The current UK policy for the distribution of scarce vaccination in an influenza pandemic is ethically dubious. It is based on the planned outcome of the maximum health benefit in terms of the saving of lives and the reduction of illness. To that end, the population is classified in terms of particular priority groups. An alternative policy with a non-consequentialist rationale is proposed in the present work. The state should give the vaccination, in the first instance, to those who are at risk of catching the pandemic flu in the line of their duties of public employment. Thereafter, if there is not sufficient vaccine to give all citizens equally an effective dose, the state should give all citizens an equal chance of receiving an effective dose. This would be the just thing to do because the state has a duty to treat each and all of its citizens impartially and they have a corresponding right to such impartial treatment. Although this article specifically refers to the UK, it is considered that the suggested alternative policy would be applicable generally. The duty to act justly is not merely a local one.
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It is reasonable to suppose that it might be merely a matter of time until there will be an influenza pandemic in which fatalities are likely to be common and for which the available medical treatment might be very limited. How should the agents and agencies of the state allocate their doses of scarce vaccine in such envisaged circumstances? Why should they so allocate them? I shall sketch a non-consequentialist alternative to the current UK plan. (Outcomes can matter. As a non-consequentialist, my assertion is that they are not of sole moral importance. My position allows for the balancing of different obligations but it does so in a different way from the UK's current plan. There is a difference between saying that it would be better if it turned out that more people survived and saying that it is the duty of the state to try to bring about that outcome. It would be better if those who commit crimes were found guilty of so doing. However, by performing their duty, members of a jury might well produce a different outcome. It is not the case that members of a jury should make a trade-off between acting justly and convicting criminals.)
The current UK policy
The current UK policy and its rationale—which are in accord with those of other major countries—are ethically dubious. The UK contingency pandemic plan states that: ‘The priority in an influenza pandemic is to reduce the impact on public health (ie, reduce illness and save lives). Interventions will therefore be applied where they will achieve maximum health benefit.’1
According to the UK plan, the population should be divided into seven priority groups. The proposed groups are as follows:
‘Group 1: Healthcare staff with patient contact (including ambulance staff) and staff in residential care homes for the elderly; Group 2: Providers of essential services for example fire, police, security, communications, utilities, undertakers, armed forces; Group 3: Those with high medical risk for example, chronic respiratory or heart disease, renal failure, diabetes mellitus or immunosuppression due to disease or treatment, women in the last trimester of pregnancy; Group 4: All over 65 years of age; Group 5: Selected industries; Group 6: Selected age groups, depending on advice from WHO for example, children; Group 7: Offer to all.’2
The suggested ethical framework to justify the plan is flawed. Indeed, it does not seem to be coherent. It states that: ‘Equal concern and respect is the fundamental principle that underpins this ethical framework’.3 However, although ‘everyone matters equally … this does not mean that everyone is treated the same…the harm that might be suffered by every person matters, and so minimising the harm that a pandemic might cause is a central concern’.3
A proposed non-consequentialist policy
What, were it to come about, would be the best outcome of a pandemic policy? That is a different question from: what ought the agents and agencies of the state to do in the face of an influenza pandemic? Different again is the question: what ought they to plan to do? Such questions might or might not have the same answers.
The agents and agencies of the state ought to fulfil their moral duties and ought to plan to do so. For instance, the state, its agencies and agents have a moral duty to treat individual citizens impartially, which implies treating them the same in relevant respects unless there are relevant reasons for treating them differently. Justice requires such impartiality: individual citizens have a moral right to be treated justly by the state whatever the consequences of such just treatment might be. Hence, the government ought to treat citizens impartially if it allocates doses of vaccination in the event of an influenza pandemic and, if it makes plans for such an eventuality, it ought to plan to fulfil this duty of impartiality. This duty will not determine its plan but will set boundaries for it. It will rule out possible lines of action. What constitutes the substance of impartial treatment will vary from place to place and time to time. Nevertheless, the duty of the state to provide it is invariant.
The agents and agencies of the state will have other duties to/ fulfil than that of allocating vaccine impartially if it allocates it at all. However, there is no obvious reason to assume that these duties will dilute or conflict with its duty of impartiality in such allocation. In any event, the basis of its planning should be the expectation of the fulfilment of its duty of impartiality even if it turns out that in some extraordinary and unexpected circumstances its fulfilment is not possible or ethically appropriate.
There is at least one relevant reason for treating some citizens differently in the allocation of vaccination in an influenza pandemic. There is at least one such reason. The state has a particular responsibility—a moral duty of care—towards those it requests, requires and employs to do, at its behest, particularly dangerous things. For instance, it should not give tin helmets or flak jackets to ministers of defence or to generals if there are not enough to give one to each and all of the front-line soldiers. Similarly, the state should give the vaccination, in the first instance, to those who are at risk of catching the pandemic flu in the line of their duties of public employment. Thereafter, if there is not sufficient vaccine to give all other citizens equally an effective dose, the state should give them all an equal chance of receiving an effective dose. It should allocate the remaining vaccinations in the manner of a lottery by the random selection of names. This would be the just thing to do because the state has a duty to treat each and all of its citizens impartially and they have a corresponding right to such impartial treatment. (It is in the general interest that the state survives pandemics and is able to function during them. The government has a duty to promote that survival and functioning. It has a duty to maintain public order and safety, which might be under threat if a pandemic led to social unrest. However, it does not follow that people such as, for instance, politicians and those mentioned in group 2 of the current plan should be given priority in the allocation of vaccine. For instance, even if we need, say, a Prime Minister, we do not need any particular person to be the Prime Minister. Prime Ministers are readily replaceable and there is no shortage of politicians who want to assume the role. We might expect that the proportion of the population that will die in a pandemic will be the same as the proportion of policemen, firemen and other providers of emergency services who will die. We need to allow for the replacement of such personnel and their augmentation by the drafting in of the various categories of members of the armed forces and of other civilian auxiliaries. Nonetheless, we are required to have similar emergency arrangements in anticipation of unpredictable contingencies other than influenza pandemics. Hence, we need not assume that it is necessary to give a priority allocation of vaccine to the providers of such emergency services. I am not convinced that it would be desirable.)
Peterson's alternative lottery system
Peterson has also proposed a lottery system for the distribution of influenza vaccination in a pandemic but it is based on principles different from mine. His position rests ‘…on a purely consequentialist account of morality: An action is right if and only if its outcome is optimal.’1 In my view ethical considerations relate not merely to the consequences of actions but to the principles according to which they are performed. Indeed, in some contexts, what is ethically important is how and why we do what we do rather than the outcome of our actions.4–7
Peterson writes: ‘I propose that it would be morally better to implement a system in which each nation sets up a lottery that gives all citizens equal chances of surviving a pandemic influenza. My view does not entail that everyone should be entitled to equal chances of getting a dose of vaccine. Some people, such as doctors and nurses, are likely to be more exposed to the virus and should therefore receive a larger number of lottery tickets than, say, university teachers.’1 My contention is that it is not the responsibility of the state to distribute such chances of survival but to distribute the vaccination and the chances of being offered an effective dose of it.
The state is not responsible for the distribution of health or for the distribution of life expectancy in society. It is responsible for the distribution of the vaccine and for the distribution of the chances of receiving an effective dose of it. It has the duty to carry out the distribution impartially. It is not responsible for the outcome of such a just distribution.8 9 If there are two policies which are equally just, ceteris paribus, the state should prefer the one which results in more survivors. However, that is quite different from saying that our pandemic policy should be chosen on the basis of the maximisation of survivors. Similarly, the state should not make a trade-off between acting justly and saving lives.
There is a case to be made, on the basis of justice, for suggesting a different policy from the current UK one for the distribution of scarce vaccination in an influenza pandemic.
There is a problem in reconciling the current UK plan and its suggested ethical rationale with the principle that the state has a moral duty to treat individual citizens justly whatever the consequences of the treatment might be. Although I have specifically referred to the UK, I think that my suggested alternative policy is applicable generally. The duty to act justly is not merely a local one.
I am grateful to Martin Peterson and an anonymous referee for helpful comments on an earlier draft of this paper.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.