In this post, Emma Curran & Stephen John discuss their recent article in Journal of Applied Philosophy on duties to prioritise vaccinating the vulnerable.

In the December of 2020, the UK seemed to breathe an, albeit small, sigh of relief as the first COVID-19 vaccinations were administered. After almost nine months of lockdowns, the vaccine roll-out was the first concrete sign that life might return to – at least something like – normality. Indeed, throughout 2020, the promise of a vaccine seemed to be the end to which lockdown pointed. Lockdown was tough but necessary to protect the lives of those most vulnerable to COVID-19, until they could be helped by a vaccine. Unsurprisingly, then, the vaccine roll-out started with the most vulnerable, with a primary focus on age. In this post, however, we explore a  seemingly small alteration to the Government’s vaccine strategy which concerned and confused many. Using this policy, we explore the reasons we have to protect the vulnerable, the complexity of ethical discourse around the distribution of vaccines, and the need for transparent, open debate.

Less than a month after the first vaccines were administered, the UK Government made what, on first glance, seemed to be merely a technical tweak to their COVID-19 vaccination strategy. On the advice of the Joint Committee on Vaccination and Immunisation (JCVI), it was decided the second dose of the vaccine should be administered 12 weeks, rather than 21 days, after the first. The justification provided was that, given the first dose seemed to provide a high level of short-term protection, more lives would be saved by vaccinating a larger number of people with the first dose, than by vaccinating a smaller number of people with both.

Despite its merely technical appearance, this decision proved to be controversial. At the time, there was considerable concern that increasing the gap between doses would reduce the overall efficacy of the vaccine. As such, the Government’s change in strategy seemed to be trading-off the degree of protection they were affording the most vulnerable in favour of reducing the risk to others. This decision wasn’t only controversial – it was confusing. As the mantra of “protect the vulnerable” had echoed around the country, it was difficult for many to make sense of how the decision aligned with the rest of their pandemic strategy.

We can understand the Government’s decisions when we recall their claims throughout the pandemic that “the overall priority remains to save lives”, alongside the JCVI’s claim that “the first priorities for the COVID-19 vaccination programme should be the prevention of mortality and the maintenance of the health and social care systems”. This end – the prevention of mortality – could be served through a variety of means – including, as in this case, failing to help the most vulnerable as much as possible.

In short, the Government’s repeated emphasis on protecting the vulnerable wasn’t because it was one of the desired ends of COVID policy. Rather, protecting the most vulnerable was simply a convenient means to the goal of minimising mortality. And once protecting the most vulnerable as much as possible stopped being the most effective means of preventing mortality, it was only sensible to divert from that means to another, more effective, one.

Yet, protecting the vulnerable need not be a mere means to some other end. It is perfectly sensible to think we have reason to protect the vulnerable outside of concerns for minimising mortality. Presumably, such reasons were in the minds of those who were confused, or even appalled, by the Government’s change in strategy.

What might these reasons be? One thought is that we ought to give priority to the worst-off. It seems – at least to a number of philosophers – that helping someone who is badly off is just worth more than helping someone who is less badly off, simply by virtue of the fact that the worst-off are in greater need of assistance. Reducing the COVID-19-related-risk of the clinically vulnerable just matters more, independent of the effect on overall mortality. Alternatively, we might ground minimising mortality in a concern for, something like, efficiency. Plausibly, we have moral reason to do that which would bring about the most good, and, also plausibly, preventing the greatest number of deaths is akin to bringing about the most good.

So, rather than being merely technical, the decision to change the spacing between doses reflected a contestable ethical commitment. The UK Government, however, obscured this by failing to adequately distinguish the goals of their policy, the normative principles which underpinned them, and the means by which they aimed to achieve them.

Whilst it might seem attractive to view the Government’s decision in terms of a conflict between priority and efficiency, the mandate to minimise mortality also receives support from priority. Insofar as death is the worst possible outcome, preventing people from dying is aligned with preventing people from being in the worst-off possible position. So, despite our philosophical grumbles, maybe the government’s decision was merely a technical one concerning how to best help the worst-off?

We think not. It’s not that the correct choice could be attained by doing further empirical work into which policy would most help the worst-off. Rather, any decision-maker would have to choose between competing notions of what priority means. One way of unpacking priority, epitomised by the view that priority requires protecting the vulnerable, is concerned with individuals’ prospects – their chances of gaining or losing out. It tells us that the worst-off are those who have the worst prospects – in this context, the clinically vulnerable – and that we ought to pay special attention to improving their prospects. But there is another way of thinking about priority which tells us to focus on outcomes, rather than prospects. This way of unpacking priority tells us that we ought to choose the option which will have the most well-off worst-off members. Such a view, naturally, would recommend choosing the option which minimised mortality. The distinction between these two conceptions isn’t merely technical – rather, they represent distinct and conflicting ethical viewpoints.

So, what seemed to be a small, technical decision, instead turns out to be quite the ethical mess. What might we learn from all this? First, many seemingly technical decisions reflect deep ethical commitments. Second, these ethical commitments are contestable, because even those who agree on broad ethical positions may disagree on what those principles mean. As such, we require transparent, open debate, rather than slogans – we need to know what we mean by “protect”, by “vulnerable”, and why we should care. Philosophy can’t resolve those debates, but it can help clarify them.

The Journal of Applied Philosophy is a unique forum for philosophical research that seeks to make a constructive contribution to problems of practical concern. Open to the expression of diverse viewpoints, it brings the identification, justification, and discussion of values to bear on a broad spectrum of issues in environment, medicine, science, policy, law, politics, economics and education. The journal publishes in all areas of applied philosophy, and posts accessible summaries of its recent articles on Justice Everywhere.