Who should be vaccinated, and who should be vaccinated first are the ethical and practical questions facing all governments.
The Covid-19 pandemic has hit the have nots harder than the haves. The longer the pandemic endures, the greater social and economic inequality will become. One would hope that the rollout of Covid-19 vaccines will slow, stall or even reverse the pandemic’s unequal impacts. Slow or delayed vaccine rollouts, particularly in poorer countries or among the poorer within countries, would dash such hopes. Already, the bulk of the initial Covid-19 vaccine supply has been secured by more prosperous countries.
The scarcity of vaccines, whether it is brought about by shortages in vaccines or delays in vaccination rollouts, poses considerable ethical dilemmas for governments centered around the question of who should be vaccinated first. The choices made by governments thus far reflect different priorities and circumstances and are underpinned by different notions of what constitutes a fair and just vaccination rollout program.
Consistent with the global norm, almost all Southeast Asian governments have given priority to the vaccination of frontline workers such as health care workers, the police and army. The rationale for prioritising health workers is that they bear the burden of taking care of Covid-19 patients and, in the process, incur an elevated risk of exposure to the virus. From the utilitarian ethical perspective, which emphasises the overall welfare of a society, vaccinating health workers would ensure a more robust health delivery system in these dire times. The same argument can be made for prioritising the vaccination of the police, soldiers, and teachers.
The elderly and those with existing serious medical conditions are other groups widely prioritised for early vaccination. For these groups, the ethical justification is different. Though this group of people may be less exposed to the virus, their fatality rate is likely to be higher if they are infected. The philosopher John Rawls proposed the “difference principle” which accords priority to the most disadvantaged in a society because of the arbitrariness of our conditions. We cannot choose when or where we were born.
Instead of the elderly, some countries have given priority to the vaccination of younger people. Indonesia, for example, is targeting those in the 18 to 59 years age group. The rationales for this policy and ethical choice are that persons in this group are economically productive and have a higher probability of getting infected. Even though these arguments appear different to those to prioritise health workers, they share the same utilitarian ethical principle – it is for the good of the society. This calculus may also reflect demographic realities. In Indonesia, about 6 per cent of its population is 65 years old and above. In contrast, in Singapore 15 per cent are, implying that the choice to prioritise the elderly for early vaccination in Singapore could have a utilitarian justification.
The philosopher John Rawls proposed the “difference principle” which accords priority to the most disadvantaged in a society because of the arbitrariness of our conditions.
In the case of Indonesia, another reason has been provided for not prioritising the elderly for vaccination. The official justification is that there is still some uncertainty about the effects and effectiveness of the vaccines being rolled out. This could be due to Indonesia being heavily dependent on the CoronaVac vaccine developed in China – which is still undergoing late-stage clinical trials in Indonesia. Obviously, not all vaccines are created equal.
The uncertainties surrounding the effects and side-effects of vaccines, whether real or imagined, also leads to another ethical and practical question – should vaccination be voluntary or compulsory. This is not just a question for less developed countries – there are reported cases of healthcare workers in the US refusing to be vaccinated. Compulsory vaccination does not depend on the full availability of vaccines. Vaccination of prioritised groups can be made compulsory. The difference between the two options is freedom. Freedom implies a libertarian approach to vaccination that favours voluntary vaccination – that each individual takes full responsibility of the consequences of vaccination or the refusal to be vaccinated after taking into account the attendant risks to themselves and others.
There is a utilitarian counter argument to this libertarian approach. Compulsory vaccination is justified as mass vaccination has “positive externalities” – its benefits extend beyond the person vaccinated to others and society as a whole and as such is likely to be under-provided if a person merely considers his/her personal benefits. However, this argument disregards vaccination’s uncertainties and risks to the individual. To overcome this problem, some countries have adopted a softer approach that entails voluntary vaccination but nudges the general public towards vaccination by public demonstration of its safety. Many countries have prioritised and publicised the vaccination of political leaders and social media influencers.
Will these ethical dilemmas of vaccination disappear when vaccines become fully tested and universally available? Yes, to some extent, as the history of vaccination amply demonstrates. Until then, Southeast Asian governments will need to choose who gets vaccinated and who gets vaccinated first.