Eight Principles and Practices for Ethical Vaccine Distribution: A Proposal

The COVID-19, once-in-a-century, pandemic has now exceeded a year in duration. Nerves are frayed and relationships are strained. This is evident within families, communities, healthcare systems, and institutions of government. Hope, in the form of declining cases and hospitalizations and a vaccine, is on the horizon and yet we are literally at our wits end. Now more than ever, we need to think carefully and not just emote. We need more dialogue and less monologue, civil discourse instead of incivility posted to social media. We need to take the time to deliberate and exhibit virtue rather than vice, to replace narcissism with altruism. This is particularly true now in regard to vaccine allocation, hesitation, and resistance.

As a public health physician-leader and a bioethicist, we, like everyone else, are also citizens, impatient with pandemic restrictions and the scarcity of COVID vaccine. Having put aside our own frayed nerves and emotions so as to think and to dialogue, we have come to agreement on a set of principles and practices for ethical vaccine distribution that we hope might be helpful even beyond this pandemic. All of us bear responsibility; and we call upon our leaders especially—in state government, county or municipal health departments, and all healthcare institutions—to demonstrate fidelity to the following commitments:

1. Allocate and distribute vaccine in keeping with agreed upon protocols and without ethically unjustifiable deviation. Seek community member input to establish local protocols and factor the social determinants of health into risk stratification. If examples are needed, it is hard to imagine ethical justification for offering scarce vaccine to one’s institutional benefactors, boards of directors, or most others who fall outside of the agreed upon protocols.

2. If there seems justifiable reason to engage in practices of vaccination that fall outside of agreed upon protocols, first engage in dialogue with colleagues who have fully acknowledged their conflicts of interest so as to check one’s assumptions and build collegial trust rather than erode it.

3. Vaccinate the greatest number possible in the shortest time possible—and not without regard to other fundamental ethics commitments related to equity and justice.

4. Exercise transparency through frequent and voluntary release of all vaccination data for public analysis. Engage with local community representatives and stakeholders in a discussion of these data and in an effort to adjust protocols as necessary in response to this data and in an effort to further promote equity.

5. Reassess vaccine allotments to county/municipal health departments in comparison with those allotted to healthcare institutions, local pharmacies, and others. Build communication channels now so as to ensure equity of vaccine access to those most vulnerable to this coronavirus.

6. Seek new and improved means for getting vaccine to vulnerable persons who lack equitable access for appointment sign-ups, transportation to vaccination sites, or even news of availability. Talk to community members and test innovations until every possible individual, even those initially hesitant or resistant to vaccination has been repeatedly offered the vaccine at no cost and at a convenient time and location.

7. Assess practices pertaining to distribution of vaccine “leftovers”. Strategize means of avoiding waste while maximizing opportunity of access to those who most need the life-saving protection that vaccines promise.

8. Address vaccine hesitancy among individuals and groups with respect, acknowledging that some distrust of vaccine may be justified and is grounded in misinformation or disinformation, while much hearkens back understandably to historic racism and systemic injustice. Repeatedly dialogue with those who are hesitant over time, so that they have multiple opportunities to reconsider and until the pandemic is completely over and can no longer impact the most vulnerable, even in small numbers. Consider intense involvement of trusted health care professionals and primary care providers in this effort.

We acknowledge that the healthcare leaders, institutions and organizations of our country are well intended, perhaps more so than many of us who are simply impatient and too often self-absorbed. Healthcare facilities and professionals have been battered and pummeled over the last twelve months. Despite intense pandemic stress they have done their best in the hardest of times with insufficient resources; and now they face a massive shortfall of vaccine. Logistics are challenging, to say the least. Form the beginning, our healthcare system has done much with far too little, from PPE to staffing. And yet our society can and must do this better, with more collegiality, communication, empathy and professionalism. Each of us as citizens are responsible for promoting justice as well. We are making a commitment to vaccine equity, to personal altruism and community solidarity. We call upon our friends, neighbors, colleagues, and acquaintances in many places to do likewise.

By K. Allen Greiner, MD, and Tarris Rosell, PhD, DMin

About the Authors:

K. Allen Greiner, MD, MPH is Chief Medical Officer with the Unified Government Public Health Department, Kansas City, Kansas.

Tarris Rosell, PhD, DMin holds the Rosemary Flanigan Chair at the Center for Practical Bioethics, Kansas City, Missouri.

The Truth of COVID-19: An Ethicist Reflects on His Experience

I have been honored and privileged to serve the Kansas City region through my work at the Center for Practical Bioethics during this challenging year of COVID-19. My role has grown during this pandemic, as I share in the work of providing ethics services in several hospital systems in the region. This has involved front-end work, including structure and policy development, as well as groundwork such as conducting clinical ethics consults and supporting medical staff with ethics education and guidance. I am grateful to help our hospitals and health systems prepare for, manage and move forward in facing the ethical challenges of the pandemic. 

But this role comes with an additional emotional burden. While I share in these organizations’ successes as they build and grow ethics services, I also share in their hardships and challenges as we work to address highly unusual and sometimes unprecedented ethical issues. This access and knowledge have led me to a foundational truth about the COVID-19 pandemic: People are our greatest resource, and they are not an unlimited one. 

Every one of the healthcare workers I’ve encountered is exceptional, and exceptional people step up and grow during the most challenging times. That is exactly what I have seen this year. As a society, we place high expectations on healthcare workers. We take advantage of their skills and rely on their dedication. When patients arrive at the ER, we expect fast response and quality service. When patients receive a cancer diagnosis, we expect the marvels of medicine and intimacies of compassion. When a family member is in the ICU, we expect the best care possible. These expectations exist because that is what healthcare workers deliver, day after day after day. And when a global pandemic uproots our lives and threatens the health and safety of everyone, new expectations are placed upon healthcare workers. And again, they rise to the challenge. 

A Finite Resource

But this resource is not infinite. Why? 

• Hospitalizations Rising –  Not every hospital is at maximum capacity or needs to implement crisis standards of care. But after months of challenges and difficulties for our healthcare workers, we are entering a new time with more expectations. In the beginning of the pandemic, we faced the crisis related to shortages of PPE (personal protective equipment). Now we must face the possibility of a shortage of those who wear the PPE. As hospitals reach new levels of capacity and with new COVID-19 units being established, staffing is stretched to extremes. There are potentially not enough qualified clinical staff to care for the levels of patients in need of care. This is only expected to worsen as infections spread.

• Moral Distress – Distress from being required to do things that conflict with one’s conscience, professional duty and moral principles is particularly stressful now for front-line healthcare workers. These are individuals who are making the decision to go to work, day-in and day-out during this crisis, risking their health and safety and the health and safety of their families because they believe in the importance of their work. Selflessness does not begin to describe that level of commitment to their fellow companions. They see first-hand the burdens, the true pain and suffering, that the pandemic brings. 

The Empty Glass

I have worked intimately with many of these front-line healthcare workers and have heard their stories. Stories that bring the truth of COVID-19 to anyone willing to listen. 

• I have heard from the physician who stayed on for an additional shift to honor his promise to a dying patient whose family was unable to visit that he would not die alone. 

• I have heard from a nurse who was unable to see immediate family because of fear of bringing the virus back home.

• I have heard from a physician who watched four patients suffer and die from COVID-19, only to return to the clinic and be told by another patient that it was all political and that the virus would be gone after election day. 

Healthcare workers pour themselves into their work and their patients, like water from a glass. Without help, support and consideration, the glass eventually empties, and they have nothing more to give. This is what comes with the job and is a load shared by all. It is a why healthcare workers earn the respect we give them. 

United We Stand

Supporting our healthcare workers must be a united fight, or it is destined to fail. When faced with nearly impossible odds, Sir Winston Churchill said he had “nothing to offer but blood, toil, tears, and sweat.” His nation stepped forward to fight the threat to life and safety; from the solider to the factory worker to the caregivers at home and leaders at the top, they all gave everything together and overcame the grave threat. 

I have seen our great healthcare workers give all this and more to fight this fight against COVID-19, but I see some in leadership outside of the hospital step away, deny or ignore the threat and the fight. This is destructive to so much that we hold dear. This is a fight that will possibly worsen before it improves. We see the impact it has right now and fear what the future might hold.

I have had the privilege to work and share with those fighting and giving everything. 

We must not let them fight alone.

Ryan Pferdehirt, D. Bioethics, HEC-C

Clinical Ethicist

Director of Membership and Ethics Education

ADVANCE CARE PLANNING

Deciding How You Want to Live in the Time of COVID19

People don’t like to talk about politics, religion or money. To that we would add advance care planning. And to that we would add there’s been no time in recent memory when it was more important to name someone to speak for you if you can’t speak for yourself…which is what happens when you’re on a ventilator!

Advance care planning is the process of clarifying your life goals and values and making sure your healthcare preferences are known and honored.

Most Americans today will die from complications of chronic illness, with slow and uncertain disease paths, affected by dementia, and 85% will die without capacity to make decisions.

So why are two-thirds of Americans still leaving it up to their doctors and ill-prepared family members to make decisions about care and life-prolonging treatments? Maybe you’re familiar with some of these mistaken beliefs that lead people to avoid advance care planning:

·      I’ll always be able to make my own decisions.

·      My family already knows my wishes.

·      My doctor will know what’s right.

·      I’ve written it down so I don’t need to talk about it.

Solutions Offered

The Center pioneered advance care planning in the 1980s and continues trailblazing work to make the patient voice heard.

·      Counseling – Responding to calls for guidance in a personal or family healthcare crisis. Call us at 816-221-1100 if you need help.

·      Resources – Providing Caring ConversationsÒ workbooks in English and Spanish.

·      Employee Benefits – Offering advance care planning education and support through corporate employee benefit programs.

·      Cultural Competence – Developing curricula and holding workshops to encourage advance care planning in African American faith communities.

·      Seriously Ill Patients – Training Missouri and Kansas providers to document seriously ill patients’ goals of care as physician orders.

·      MyDirectives.com – Enabling family and providers to easily access advance care planning documents and video testimonies online.

Three Lessons Learned

1.     Advance care planning is for everyone. A medical crisis could leave you too ill to make your own healthcare decisions at any age.

2.     Start with the conversation. Share your wishes with someone you trust to speak for you if you can’t speak for yourself.

3.     This is not a one-and-done process. Wishes change through various life stages. Revisit your plan.

Things happen. People have accidents. Get chronic illnesses. Receive life-threatening diagnoses. And, now, pandemics.

Advance care planning is not about death and dying. It’s about how you want to live.

April 16, 2020

National Healthcare Decisions Day

Founded in 2008, National Healthcare Decisions Day is a collaborative effort of national, state and community organizations to inspire, educate and empower the public and providers about the importance of advance care planning.