lives as possible. So the ethical question about vaccine prioritisation is really about how we should
strike a balance between these two values of ensuring fairness on the one hand,
but also achieving certain kind of benefit. The benefit is complicated, though, isn't it?
Because you might think that if you save a five year old's life,
you're giving this child another 85 years of hopefully happy existence, whereas an 85 year old obviously doesn't have another 85 years.
That's also true,
and it speaks to a broader range of philosophical questions about how we should understand the relevant benefits in a prioritisation system.
So the U.K. and other countries, I should mention, appear to adopt a broadly consequentialist principle,
essentially seeking to maximise the benefit of saving the most lives.
That's a principle that can be supported by a wide range of theories.
Other things being equal, I think a lot of various would agree that it's better to save more lives from fewer.
It's also a principle that accommodates this broadly egalitarian point that all lives matter equally.
Now, during the pandemic, this principle is sometimes described as a utilitarian approach,
but that's perhaps a little misleading, and it speaks to some of the points you are raising in the question, Dave.
So utilitarianism is the view that we should bring about the greatest happiness for the greatest number for the utilitarian.
It's not lives per say that matter morally, but rather happiness or well-being.
So the utilitarian is going to be interested in a range of other factors beyond the number of lives prioritisation strategy will save.
So they might first be interested in the expected length of the lives that will be saved,
on the assumption that saving those who will live longer will lead to greater expected well-being.
So that approach would speak in favour of perhaps prioritising the youngest at risk patients,
such as clinically compromised 18 year olds, for instance, over the elderly, even if they're at considerable risk themselves.
Perhaps even more controversially, though, a true utilitarian approach would be interested in the well-being of those whose lives are saved.
Now, that approach is controversial because it perhaps fails to accommodate this idea that all lives matter equally,
and it would require us to make complex judgements about how good someone's life is for them.
In other words, it might suggest that you should save a happier life over a less happy one, because for the utilitarian, it's happiness that counts.
Absolutely on that true utilitarian perspective.
Now, that was, in fact, a considerable debate about this kind of utilitarian thinking in the pandemic.
There were some public figures appearing on media shows arguing against lockdowns
by invoking this idea that we should be really adopting a utilitarian mindset.
That provoked a lot of public debate. One point that we didn't fully acknowledge,
and that is that this kind of broadly utilitarian thinking does play some role in health resource allocation elsewhere.
So the U.K. has an advisory body called Nice, which advises on the use of treatments in the NHS,
and they said decisions on how much a new treatment costs per quality of life gained or quality.
So actually is a generic measure of disease burden,
including both the quality and quantity of a life lived where one quality amounts to one year of healthy life,
whereas a score below one but above zero amounts to one year of life lived with a disease burden that undermines quality of life.
So that's very interesting.
So colleagues are used by this organisation, nice to adjudicate on which drugs should be paid for by the National Health Service.
But we didn't smuggle in this idea of quality into pandemic thinking.
That's absolutely true. I think the first thing to say is that the use of colleagues in Nice is itself highly controversial amongst ethicists.
So that's perhaps one reason. The second reason is that it's far from clear that the role that niceness playing in medical resource
allocation can be translated straightforwardly to a prioritisation strategy in a pandemic context.
Certainly, I think the guiding principle for a lot of the decision making the.
Prioritisation in the pandemic was based on this fundamental notion that all lives matter equally.
And that's something that the broadly utilitarian approach takes into account.
The length and quality of lives being saved, if you like, fails to adequately accommodate.
Okay, so we talked a bit about the direct benefits which are lives saved and perhaps we include in that years saved.
Are there other benefits? Presumably a more indirect benefit is if I don't get ill from COVID, I can carry on being economically active, for example.
That's absolutely true. And in fact, some other countries accommodated that insight into their own prioritisation strategies.
So a number of countries around the world included key workers in their first phase of vaccine prioritisation, most notably China.
But also, Germany prioritised some key occupations in their initial vaccine prioritisation strategy.
The idea there being that as well as affording protection to vulnerable individuals,
it can be really important to safeguard certain social goods in your pandemic response.
So is that the only rationale for giving some kind of priority to NHS workers and other key workers in, say, the police or in key retail sectors?
Is it purely about these people being essential for the flourishing of society?
I think that's a significant justification, but it's not the only one.
So throughout the pandemic,
a lot of people working in these key occupations were asked to take on significant risk in delivering these key social goods.
Before we had the protection afforded by vaccination, there is an argument that once the vaccines were available, we had reasons of reciprocity.
If you like, to prioritise these professionals for vaccination,
an idea they perhaps deserved priority given what they had sacrificed in the pandemic already.
It's also worth noting that health care workers and care home workers were placed at
perhaps the highest degree of priority across a wide range of prioritisation strategies.
They are a particularly key occupation in the pandemic for obvious reasons.
If you are interested in saving the most lives with your prioritisation strategy, the first thing you need to do is to protect your healthcare system.
So healthcare workers and care home workers were placed at the highest priority of any profession for a wide range of reasons.
But even in phase two, the UK strategy was not to give priority beyond NHS workers to other professionals.
Yes, that's true. We continued to prioritise solely in accordance with age.
I think one rationale for that was that it was simply the most practicable approach that could be carried out very quickly.
We wouldn't have to obtain proof of which individuals were serving, in which professions and other important factors to take into account.
So it was really a decision made out of practicality.
There was at the time a great deal of public discussion about whether certain professions, particularly teachers, should be prioritised.
Again, drawing on these arguments to do with reciprocity, but also the need to ensure that schools could reopen.
For example, there were other safety risk factors, of course, that could have been taken into account at that second phase stage.
So even if we assume that in phase two, we should be seeking to save as many lives as possible,
we could perhaps have brought about the risk factors we took into account.
So occupational exposure to the virus was one important factor, but we also had a fair amount of data for that point to show that ethnicity,
obesity and social deprivation to take a few examples were also important risk factors for COVID mortality.
So Johnny, you're an applied ethicist and you've been focusing a lot of time looking at this.
Do you think we got it right? Not focusing, as other countries did, on those other risk factors and on issues of reciprocity,
pointing out that some people in some professions are more exposed to the pandemic and so are more deserving of a vaccine.
Yes, that's a very difficult question to answer in hindsight, because in many ways the UK appeared to do extremely well with its vaccine rollout.
I think the first thing to say is that I think we absolutely got phase one right.
I think prioritising 99% of mortality was an extremely important goal to achieve.
I think when we reached Phase two,
there were certainly more reasons to consider protecting certain key professions for the reasons of reciprocity and achieving social goods,
I've pointed out. But it's difficult to look at in hindsight because, as I said, the age based prioritisation had the virtue of practicality.
It could be carried out extremely quickly. It's not at all clear how quickly we could have rolled out the second phase of
vaccination if it had focussed solely on prioritising certain occupations.
So from a moral perspective, I think there were very strong reasons we would need to speak to those at the centre
of policymaking to find out just how practicable they would have been in the UK.
Context. Bringing in the international perspective raises another question.
Of course, we've assumed that the states priority is to help its citizens.
Is that an entirely contentious assumption?
Well, the short answer to that question is no.
So there's been a great deal of debate about the extent to which nations should prioritise their own citizens for vaccination.
Typically, when they've reached a stage where large numbers in their own countries have already received two doses before,
individuals living in less developed nations have been able to access a single dose.
In fact, the director of the World Health Organisation previously called for a moratorium on booster programs
until a larger number of vulnerable individuals in less developed nations had received vaccine doses.
Now this is a hugely complex issue. One complexity arises from whether vaccine scarcity alone was responsible for the
considerable inequity between vaccine uptake in developed and less developed nations.
There's also a question about whether it was in developed countries best interests to prioritise their own citizens.
Certainly there was an argument that if more doses had been delivered to less developed nations,
perhaps we might have had a better chance of reducing the likelihood of dangerous mutations such as the variant that we saw arise.
So there are those empirical complexities, but once we assume that scarcity was partly responsible for the vast inequity we saw in vaccine allocation,
then really settling the question is going to require us to form a view about how we should set up the debate between cosmopolitanism and nationalism.
And that, of course, is a debate that has a huge history and philosophy, and we probably can't settle it here.
I think one thing we can say is that it would perhaps be appropriate to set a threshold of protection in developed nations,
such that once that level of protection has been achieved, it can no longer be justifiable to prioritise your nations own citizens if other
countries have a level of protection that falls far below that threshold.
Now, of course, the devil is going to be in the detail. Where should we set that particular threshold?
One suggestion from Owen Schaefer and colleagues has been that we should set it at an influenza standard.
So once we have reduced the threat of COVID in our community to the level of background public health risks,
then it can no longer be justifiable to prioritise our own citizens for vaccination
over those in less developed nations still require much better protection.
There is a lot of complexity here.
I think it's certainly something going forward for future pandemics that it would be useful to get a much clearer view of them.
So I was going to end with that and the lessons for the future.
There's something very particular about the pandemic we've just been through,
still going through, which is the older you are, the more at risk you are.
That won't necessarily be the case with future pandemics, but what lessons are there from the last few years?
This is a really important question. Turning to your example, that you're absolutely right.
We don't know what the mortality risk profile of the next pandemic will be.
In some ways, though, from a moral perspective, this pandemic was particularly challenging for the reason that risk arose in accordance with age,
because it forced us to confront what matters morally. Is it saving lives per say, or is it maximising expected life years?
So that was a really deep conflict that we faced, not just in vaccine prioritisation,
but also thinking about ICU admission, intensive care unit admission.
So I think we saw a pandemic where say, 18 to 30 year olds had the highest mortality risk,
then I think there would be very little doubt they should be prioritised for
vaccination because that would be supported by a wide range of moral principles.
But I think there are much broader lessons we can draw from how we dealt with the COVID 19 pandemic.
I think the first important point is one of transparency.
Now, there are good reasons why there wasn't a widespread public debate about the appropriate vaccination
prioritisation strategy in different countries simply due to the urgency of the situation.
And I think that the decision making bodies did a very good job of delivering a practicable strategy in the very short time frame they had.
I think when we reached phase two, there perhaps could have been a little bit more public discussion,
particularly on the question of prioritising key occupations,
given the reasons of reciprocity and social value that we've considered in our discussion.
And more broadly going forward,
I think there are lessons that we can draw about where we struck the balance between benefit and fairness in this pandemic and whether
that balance should be the same across different phases of a prioritisation strategy that we might need to adopt given a future pandemic.
So I think a really important lesson to draw here is that although we did a lot of things really well in our pandemic response,
we shouldn't be complacent. There are still a lot of important lessons to draw from our experience of the COVID 19
pandemic that we really ought to take forward for future public health emergencies.
What is the role of the professional ethicist in all this?
You've been writing and talking about the pandemic, but how central a role should philosophers have in future pandemics?
So I think philosophers can play a really important role because a lot of the crucial policy
decisions that we were facing in the pandemic ultimately relied on moral judgements.
Vaccine prioritisation is a really great example of this.
So what I think the philosopher can do is lay out the relevant arguments and identify
the kinds of ethical trade-offs that we have to make in crucial policy decisions.
There was a bit of a mantra in the U.K. policy decision making circles that the U.K. government was following the science at all times.
That may have been wrong to some extent, but what it fails to accommodate is the point that in following the science,
you are implicitly making a really important moral judgement. Science can only tell you what to do.
It can only give you direction to follow if you're already making some implicit moral judgements.
The key role of philosophy, I think, is to tease out where those judgements are being made and identify where there can be conflicts.
John Compute, Thank you very much indeed. Thanks for having me.
Thanks for listening to the Pandemic Ethics Accelerator podcast.
You can hear more in this six part series on University of Oxford Podcasts.
Well, that's Pandemic Ethics dot UK.