Proposing a Legal Framework for Distribution of the COVID-19 Vaccination [Part I]

Introduction

Distributing the COVID-19 vaccination has been touted as the biggest policy decision in 2021. This stems from the utility and efficacy of vaccines in immediately addressing pandemics. Specifically, the COVID-19 vaccination not only protects the injected person, with a 70%-95% efficacy[1] but also provides ‘herd immunity’.[2] That is, the non-injected population is also benefited due to a reduced risk of transmission and infection, so long as 70% of individuals in society are vaccinated. Therefore, access to the vaccine determines how much and for whom the adversity of the pandemic is mitigated.

Currently, most vaccine developers are in the final two phases of clinical trials, with some, like Pfizer/BioNTech’s and Oxford University/AstraZeneca’s, already receiving ‘emergency use authorization’ from multiple countries. Most countries have prepared a ballpark action plan for distribution, while the United Kingdom has already vaccinated more than 3.5 million people.[3]

In this paper, I evaluate the most ethical framework for distributing COVID-19 vaccinations, amongst the population of one country, by its government. I address this question from the perspective of marginalized communities, using the approaches of realism, syndemics, and intersectionality. In Part I of this article, I will evaluate the conventional models for vaccine distribution. In Part II, I will provide an alternative framework for reassessing vulnerabilities during a pandemic, and propose a multi-value ethical framework.

1. Evaluating the Conventional Models for Vaccine Distribution

The decision to distribute COVID-19 vaccines is inherently ethical because it involves allocating an important resource in a resource-scarce world. Thus, determining who can pre-maturely mitigate the pandemic’s adversity. There are four models in conventional discourse that have sought to answer the distribution question. In this section, under each model, I will critically evaluate the role of law in distribution and the ethical values that guide prioritized distribution.

Neoliberalism

Neoliberalism is characterized by a strict separation between the state, society, and the market.[4] The objective of all economic activity in the markets is wealth and efficiency maximization.[5] To this end, greater involvement of the private sector in the economy is justified because the market allocation of resources is more efficient. Any state intervention beyond a minimum supporting role is conceived as inefficient because rent-seeking, corruption, and capture by special interests are inevitable.[6]

The diminished role of the state in securing redistribution means that individuals are responsible for their welfare and income. Therefore, individuals would themselves be responsible for ensuring access to the vaccination, notwithstanding their socio-economic status. They must attain this access by successfully competing in the “free market”, through instruments like price point discovery.[7] The underlying rules of competition create a level playing field where fair bargaining over market transactions can occur, so long as the requisite effort is made. This is because the rules are universal in their applicability, and create a distinct economic space, free from state coercion.[8] Therefore, access to the vaccine is determined by one’s ability to pay for it.

State intervention is only justified when there is a market failure, but even then, preference is accorded to non-state solutions like direct public action or self-regulation.[9] Neoliberalism addresses equity concerns, like non-access to the vaccine, through safety nets and income transfers rather than through market regulation.[10] Otherwise, inefficiencies are introduced into the system, which distorts market incentives, and thus undermines the goal of economic growth.[11] This means that vaccine developers would lose the incentive to undertake expedient and mass production.

Critique:         Neoliberalism denies that any redistribution to disadvantaged groups is covered by legal reforms. There is no focus on how economic gains are distributed, and the effect of reforms on vulnerable social groups.[12]Neoliberalism’s refusal to acknowledge the distributive function of legal regulation is flawed because rules necessarily always operate to distribute resources and powers to various groups and actors in particular ways.[13] The neoliberal machinery devises a particular allocation of risks, resources, powers, costs, burdens and benefits among different market actors. The effect is that the existing propertied class receive greater entitlement, whilst others are disadvantaged.[14] This perpetuates the inequalities already in status quo, impacting accessibility to the vaccine. Therefore, the relevant question is not whether distributive concerns must be considered, but rather their manner of incorporation in the process of market reform. To this end, the state, which guarantees the regulatory underpinnings of a market economy, must inherently play a greater role in regulating the distribution of economic gains from the market.

The idea to distribute vaccines based on personal purchasing power is flawed because it ignores the fact that vaccines possess inelastic demand. Therefore, given short supply at short-term and medium-term levels, the price will continually go up to unaffordable rates. This increased price does not encourage new suppliers because the intellectual property rights and R&D is held only by a few developers.[15]

Utilitarianism

Utilitarianism assesses the morality of a decision based on its consequences, whether it maximizes benefits and/or minimizes harms. Under this rationale, priority is accorded based on the greatest clinical risks and greatest utility to social functioning. The clinical factors consider the risk of severe morbidity and mortality, risk of infection, and risk of transmission.[16] The greatest utility to society is measured in terms of the risk of negative societal impact, i.e., the public utility of one’s occupation/social role to society and other individuals’ lives and livelihood.[17]

Therefore, in this pandemic, utilitarianism would prioritize age (above 50/60 years) and associated comorbidities (identified set of diseases) based on the risk of morbidity/mortality and infection, followed by occupation (healthcare and frontline workers) based on the risk of negative societal impact and risk of infection.[18]

Critique:         Unlike neoliberalism, there is limited value in the utilitarian model because it recognizes the distributive role of law in allocating benefits. Moreover, it pursues this based on a rational objective criterion.

However, its main problem lies in assessing vulnerabilities through only a clinical lens. It ignores that socio-economic factors also contribute to overall vulnerability during the pandemic, as I argue in the next section. Additionally, it doesn’t acknowledge that even within the identified categories, some are more vulnerable than others. Therefore, it has the effect of compounding existing socio-economic inequalities.

Lottery

This approach prioritizes distribution through a random selection of names. This is premised on the assumption that such selection is egalitarian and impartial, and also overcomes the inherent moral relativity/ambiguity of human reasoning.[19]

Critique:         Random lotteries acknowledge the role of law in distributing benefits, but they lack any rational prioritization to effectively and immediately address the pandemic. While absolute objectivity is unattainable, avoiding moral reasoning altogether is merely “an easy method to avoid hard decisions”.[20] The assumption that everyone’s life is equally important fails to acknowledge the differential disparities that differentially threaten such lives.^[21]

First Come First Serve

Like lotteries, this approach is premised on avoiding moral decisions and the assumption that everyone has an equal opportunity to access the vaccine.[22]

Critique:         While this approach acknowledges the role of law in distributing benefits, it is completely blind to the socio-economic realities. Given scarcity, it is inevitable that access will be confined to those with better connections, access to information, communication, and transportation. All these factors are, in turn, tied to one’s socio-economic status. Thus, there is disproportionate denial to disadvantaged communities.

References:

[1] James Gallagher, ‘Covid vaccine update’ (BBC, 30 December 2020) <https://www.bbc.com/news/health-51665497> accessed 8 January 2021.

[2] Rebecca Weintraub, ‘A Covid-19 Vaccine Will Need Equitable, Global Distribution’ (HBR, 2 April 2020) <https://hbr.org/2020/04/a-covid-19-vaccine-will-need-equitable-global-distribution> accessed 8 January 2021.

[3] Lucy Rodgers & Dominic Bailey, ‘Covid vaccine: How will the UK jab millions of people?’ (BBC, 23 January 2021) <https://www.bbc.com/news/health-55274833> accessed 24 January 2021.

[4] Manfred Steger & Ravi Roy, Neoliberalism (OUP 2010) 3-4.

[5] Kerry Rittich, Recharacterizing Restructuring (Kluwer Law International 2002) 50-52.

[6] Rittich (n 4) 55-59.

[7] Sahil Deo, Shardul Manurkar, et al, ‘COVID19 Vaccine: Development, Access and Distribution in the Indian Context’ (2020) Observer Research Foundation Issue Brief No. 378, 6 <https://www.orfonline.org/research/covid19-vaccine-development-access-and-distribution-in-the-indian-context-69538/> accessed 8 January 2021.

[8] Rittich (n 4) 131.

[9] Rittich (n 4) 74-76.

[10] Ibid.

[11] Steger (n 4).

[12] Rittich (n 4) 130.

[13] Steger (n 11)

[14] Rittich (n 4) 158-160.

[15] Deo (n 7).

[16] National Academies of Sciences, Engineering, and Medicine, Framework for Equitable Allocation of COVID-19 Vaccine (National Academies Press 2020) 102-105.

[17] National Academies (n 16) 8.

[18] Ibid.

[19] Richard Zimmerman, ‘Rationing of influenza vaccine during a pandemic’ (2017) 25 Vaccine 2019, 2023.

[20] Ibid.

[21] Erica Moser, ‘Many ethical questions involved in prioritizing groups for vaccine distribution’ (The Day, 13 December 2020) <https://www.theday.com/article/20201213/NWS01/201219766> accessed 8 January 2020.

[22] Zimmerman (n 19).

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