- Hello, I'm Mike Titelbaum,
chair of the philosophy department
here at the University of Wisconsin-Madison.
It's my pleasure to welcome you to this year's installment
of our UW Philosophers at Work series.
I have the added pleasure of thanking Tom Zinnen
and our co-sponsor for tonight's talk,
Wednesday Nite @ the Lab.
I also want to acknowledge the Charles Manthey Winter
Special Philosophical Events Fund for funding this event.
And thanks to Rita Richter in the philosophy department
for organizing, and to PBS Wisconsin
for making the broadcast happen.
Our speaker tonight is Paul Kelleher.
He is associate professor of bioethics
and philosophy at UW-Madison.
His teaching and research focus on ethical
and philosophical issues concerning public policy,
especially health policy and climate change policy.
He has published scholarly work
on the foundations of justice in healthcare,
the moral evaluation of inequalities
in health outcomes,
the ethics of rationing healthcare,
the role of paternalism
in the practice of public health,
philosophical issues in health economics,
and clinical ethics issues
such as conscientious refusal by health professionals
in the treatment of severely disabled newborns.
Most recently, he's just written a book
on philosophical issues and climate change economics.
More to the point for tonight's presentation,
Professor Kelleher serves on the ethics committee
at University Hospital here in Madison
and is the chair of the advisory committee
for University Health Services,
the student health center here at UW.
In 2018, he was elected a fellow of the Hastings Center,
the nation's oldest bioethics institute.
Since the start of the COVID-19 pandemic,
Professor Kelleher has served on two state-level committees
concerned with the allocation of scarce medical resources.
He'll tell you the details of these committees
during his presentation.
He's also served as a rapid response,
on the rapid response ethics committee
at University Hospital.
Given his scholarly expertise and his real-time engagement
with policy issues that affect all of us these days,
I can think of no one better to speak to us
about the ethics of vaccine allocation.
Please join me in welcoming Professor Kelleher.
- Thank you very much for that introduction.
Since the COVID-19 pandemic began,
I've served on several coronavirus-related
health resource allocation committees.
For example, I'm a member
of the rapid response ethics committee
at the University Hospital in Madison,
which provides guidance
on the allocation of scarce critical care resources
such as ventilators, ICU beds, and other therapies.
And I've served on a state-level committee
that wrote allocation guidelines
for scarce COVID-19 therapeutics,
such as the monoclonal antibody treatment
given to President Trump during his COVID-19 infection.
And today I'm gonna talk about
the ethics of vaccine allocation.
I have three goals.
First, I want to explain where
explicit thinking about ethics and ethical principles
has shaped the actual vaccine allocation process
that's now unfolding across the state
and indeed, across the country.
Second, I wanna demonstrate what it looks like
to engage in substantive analysis of ethical claims.
And finally, I wanna give you a sense
of how Wisconsin is doing in this challenging,
unprecedented, and ongoing vaccine allocation effort.
I'll share these impressions not only as a bioethics scholar
and a concerned citizen,
but also as a former member of the state-level committee
that was tasked last year to write the ethics principles
to guide this entire enterprise.
Of course, I'm just one among many members of that committee,
and like everyone else, I can't and I don't claim
to be perfect in lacking bias of one kind or another.
And in having properly weighed
all of the ethical principles and values
that I'll be talking about.
But I've done my best
to evaluate the situation impartially,
and my main aim is to put some ideas
and arguments forward in the public sphere
for others to discuss, criticize, modify,
and maybe even accept.
So let's start in late summer of 2020.
At some point in August,
staff at the Wisconsin Department of Health Services
or DHS began to put together an ethics subcommittee
of the State Disaster Medical Advisory Committee or SDMAC.
SDMAC is a standing committee of 12 members
that advises DHS leadership regarding medical ethics
during a declared disaster or public health emergency.
The SDMAC ethics subcommittee that was convened in late 2020
had the charge of drafting a document
that outlined ethical principles that should guide
the state-level allocation
of scarce COVID-19 vaccine and therapeutics.
And I served on this ethics subcommittee
along with 15 other Wisconsinites
from a diverse array of backgrounds.
We had representation from community health centers
and tribal health systems,
the disability rights community, AARP Wisconsin,
clinical and public health ethics,
and several health and social service
and advocacy organizations
that serve many different communities across the state.
The plan was for the SDMAC ethics subcommittee
to draft ethics principles and other high-level ethics guidance
that would then be released for public comment
and then finalized by the committee.
And then if approved by the larger,
standing SDMAC subcommittee, be passed along
to other committees that were going to be responsible
for writing concrete recommendations
for vaccine allocation and for therapeutic allocation.
DHS would then make its own decision whether to accept,
reject, or modify these subcommittee's recommendations
before implementing an official allocation policy
of the sort that we see now.
What I wanna do in this talk is to explain both the process
and some of the ideas
that underlie the allocation framework
and the vaccine eligibility criteria
that now prevail across the state.
So let's begin with the SDMAC ethics subcommittee.
While COVID-19 trends in August 2020 had improved
from the prior spring,
it was clear to all of us on the ethics subcommittee
that we were by no means out of the woods,
and that any return to normal
would require widespread vaccination.
And of course, vaccination not only provides
the community benefit of lower disease prevalence in general
and affords individual benefits
to those who are undergoing vaccination.
This is a personal health benefit that comes in addition
to whatever benefit that we get at the community level.
So our committee had to consider both the ethics
of pandemic mitigation at the community level
as well as the ethics of equitable resource allocation
to individuals, each of whom may want vaccination
and who may carry a different degree
of personal risk of contracting COVID-19
or of severe illness or even death of course, if infected.
Because the ethics subcommittee included members
who don't normally engage systematically
with medical and public health ethics
in their day-to-day activities,
and because we were in the midst
of an ongoing pandemic that created real urgency for us,
the ethics subcommittee wanted to get started
without having to reinvent the wheel, so to speak.
So we were asked by the subcommittee co-chairs
to review previously-issued ethics documents.
And one of these was a document produced in 2008
by an ethics panel in collaboration
with Wisconsin Hospital Association
and the Wisconsin Division of Public Health.
Now, as with virtually every ethics framework that I've seen
for guiding resource allocation in the current pandemic,
this earlier 2008 document helpfully distinguished
between two sets of ethical values or ethical principles.
On the one hand, there are the ethical values
that bear on what makes for socially responsible allocation.
Call these the substantive ethical values,
since they bear on the substance of the issue at hand.
Second, the 2008 document also stressed the importance
of what it called procedural values.
So think of these as values that all public decisions
of immense consequence should respect and embody.
Examples of these include the value of being based on
well-established scientific evidence,
the need for public decision making to be carried out
in a transparent, open, and inclusive manner.
In a manner that doesn't exclude or silence,
but is affirmatively responsive to the concerns
and inputs of the wide diversity of Wisconsin residents.
These and potentially still other procedural values
are obviously extremely important.
And the state ethics subcommittee that I served on
drafted its own similar list, but in the interest of time,
I'm gonna focus in this talk on the other so-called
substantive values and principles,
as they're the ones that purport to speak directly
to how different groups should be ranked for prioritization
when the task is allocating scarce healthcare resources
such as scarce doses of vaccine.
So now consider this substantive ethical principle
that comes from that earlier 2008 document.
This is a principle that says, that speaks to fairness.
It says, "This value requires that healthcare resources
"be allocated fairly, with special concern
"that the most vulnerable are treated fairly.
"However, given the fact that there will be limited resources,
"the fair distribution of resources is governed
"not by what is best for the individual,
"but rather by the principle
"of the greater good of the community."
So that was the principle from that 2008 document.
Notice the "however" in the middle of the principle.
This "however" suggests that there is
or at least can be a conflict
between treating people fairly on the one hand
and on the other hand,
promoting what this document calls
the greater good of the community.
And indeed, that's a very common distinction
in ethics as an academic discipline.
Sometimes it's possible to promote health
or well-being a great deal, but to do so would require
neglecting the needs of those who are worst off.
Now, here's a philosopher's thought example
to make the point.
Suppose that for whatever reason you found yourself
in the unfortunate position of having to choose
which of two groups to help, and you can't help both of them.
So suppose, for example, that group A
contains just two people, both of whom are very ill
and who will die without your assistance.
And that if you choose to help them,
you could prevent both of them from dying.
Or, and this is option two,
you could choose not to help group A
and instead you could help group B.
Now imagine that group B is such
that no one in the group faces any risk of dying,
but that if you don't help group B,
all 10,000 members of the group will lose their sight
for the rest of their lives.
Now obviously, this is a very academic
philosopher's thought experiment.
It tells you very little backstory,
and it asks you to imagine
that no other ethically-relevant factor
distinguishes one group from the other.
But the example is intended to illustrate a conflict,
at least at the conceptual and theoretical level,
between helping the worst off on the one hand
and doing the most good on the other.
It's a choice between helping those who will be worse off
if not helped, these were the two people in group A,
but in helping the group that is so large
that you could do more overall good if you help them,
even if no individual in that group
faces anything nearly as bad as death.
So anyway, I hope that you can see what it might look like
for there to be a tension between aiding the worst off
on the one hand and producing the most
overall aggregate benefit on the other.
But now notice if there is such a possible tension,
then really that proposed principle of fairness
that we just talked about in the 2008 document
really could be broken down into two different principles.
First, you could have a principle of fairness,
which concerns perhaps showing special concern
for those who are worse off
or who will be worse off if not helped.
And second, a principle that we might call
the greater good principle,
which articulates the ethical importance of policies
that produce as much health and well-being as possible
in a community.
So here you have an example of just the sort of
conceptual slicing and dicing that academic philosophers
like me are kind of obsessed with.
So now, that fairness principle from the 2008 document
is just one principle from one framework
that the Wisconsin COVID-19 ethics subcommittee considered
when we were doing our work.
We were also very fortunate to have as a second example,
a report that was written and released in the fall of 2020,
just as we were doing our work, by the National Academies
of Sciences, Engineering, and Medicine.
The National Academies is a collection of experts
in fields relevant to public policy,
and it's often tapped by Congress
and federal agencies to study
and to make recommendations regarding matters
of pressing public importance.
And that report,
the National Academies report, was a major event.
It was always clear that the federal government
and the 50 states
would look to the National Academies' framework
as they themselves grappled with these allocation issues.
And that's exactly how our ethics subcommittee
at the state level used that report too.
So what did the National Academies say?
Well, in addition to articulating
its own set of procedural principles and values,
it put forward three substantive ethical principles
to guide vaccine allocation.
These were a principle of maximum benefit,
a principle of equal concern,
and a principle of mitigation of health inequities.
Now the maximum benefit principle is pretty similar
to the greater good of the community principle
that we considered just a moment ago.
But the National Academies stressed
that in considering the extent to which
an allocation strategy creates benefits,
policy makers should focus not only on health benefits,
like the prevention of illness and death,
but also on socioeconomic well-being,
the sort of thing afforded by in-person education
and reduced unemployment.
Now, under the heading of equal concern,
the National Academies stressed that
no one person is intrinsically more valuable
or worthy of consideration than any other person.
And that equitable vaccine allocation mustn't prioritize
people purely on the basis of religion, race,
ethnicity, national origin, disability, or age,
but at the same time, the National Academies stressed
that it's absolutely possible to show equal concern
and equal respect while also prioritizing some groups
over others for the purposes of phased vaccine allocation.
To take an example that hits very close to home,
it doesn't show me less than equal concern
or less than equal respect to put me
at the very back of the vaccine allocation line,
given that I am a healthy university professor
who can fulfill my essential job duties safely from my home.
When vaccine doses are scarce,
the aim of any allocation framework
must be to prioritize some over others
on the basis of principled moral reasons
rather than on the basis of reasons that in fact offend
against the equal moral status of any individual.
So the National Academies' final substantive ethical principle
was one of mitigation of health inequities.
And health equity is defined in different ways
by different people.
The National Academies adopted a definition
on which health inequities are quote, "Systematic differences
"in the health status of different population groups
"which have significant social and economic costs
"both to individuals and to societies," end quote.
A paradigmatic example of a health inequity
is the difference in life expectancy
between white Wisconsinites and Black Wisconsinites.
According to the most recent data available
on the state's website,
white Wisconsinites on average live six years longer
than Black Wisconsinites.
And according to a recent report by the Pulitzer Prize-winning,
nonpartisan news organization ProPublica,
the white/Black life expectancy gap
is a staggering 14 years inside the city of Milwaukee.
Now, health inequities just like this
reflect systematic differences in opportunities
to live a full, healthy life,
and the National Academies maintained
that these differences in opportunities and outcomes
are rooted in structural inequalities, racism,
and residential segregation, in that to quote them,
"Any vaccine allocation scheme designed to reduce COVID-19
"must explicitly address the higher burden of COVID-19
"experienced by the populations affected most heavily,
"given their exposure
"and their compounding health inequalities."
Here, for example, are two diagrams produced
by the award-winning American Public Media Research Lab
that illustrate the sort of health inequities
that the National Academies group was referencing.
This diagram shows the comparatively higher risks
of dying from COVID-19
faced by people of color across the entire country.
For example, when adjusted for age,
Latinos are 2.4 times more likely to have died
than white Americans,
while Black Americans are twice as likely.
Now, the second diagram displays Wisconsin-specific data.
This shows for instance, that when adjusted for age,
the Native American population in Wisconsin
has seen 309 COVID-19 deaths per 100,000 residents,
compared to 105 deaths per 100,000 white residents.
Such are the health inequities
that the National Academies emphasized
must be explicitly addressed in the vaccine allocation.
So those were the National Academies'
three substantive ethical principles.
Maximum benefit, equal concern,
and the mitigation of health inequities.
And in the end, this set of principles was very similar
to the principles that our Wisconsin ethics subcommittee
recommended to the state.
There were some differences, but in my opinion,
they're mainly differences in presentation
and not significant differences in substance.
For example, instead of maximizing benefit,
the Wisconsin subcommittee stressed the importance
of promoting the overall common good,
as well as the requirement that every resident be treated
with equal respect and dignity.
And we also put forward a principle
calling for attention to
and mitigation of preexisting health inequities.
We called in particular for the state
and for vaccinators to attend to individuals and groups risks
by accounting for what we called the
compounding multiple risk factors
associated with COVID-19.
And finally, like most other major ethical frameworks
released in the fall,
our Wisconsin ethics subcommittee articulated
a list of procedural considerations
that stress the importance of transparency, trustworthy...
being trustworthy, and inclusivity.
Now as I've said,
the Wisconsin ethics subcommittee that I served on
was tasked with drafting ethics principles and general guidance.
And we were not tasked
with proposing concrete vaccine allocation phases
of the sort that are now being implemented.
But the National Academies did propose phases,
and let me show you what their proposal looked like.
You can see that the National Academies' proposed Phase 1
includes several groups who are at high risk
of COVID-19 exposure and/or severe illness if infected.
The National Academies' Phase 1a,
which are called the jumpstart phase,
focused on high-risk healthcare personnel
and first responders, two populations that were essential
for the ongoing COVID-19 response in all states.
And after that, the main focus was on individuals
whose absolute risk of dying was deemed the highest.
For example, people with high-risk medical conditions
and adults residing in congregate living settings,
especially older adults.
Now I'll show you some data
on those populations in a moment.
For now, just notice that in its Phases 1 and 2,
the National Academies group appears to have prioritized
populations on the basis of their elevated COVID-19 risks,
or in some cases, on their role
in maintaining social functioning.
You can see, for example, that older adults
not included in Phase 1 is listed last
among the National Academies' Phase 2 priority groups.
Compare that to some States such as Maine,
where I'm from and where my family still lives,
that's been using an exclusively age-based approach
to vaccine allocation.
By contrast, the National Academies understood
that while risk of hospitalization
and death worsen with age,
other non-age risk factors can be equally,
if not more concerning.
And they must also be considered for prioritization.
I'll return to this point in just a moment.
So take a look now at the brown oval
beneath the National Academies' proposed phases.
The National Academies proposed to respond
to health inequities by treating equity
as a so-called crosscutting consideration.
Specifically, it proposed that in each group singled out
for prioritization in each of the phases,
vaccine access should be prioritized for geographic areas
based on the CDC Social Vulnerability Index,
which is an index that was developed
for local preparedness in public health emergencies,
exactly of the sort that we're in right now.
The index identifies geographic areas of vulnerability
based on 15 census variables, which reflect many
of the recognized social determinants of health.
In general, the National Academies propose
that vaccine doses be allocated largely
on the basis of individual risk,
and then proposed that the Social Vulnerability Index
be used to make it even finer-grained subprioritizations
within those risks categorizations,
within those risk groups.
Now, while I think there's much to commend
this general approach to prioritization,
I along with two other bioethics colleagues
submitted a public comment to the National Academies,
underscoring something we thought was very important.
We noted that many individuals at elevated risk
for severe COVID 19 outcomes
may lack access to the very healthcare that would lead
to the very medical diagnoses of co-morbid
and underlying conditions
that the National Academies referred to
in its Phase 1b proposal.
After all, a central dimension of health inequity
is the degree to which members of socially-marginalized groups
have been historically disenfranchised
from access to affordable healthcare services.
To the extent that vaccine eligibility
was going to be policed, that's to say to the extent
that individuals were going to be asked to prove
whether or not they had hypertension
or diabetes or asthma,
then barriers to affordable health care could translate
into barriers to much-needed protection
against COVID-19 risks.
As a way to mitigate these background inequities,
my colleagues and I proposed a place-based approach.
This is approach where priority would be given
to geographic areas where social vulnerability is high
and where vaccinating entities would engage
in proactive outreach rather than
in passive, internet-based scheduling for vaccination.
Unfortunately, these suggestions were not ultimately incorporated
into the final draft of the National Academies report.
Now, as I've mentioned,
our Wisconsin ethics subcommittee guidance
was intended to inform the work
of a separate, state-level vaccine subcommittee.
That second subcommittee began its work
around November 2020,
and it issued its first official recommendations
to the state in December.
That timeline enabled the state vaccine subcommittee
to respond to recommendations from the CDC,
which were informed by the advisory committee
on immunization practices or ACIP.
That's a group of medical and public health experts
who develop recommendations
on the use of vaccines in the United States,
and they've recommended vaccine schedules
for childhood immunizations,
and now they were tasked with doing the same in this context.
Now I wanna turn to ACIP's decision making
in November and December of 2020
because I think it reveals important lessons
both for the substantive ethics of vaccine allocation
as well as for how meaningful ethical analysis,
as well as well-meaning ethical analysis can misfire.
Okay, so after uncontroversially
prioritizing health care personnel and residents
of long-term care facilities in Phase 1a,
the ACIP turned its attention next to its other phases,
which are called Phase 1b and 1c.
At a meeting just before Thanksgiving in November 2020,
ACIP staff presented key
epidemiological background information
along with three options for Phase 1b prioritization.
So let me first show you some of the data
that ACIP considered, and then we'll examine
how ACIP attempted to analyze the decision
from the perspective of ethics.
The three populations that ACIP considered
for Phase 1b prioritization
were non-healthcare essential workers,
which was a large category that encompassed nearly
90 million people, adults aged 16 to 64
with high-risk medical conditions,
and the third group was adults ages 65 and older.
The task was to choose which of these groups
would be vaccinated in Phase 1b
and which would wait until Phase 1c.
ACIP proposed to analyze this decision
along three dimensions.
These were the underlying clinical
and epidemiological science,
the feasibility of implementation, and ethics.
Regarding the science,
let me show you just two of the several slides
that ACIP staff presented at the November 2020 meeting.
This is a slide showing relative risks
for COVID-19 associated hospitalization.
Take a look first at the right-hand side of the table.
These are so-called adjusted relative risks, that is,
they've been adjusted for age, sex, and race and ethnicity.
Look first just below the red box.
Here it's reported that those 65 years and older
face a bit more than two and a half times the risk
of being hospitalized with COVID-19
as compared to the specific reference group
of individuals ages 18 to 44.
Now look inside the red box.
This shows that individuals with one, two,
and three medical conditions have two and a half,
four and a half, and five times the risk
of COVID-19 related hospitalization
as compared to individuals
with no underlying medical conditions.
Finally, you can see on the right-hand side
at the very bottom that individuals who are Black
or who are members of other racial
and ethnic minority groups
face risks that are between three and four times higher
than those faced by non-Hispanic white individuals.
Each of these findings reported in this chart
is certainly relevant to the question
of which of these three groups ACIP should have prioritized
in Phase 1b.
I have no question about that.
While older age is definitely a serious risk factor,
so too as you can see is having certain pre-existing
medical conditions or being a member of a racial
or ethnic minority group.
Relevant too is that because of background differences
in baseline life expectancy,
the 65 and older group is disproportionately white,
whereas racial and ethnic minorities
make up a disproportionate share of those
with high-risk medical conditions as well as those
who are non-healthcare essential workers.
Okay, here now is a second slide
that was shown by ACIP staff at the November meeting.
This slide compares the proportion of deaths
that would be prevented over the six months
following the implementation of Phase 1b,
depending on which group was prioritized for 1b
and which were prioritized for Phase 1c,
and the diagram also reports on expected deaths averted
in two different scenarios.
First on the left is the scenario in which
COVID-19 incidence is rising in the population,
as it was expected to do in December
following the Thanksgiving holiday.
You can see on the right the scenario
in which incidence is falling;
that's the modeling in that scenario.
So let's focus on the first scenario,
the one where on the left, where incidence is rising.
What ACIP's modeling suggested is that
though slightly more deaths would be averted
if those 65 and older were prioritized in Phase 1b,
almost as many deaths would be averted
if either of the other two groups were prioritized instead.
Meanwhile, prioritizing those 65 and older
would not prevent as many COVID-19 infections
as would prioritizing those
with high-risk medical conditions or essential workers.
So on the assumption that
preventing overall deaths is important,
but not necessarily the only important thing
because infections that don't result in death matter too,
many people found it difficult to conclude,
on the basis of this epidemiological modeling alone,
which of the groups should be prioritized.
And indeed, that was ACIP's opinion as well.
They said that in their view, the quote
"differences among three prioritization strategies
were minimal," end quote.
So ACIP declared that the decision should turn
on considerations of implementation or feasibility
and then on ethics.
Since the potential long-term effects
of non-fatal COVID-19 infection are not insignificant
and since, as we've already seen,
a person's individual risk of dying
is strongly correlated with their medical history
and with their race and ethnicity,
ACIP staff believed that vaccine prioritization
could not be determined on the basis
of the epidemiological science alone.
Now because my focus is on ethics,
I'm gonna skip over ACIP's discussion of implementation.
In general, ACIP believed that overall, essential workers
and those with high-risk medical conditions
would be somewhat harder to reach
than individuals aged 65 and older,
and we'll come back to that.
So acknowledging that that's a topic that I'm gonna skip over,
here's where things stood
before the ACIP panel turned to consider ethics.
On a straightforward reading
of ACIP's plus-based tally system,
it seems that adults age 65 and older are slightly ahead,
with the other two groups not far behind
going into the consideration of ethics.
So now let's take a look at how the ACIP
analyzed those ethics.
Just like the National Academies,
the ACIP adopted a principle of maximum benefit,
a principle concerned with mitigating health inequities,
but then it also also adopted a new principle,
or at least a principle with a new name.
It termed this principle the promote justice principle.
In a background white paper
released around the same time in November in 2020,
ACIP staff, or I think this was possibly CDC staff
said that the promote justice principle was described,
or could be described as quote,
"intentionally ensuring that persons have equal opportunity
"to be vaccinated, where this includes a commitment
"to removing unfair, unjust, and avoidable barriers
"to vaccination that disproportionately affect
"those that have been economically
"or socially marginalized," end quote.
With that in mind, let's take a look
at the ACIP's key ethics slide.
This slide purports to compare the three populations
under consideration with respect to each
of the ACIP's three ethics principles.
At the November meeting where this was discussed,
the ACIP presenter noted that a darker green color
indicates stronger support for that ethical principle.
For example, in looking at the first row of the table,
ACIP is saying that vaccinating essential workers
and adults 65 and older does better
when it comes to maximizing benefits
and minimizing harms than does vaccinating adults
with high-risk medical conditions.
Curiously though, neither the ACIP
nor the background white paper that it cited
gave any explanation for why
a lighter green shade was given to the option
of vaccinating those with high-risk medical conditions.
And after all, we've already seen
that the epidemiological modeling
that the ACIP considered showed that prioritizing adults
with high-risk medical conditions
would avert both more infections
and more deaths in the six months following vaccination
than would vaccinating essential workers instead.
Take a look now at the second row of the table.
Here, ACIP reports that in their judgment,
prioritizing essential workers does better with respect
to promoting justice than would prioritizing those
with high-risk medical conditions or older adults.
But once again, ACIP didn't explain why
it drew this conclusion.
And recall that the ACIP's ethics principle
concerned with promoting justice says
that all persons should have equal opportunity
to be vaccinated and that there should be a commitment
to removing unfair, unjust,
and avoidable barriers to vaccination.
Barriers that disproportionately affect groups
that have been economically
or socially marginalized in the past.
And if you look at the very middle box,
you'll see that ACIP seems to warn
that if those with high-risk medical conditions
are from disadvantaged backgrounds,
from socially marginalized backgrounds,
then they will require focused outreach.
As they put it,
focused outreach to those with limited
or no access to health care.
That, if you recall, was precisely the point
that I and my bioethics colleagues stressed
in that comment that we submitted
to the National Academies.
But here's a question: why should this fact,
which warns about a need created by a historical
and systemic inequity, translate into a lower score
for a group that disproportionately faces
that very inequity.
The ACIP never explained this,
and I admit that I'm still pretty mystified by it.
Now look at the final row of the ACIP's ethics table.
You'll see that ACIP thinks that
prioritizing essential workers does much better
with respect to mitigating health inequities.
And here too, they cited more or less
the same phenomenon that I and my colleagues
had flagged earlier.
Namely, that historical and inequitable barriers
to healthcare access can prevent those
who are burdened by health inequities
from receiving diagnoses of high-risk medical conditions
in the first place.
ACIP also noted that the group of individuals aged 65 and older
is whiter than the United States population,
something that I've already mentioned.
And this to them suggested that
if those 65 and older were prioritized,
it would unfairly restrict access to vaccination
among people of color.
Now, as I mentioned, each of these observations is accurate,
but the question is this: given how issues of equity intersect
with all three of these population groups,
do these observations that the ACIP flagged,
do they justify giving such different scores
to the three groups on the ethical principle
of mitigating health inequities?
The ACIP never really gave a satisfactory rationale
for where they came down on that.
The AC... Y'know, clearly they thought that
their considerations did justify that,
but it didn't present an argument
in favor of the conclusion.
Instead, it simply translated the judgments
it expressed with its shades of green
into its plus-based tally system like this.
Now at the time,
many commentators chose to focus on the ethics scores
that ACIP gave to the groups of older adults.
That is, the scores that are listed in the rightmost column.
By contrast, I've just raised some questions
about the scores given to adults
with high-risk medical conditions.
That's the group listed in the middle column.
Not only do I myself not understand why this population
didn't receive three pluses along the dimension
of maximizing benefits or why it received just two pluses
for promoting justice,
but if the way that justice were promoted in this population
was to use proactive outreach to those communities
who are most likely to be burdened
by multiple high-risk medical conditions,
then I don't see why the high-risk adults option
should also be scored so low along the dimension
concerned with health equity.
After all, the National Academies
already flagged the CDC's Social Vulnerability Index
and that it was a tool that could be used
to address precisely the barriers to access
that led ACIP to give just a single plus to the option
of vaccinating those with high-risk conditions.
Nevertheless, here in the bottom row
is how the ACIP summarized its overall ethics discussion.
And from the table as a whole, you can see why ACIP ended up
prioritizing essential workers in its November recommendations,
even though adults aged 65 and older seem to be in the lead,
so to speak, before going into the discussion of ethics.
You can see that if adults 65 and older
had gotten just one more plus on ethics,
or if ACIP had better appreciated
the equity-based merits
of proactive outreach and vaccination of individuals
who live in areas of high social vulnerability
who are comparatively more likely
to have high-risk medical conditions,
then at least one of these other groups may well
have been tied with the essential workers group.
Now I wanna make it clear that I'm not stressing this
because I'm somehow against vaccinating essential workers.
Of course I'm for vaccinating anyone
and everyone who chooses vaccination for themselves.
I simply want to emphasize two things.
First, it's not as easy as it might look
to shoehorn a subtle, complex ethical analysis
into a simplified plus system, as the ACIP sought to do.
And second, I wanna highlight that the ACIP's choice
to downgrade the option of vaccinating individuals
with the highest-risk conditions
seems to have added a further disadvantage
on top of the preexisting disadvantages that leads so many
of those individuals to be at greater risk to begin with.
The ACIP was absolutely correct to highlight the fact that
high-risk individuals in high social vulnerability areas
will require focused outreach for vaccination.
But that should be acknowledged
and navigated as an unjust barrier to access.
It definitely should not be cited as a reason
for the conclusion that it's less ethical
or less ethically compelling to vaccinate adults
with high-risk medical conditions
than it is to vaccinate
the entire category of essential workers,
some of whom, many of whom are young
and at comparatively lower risk
of severe outcomes of COVID-19 infection.
Of course, there are individuals who have high risks
in the essential worker population,
and basically what I'm saying is that the three categories
that the ACIP worked with
may not have been the best three categories
to treat as exclusive comparators.
Ultimately, ACIP's November recommendation
was to suggest that essential workers
should be prioritized under Phase B,
and that Phase 1c should include all adults aged 65 and over
and that it should also include all individuals 16 to 64
who have high-risk medical conditions.
Prior to the vote on this proposal,
many voting ACIP members cited considerations of equity
as the main reason to prioritize essential workers,
and I've tried to raise some questions
about that line of thinking here.
Nevertheless and in the end,
that was not ACIP's final 1b and 1c recommendation.
The November vote was just a preliminary vote,
and the final vote was to come in mid December.
And in that vote, the ACIP radically changed course.
It recommended that Phase 1b comprise
frontline essential workers and persons 75 and older.
Gone too was any reference to the plus system
and really any concrete rationale
for the major change from November to December.
Accordingly, there was no affirmative reason given
for why it was equitable to delay vaccination
among those with high-risk health conditions
who live in high social vulnerability areas.
It was left up as a question mark.
With all that said, the category of frontline essential workers
does include many people
who face enormously high COVID-19 risks.
Key among them are individuals who work in meatpacking plants
within the food and agriculture sector.
This is a sector and industry that's seen ongoing
and severe outbreaks of COVID-19
all the way through the pandemic.
And those who are employed in the sector
live in areas of the country that rank comparatively high
on the social vulnerability index.
So that is a key demographic that creates overlap
between very high-risk individuals
and essential workers.
But notice that this sector could have been the focus
of an explicitly place-based approach to vaccine allocation,
rather than an approach that combined an age-based criterion
with a still very wide,
employment classification-based criterion.
Now, ACIP's final 1b recommendation
was accepted by the CDC director in late December 2020.
And around that same time,
the Wisconsin state vaccine subcommittee took up the issue
of what the state's 1b priorities should look like.
After several weeks of deliberation,
many of which I watched in early morning Zoom sessions,
the state committee proposed the following groups
be included in Phase 1b: those 70 years and over,
Wisconsinites who are the recipients of IRIS
and Family Care, a group that includes frail elders
and adults with physical and intellectual disabilities,
individuals who reside in congregate living settings,
for example homeless shelters, jails, prisons,
mental health institutes,
and various public-facing and frontline essential workers,
including non-EMS first responders, educators,
and non-frontline but essential healthcare personnel.
As you can see, many of these state-level recommendations
departed from ACIP's December recommendations.
The Wisconsin subcommittee was in my view,
much more sophisticated in its deliberations
on how to craft vaccine allocation priority schemes
that harmonize the two ethical principles
that virtually all ethical frameworks included:
a principle concerned with promoting benefits
or maximizing benefits, and a principal concerned
to mitigate health inequities.
Especially important for these two principles
is the committee's focus on congregate living settings,
where individuals who disproportionately hail
from high social vulnerability index areas are brought together
and where COVID-19 transmission is comparatively high
and relatively more difficult to keep in check.
At the same time the Wisconsin subcommittee
was finalizing its 1b recommendations,
President Trump's outgoing Department of Health
and Human Services Secretary called
for every state to broaden its vaccine eligibility
to everyone 65 and over and everyone who had at least
one high-risk medical condition.
And very soon after that, Wisconsin adopted the
vaccine subcommittee's 1b recommendations
with two key changes.
That age-based eligibility would be lowered from 70 to 65,
in line with what the Trump administration
had asked of states, and that educators
and childcare professionals would be given priority
among those who would be eligible in Phase 1b.
Now, I wanna make it clear that I'm glad for all of those,
I'm ecstatic for all those who have been vaccinated
under 1b or who maybe even have an appointment
in the future, near future I hope.
But I also feel an obligation to flag the important trade-offs,
the important ethical trade-offs
that are embodied in the approach
that Wisconsin ultimately adopted for Phase 1b.
These are trade-offs that were starkly underscored
by a statement from a DHS official
that was quoted in a news story on March 10th.
This is a story that announced that the state was beginning
to consider who would be eligible in a future Phase 1c.
The official explained that the state was trying quote,
"to include in Phase 1c the people who we know are at risk,
"to think about how do we do this in a way
"that doesn't overwhelm the vaccinating system," end quote.
In light of this concern to avoid
overwhelming the vaccine allocation system,
I think it's immensely important to stress
that the decision that was made in January,
the decision to make everyone over the age of 65 eligible
for vaccination then in January, that was a decision that meant
that many individuals who face the very highest risk
of adverse effects and who may also live in areas
ranking high on social vulnerability
would have to wait all the way until March 22nd,
when they will finally become eligible
for COVID-19 vaccination under the state's Phase 1c criteria.
I also wanna stress that this is not true
of all high-risk individuals.
I've already mentioned that those who reside
in congregate living settings,
as well as those with intellectual disabilities
who are on certain,
receive benefits from certain state programs,
they are already covered under 1b.
People with Down syndrome, for example,
have been especially hard hit by this pandemic.
A large study in the United Kingdom found that,
if infected, people with Down syndrome are five times
more likely to be hospitalized and 10 times more likely to die
than the general population.
And I think it's a real credit to the state of Wisconsin
that many of its residents with Down syndrome
have been eligible for vaccination under 1b.
I think another bright spot from the point of view
of marrying the ethical principle of maximizing benefits
with mitigating health inequities
is the state's policy,
which was adopted in January of filling all vaccine doses
that are requested across the state
by community health centers, free clinics,
and tribal councils.
And because Native American tribes are sovereign nations,
they can formulate their own eligibility rules.
And so they've been able since January to vaccinate everyone
in their communities that they deem have the highest risk.
And I think that the state deserves enormous credit
for adopting this policy of filling all of these requests
from these communities.
It's a policy that empowers many underserved
and marginalized communities across the state.
I've been mostly talking about vaccine eligibility rules,
although at that time stressed the importance
from an equity perspective of proactive outreach
and place-based vaccination efforts.
And I'm encouraged to see mobile vaccination units
setting up clinics in, for example,
churches on the north side of Milwaukee.
The first of these took place in early March,
as best as I can tell,
and that's precisely when West Virginia,
a state that has been a national leader
in proactive outreach, was doing the same.
West Virginia's been using
the one-shot Johnson and Johnson vaccine in these efforts,
and while I don't know which vaccine is being used
in similar contexts here in Wisconsin,
there's every reason to provide a one-and-done option
to those who live in areas of high social vulnerability,
where residents face many constraints,
including constraints on their ability
to take time away from work
to receive a second vaccine dose or time away from caregiving
to get through feeling a little crummy for example,
as is not uncommon after the second dose
of the Pfizer or Moderna vaccines.
And speaking of the CDC Social Vulnerability Index,
it was announced on March 16th,
just the day before I'm recording this talk,
that as of March 22nd, all residents,
all residents who are 18 or older
in 10 zip codes in Milwaukee
will be eligible for vaccination.
These are zip codes that score extremely high
on the CDC Social Vulnerability Index
and that have borne a disproportionate share
of the state's overall COVID-19 death toll.
I hope that these expanded eligibility criteria
will be combined with focused, proactive outreach
to make vaccination easy and accessible
to this newly eligible population.
For example, they should take a page out of the playbook
of that north side church I just mentioned.
In that case, the city of Milwaukee helped church staff,
and together, they sent out robocalls to parishioners
and even reached out directly to some of them
to encourage them to come in to be vaccinated,
to tell them that that was an option for them.
That sort of approach, one that doesn't require people
to have routine access to the internet,
it really ought to be the rule, not the exception,
and I hope to see more of it.
I've heard some ethicists say, regarding vaccine eligibility,
that the question isn't who gets vaccinated, but when.
Everyone will get a vaccine in due time, they say,
and that certainly will be true of most of us,
but it may not be true of all of us.
And it's more likely to be false
for those who face the highest risks.
Some of them will have died
before they can be fully vaccinated.
And I hope that I've given some indication of what ethics,
as a serious professional enterprise, can contribute
to these important life and death conversations.
I certainly don't have all the answers,
and I know very well that a one-way monologue like this
is not the ideal way to converse with one's fellow Wisconsinites,
but I'm very grateful to have had this time
to share my thoughts.
And I want to invite you very sincerely
to reach out to me via email whenever you'd like,
if you'd like to consider continuing the conversation.
Thank you very much, and please be well.