Ireland’s vaccination programme must not deepen existing social inequalities – Dr Siobhan O’Sullivan, Chief Bioethics Officer, NPHET.

• Those who have been prioritised for vaccination are the most likely to die, or those who have shouldered the heaviest burden in the pandemic so far
• Ireland’s vaccination programme must not deepen existing social inequalities
• “A catastrophic moral failure” – WHO warns against worsening global inequality with unfair vaccine distribution

From the outset of the COVID-19 pandemic, the response in Ireland has been anchored in seven key ethical principles: solidarity, fairness, minimising harm, proportionality, reciprocity, privacy and a duty to provide care.  

In March 2020, the Department of Health published the Ethical Framework for Decision-making in a Pandemic, which sets out these principles that have guided our collective response to this unprecedented public health emergency.

This pandemic has adversely affected every person in Ireland in diverse and challenging ways. In working together to suppress the virus, we have made sacrifices at an individual and societal level – and in doing so, made many difficult personal choices.

Similarly, difficult decisions have been faced by policymakers and clinicians. Having multiple principles in our ethical framework, reflecting a plurality of values, has been and will continue to be vital to ethical decision-making. These core principles have also laid the foundation for Ireland’s approach to rolling out a vaccination programme to protect us all against COVID-19.

The pandemic has brought into sharp relief questions regarding what we owe to each other  – and what values we wish to prioritise as a society

It has forced us to examine how and to what extent public goods are valued in our society. The emphasis on solidarity during the pandemic has been a welcome one and has been important for societal cohesiveness. Solidarity is about standing beside and up for others, in facing a common threat and in achieving our shared common goal of containing this virus. It is a recognition of our shared humanity and interconnectedness and is characterised by people acting in mutual support of each other. Solidarity has been described by the philosopher Jurgen Habermas as “the other side of justice”.

COVID-19 has exposed, as well as exacerbated pre-existing health and social inequities, with a disproportionate burden falling on vulnerable and disadvantaged populations. We need to take care that the decisions we make during this pandemic do not deepen these inequalities. 

Vaccination is the one of the most important things we can do to protect ourselves and others against ill health. Simply put: getting a vaccine is something we do for each other, as well as ourselves. The starting point for deciding which groups should receive the earliest allocations of vaccine especially during this period of constrained supply, is to recognise that every person deserves equal respect and consideration.

The vaccine allocation strategy seeks to balance the requirement to produce the most good while ensuring the equitable treatment of people. The latter involves giving special consideration to those who are most vulnerable. 

• Those who have an increased risk of dying or developing severe disease have been prioritised to receive a COVID vaccine. Increasing age is the clearest risk factor associated with dying or becoming very ill if you contract the virus. This risk is amplified for older persons living in long term residential care as they have a higher risk of exposure to infection. In Ireland in the first wave of COVID-19, 56% of deaths occurred in this setting. This is likely compounded by the presence of underlying conditions which increase with advancing age.

• Frontline healthcare workers have also been prioritised in this initial phase. This group is also at high risk of exposure to the virus. In the first wave, over 30% of cases of COVID-19 were in this group. If our healthcare workers contract the virus this will not only affect their own health but will also impact on their ability to provide essential care. Prioritising healthcare workers recognises the significant burdens they carry daily in protecting wider society and our healthcare system.

• Some people with underlying health conditions will be vulnerable to developing severe infection and are at increased risk of dying compared to healthy individuals of the same age. It is also clear that socio-economic factors including occupation, as well as living or working in crowded conditions can increase susceptibility to COVID-19 and impact on outcomes following infection with the virus. From the perspective of fairness, it makes sense to afford these vulnerable groups early access to vaccination.

No-one is protected until everyone is protected

Solidarity becomes a very thin concept if we only apply it to those who are very much like us and if it comes with terms and conditions. Efforts to control the pandemic at the national level will only succeed if we play our part in the global effort. Human dignity and respect is due to everyone, not just those who live within our borders.

While we in Ireland and the rest of Europe have already commenced vaccinating our priority groups, it is a sobering thought that nearly a quarter of the world’s population mostly in low- and middle-income countries, will not have access to a vaccine before 2022.

WHO Director-General Tedros Adhanom Ghebreyesus has described this as a “catastrophic moral failure”. Equitable, global distribution of COVID vaccines is not only the right thing to do, but in protecting the most vulnerable we are protecting ourselves. Importantly, the ethical principles which have guided the vaccine allocation strategy are grounded in and informed by the WHO values framework for the allocation and prioritisation of COVID-19 vaccination.

In 2020, we saw how we can collectively make a difference at a population level by abiding by public health measures. It has never been more clear that our own actions impact on other people, both at a national as well as a global level. Solidarity remains a relevant ethical lens through which to view our pandemic response.

About the author:

Dr Siobhán O’Sullivan is the Chief Bioethics Officer in the Department of Health and is a member of the National Public Health Emergency Team. Dr O’Sullivan the Vice-Chair of the European Group on Ethics in Science and New Technologies (EGE) and has recently been elected Vice-Chair of the Committee on Bioethics in the Council of Europe. She is a honorary Professor in the Royal College of Surgeons in Ireland where she teaches Health Care Ethics and Law. 

Notes to editor: 

• Ethical framework for decision making in a pandemic: https://www.gov.ie/en/publication/dbf3fb-ethical-framework-for-decision-making-in-a-pandemic/

• Vaccine allocation prioritisation strategy: https://www.gov.ie/en/publication/39038-provisional-vaccine-allocation-groups/

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