COVID-19 has infected over 8 million residents of the United States and has claimed the lives of over 220,000 people. The coronavirus pandemic is continuing to wreak havoc not only on the health and economy of the US but on countries globally. For this reason, “the world is anxiously awaiting a vaccine against COVID-19.”1 But although vaccination may be “widely considered” an endpoint in this global health emergency, the actual endpoint will take place not only when we have a vaccine, but “when we have an adequate vaccination policy to get the vaccine out to people in the most effective way.”1

There are currently 149 COVID-19 vaccines in preclinical development and of these, 38 are being evaluated in clinical trials.2 However, even when a vaccine becomes available and authorized for use, it is “very unlikely to be immediately available in amounts sufficient to vaccinate a large portion of the US population, despite plans to begin large-scale production of promising vaccines even before trials are completed.”2

In the event of a likely scarcity of vaccines, a framework must be developed to inform who should get priority. However, the decision as to who should get priority in receiving vaccination is fraught with thorny ethical and practical issues. Numerous organizations and advisory groups have proposed frameworks for equitable and effective vaccine allocation, including the World Health Organization,3 the Centers for Disease Control and Prevention (CDC),4 and the National Academy of Sciences, Engineering, and Medicine.2

To shed light on the ethical complexities of COVID-19 vaccine allocation, we interviewed David Marcus MD Clinical Ethicist at LIJ Medical Center in New York and former Director of the Medical Ethics Curriculum at the Zucker School of Medicine at Hofstra/Northwell. Dr Marcus is also a practicing emergency physician and internist. 


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David Marcus MD Clinical Ethicist at LIJ Medical Center in New York and former Director of the Medical Ethics Curriculum at the Zucker School of Medicine at Hofstra/Northwell.

There are many currently proposed frameworks for vaccine allocation. Which do you feel to be closest to your approach?

The recently published framework of the National Academy of Sciences, Engineering, and Medicine2 makes sense. Like other frameworks, it assumes that there likely will not immediately be enough vaccines for everyone and, assuming the vaccine is safe, there are certain people who should be prioritized, based on their risk of exposure.

But what is nice and novel about their statement is that they lay out “allocation phases,” which they describe as “successive deployment” and that they explicitly aim to “mitigate health inequities.” In other words, within each phase, all groups should have equal priority.

Can you please elaborate on what that means?

The CDC has a Social Vulnerability Index (SVI) and an even more specific COVID-19 Community Vulnerability Index (CCVI).

Given that people of color have been disproportionately affected by COVID-19, using these indices informs focusing on specific needs of those communities, rather than particular racial and/or ethnic groups.2

It is also important that the statement suggested that local governments, states, and tribal governments should focus on allocating vaccines, with an eye toward social justice. Regardless of the phase of distribution, social justice should always be centralized.

There are 4 values in medical practice and medical ethics: autonomy (self-determination), beneficence, nonmaleficence, and social/distributive justice. Of these 4 pillars, the last one often gets overlooked, so I am glad that this statement has focused on it.