The Ethics of COVID Vaccine Line Jumping

Back in the middle of February I got a text from a friend asking if I was interested in getting vaccinated. The friend in question is an audiologist for the VA, and I assumed he had an inside line on an appointment cancellation or something, so I responded that I was. A few minutes later he forwarded me a confirmation for an appointment several days later at a pharmacy about an hour from where I live. I live in Pennsylvania, and at the time the state had recently expanded eligibility to include smokers and those with a BMI over 30, as well as to healthcare workers who don't work in hospitals. I don't really fit into any of these categories, though my friend probably saw me smoking at a party or something and decided I qualified based on that, though I'm not a smoker in any realistic sense of the term. I spent the weekend mulling over the ethics behind this; at the time I had older relatives who couldn't find appointments and felt bad that I'd be taking a shot away from someone who really needed it. Eventually, though, it became clear that I couldn't transfer my appointment to another person, and cancelling outright the day before the appointment led to the risk that the shot would be wasted, and, after all, I didn't make the appointment myself, and I though I was getting an unused vaccine when I agreed to it. So I was among the first of my friends who don't work in hospitals to get vaccinated.

A month and a half later Pennsylvania still hasn't expanded its eligibility requirements. But unflinchingly moral people have since been gradually expanding their definitions of who qualifies to the point that there seems to be an agreement among everyone that it's every man for himself and get vaccinated wherever and whenever you can, even if you have to lie about being a smoker or drive to West Virginia. When I first got vaccinated I was hesitant to inform my family lest it ignite some controversy about my undeserved priority and require explanation. Now I'm scheduling appointments for family members with both stronger ethics and less of a plausible qualification than I have.

I think this whole situation is interesting and lends itself to an analysis of how bad public policy can lead to a sense of flippancy among people who would normally be rather principled. I don't want to suggest that public policy is directly responsible for a degraded morality, but that it fails when it pulls the rug out from under people and eliminates the reason those principles exist in the first place.

Back in December I expressed concern about the lack of planning that was going into the vaccine rollout. At the time we were only a few weeks away from the first approval but neither any state nor the CDC had publicly released any kind of plan detailing who would be receiving the vaccine when. I predicted that while hospital employees and residents of personal care homes would uncontroversially get top priority, there would be a ton of political wrangling about when everyone else got to go, with various special interests jockeying for position. I also predicted that unclear or not easily verifiable criteria would create incentives for cheating, and suggested that a strictly age-based prioritization scheme would be ideal.

In Pennsylvania, the reality was even worse than I predicted. Toward the end of January, when the state first started looking at expanding vaccine availability beyond front-line hospital workers and care home residents, people over the age of 70 (or possibly 75) were added to the list. I can't remember the exact age because this lasted for about a week before the age was lowered to 65. A few weeks later, Phase 1-A was expanded to include adults under 65 with certain high-risk conditions and an increased eligibility among heathcare workers. The approved high-risk conditions included a few relatively rare ones like chronic kidney disease and taking immunosuppresive drugs, as well as two extremely common and controversial ones, namely obesity and smoking. These last two were particularly controversial; seemingly more serious conditions like COPD, heart disease, and cancer were left off the list in favor of them, both are more attributable than lifestyle (and smoking is viewed as a personal choice), but most importantly, they both vastly expand the class of eligible people, especially considering that obesity guidelines only require a BMI of 30. So a lot of people didn't feel as bad about jumping the line if it only meant stealing a spot from a smoker or fat person who "really deserved it".

But what really killed the rollout's credibility in the eyes of the public was the expansion to healthcare workers. The official guidelines stated that the phase covered "essential" healthcare workers including, but not limited to people like doctors, dentists, pharmacy techs, etc., i.e. people who actually deal with patients or the public in a healthcare setting. The problem wasn't that members of the general public were lying about their jobs to jump the line; few enough people would normally be inclined to do that that it wouldn't make much of a dent in the overall numbers. The problem was that large healthcare companies that were responsible for distributing the vaccine were vaccinating their own employees before making their doses available to the general public. No one has a problem if UPMC vaccinates its hospital employees first; that's expected. People do have a problem if it's vaccinating its administrative staff who have been working from home for the past 8 months. And these are some of the largest employers in the state, so everybody knows someone who is young and healthy and works from home but got the vaccine before their uncle with COPD.

Every outcry and controversy only causes the state to continually fiddle with eligibility requirements, with the result that we're stuck in an ever-expanding Phase 1-A. So people with high-risk conditions like heart disease and COPD who were previously in 1-B were moved to 1-A. The whole school reopening controversy led them to add school personnel once the J&J vaccine became available. This outraged the police union, so they added first responders. Since they were now running out of groups that would have been covered in Phase 1-B, they had to start bumping "essential" manufacturing workers from 1-C into that category. By this point service worker unions were complaining that they were left out, so grocery workers got added to 1-B. I should pause for a moment to clarify that I was only able to piece this information together after the fact. I remember the people complaining in the media, but the changes to the eligibility criteria were done quietly and without fanfare. So people don't find out until well after the fact that these changes were made, reinforcing the impression that the whole thing is a shit-show.

Since they gutted 1-C to move people to 1-B and added a whole litany of dubious categories to 1-C. Lawyers, media, finance, IT, construction, are now eligible, provided they're "essential", of course. It really doesn't matter, though, because the growing perception among everybody is that if you're actually waiting for "your turn" you aren't being ethical or altruistic, but stupid and naive. It's gotten to the point that companies are signing up all their employees for vaccinations even though they know most of them don't qualify. the general consensus is that it's better for as many people to get vaccinated as possible than to insist on a quixotic attempt to target certain populations. By the time we get to 1-C everybody in it will already be vaccinated and we'll just be picking up stragglers and talking about how much vaccine we can export to South America.

So what led to this mess? The things I mentioned in my earlier comment certainly played a part, but there were a few additional things that I hadn't predicted, and I think these were more responsible for the current state of affairs than anything else. The number one item was the relatively early addition of smokers and obese to Phase 1-A. The state's official rationale for doing this was that they were simply following CDC guidelines. While giving these groups priority certainly left a bad taste in people's mouths and struck a blow to the state's credibility, the much larger problem was that it made the size of 1-A so unwieldy that it was going to take entirely too long to start moving to other phases. About 30% of the state is obese and about 20% smoke. When you add that to the 6% of the state that work in healthcare and the 20% who are over 65, some crude assumptions give an estimate that about 60% of adults were eligible under 1-A. That didn't include any of the other health conditions, and was before they expanded 1-A eligibility. Now that it includes school personnel and first responders I wouldn't even want to hazard a guess at the eligible percentage of the population. While there may have been good, science-based reasons for adding obese and smokers to 1-A, good science doesn't always make good policy. Pennsylvania's rollout is already bad, but keeping the categories small would have at least given the public the impression that progress was being made.

Second, the decision of some vaccine providers to vaccinate their entire staff before making any of their vaccine available to the public sent the message that looking out for your own interests is more important than considering the big picture, and the state's condoning of this reinforced it, as did the decisions of healthcare-related industries that had no frontline workers telling their employees to get vaccinated under 1-A.

Finally, and this is a minor component, but important nonetheless, the system of vaccine scheduling makes it so any motivated individual can find an appointment, but unmotivated individuals have a very difficult time. Until the CDC updated their website a few weeks ago, their was no centralized repository of information about where to sign up for a vaccine. I am not suggesting that the state should have set up a boondoggle of a centralized scheduler that would have caused more problems than it solved. I am suggesting that the state should have at least provided a list of links to websites that the vaccine providers were using for scheduling. As it was, you had to know which pharmacies were providing vaccines and go to the individual websites. I got mine at a local grocery chain, and when some friends found out that was the first they heard that vaccines were available there. The individual provider websites compounded the issue by using zip codes to find available appointment times. For most things, this isn't a problem, but many sites arbitrarily restrict what they will show you to an arbitrary radius. If one is willing to drive beyond this radius, they are out of luck, and it doesn't help that they don't even tell you what the radius is. But motivated people can get around this limitation. Some sites have a hidden page that lists all the locations where appointments are available, and you use the zip code closest to that location. Others require you to enter a bunch of zip codes until something pops. The CVS website has a ton of information about Covid the vaccine, but no link to an actual scheduler. For that, you have to google "CVS covid vaccine" and go down a few hits until you find the third-party site they are using for scheduling that inexplicably isn't linked from the main CVS site. People with better knowledge of computers and the savvy to figure out these tricks are at an advantage compared to others, who overwhelmingly tend to be older. You also have to be willing to drive some distance. For whatever reason, most locations are fully booked, but some rural locations have a seemingly endless supply of appointments.

Anyway, I find this whole situation fascinating. In less than two months the attitudes of most people concerning lying about health conditions to get the COVID vaccine before you were officially eligible went from "It's immoral to do that" to "I wouldn't do it personally but I understand why someone would" to "I did it" to "I did it and you should do it if you can" to searching out appointments online to find them for friends and even acquaintances who haven't been vaccinated yet and yelling at them if they say they're not interested. And it's all the result of a state regulatory system that sought to stick with the science and abide by CDC guidelines while trying to appease various interest groups. In the meantime, articles are appearing in the New York Times and other highly-respected publications about how great a job West Virginia is doing at vaccine distribution. It's certainly easy to imagine worse outcomes from a personal standpoint—I and almost everyone I care about has been able to get vaccinated—but from a public health standpoint it certainly feels like a disaster. For all of the state's attempts to do it the right way they ended up with a mediocre vaccination rate and a state full of line jumpers.