Focus on ethics is encouraging but should extend beyond the discussion of COVID-19 vaccine access

December 7, 2020 8:00 am

Johnson & Johnson vaccines for COVID-19 have temporarily been pulled. (Creative Commons photo via Pxhere)

It didn’t get much attention, but one of the tidbits of information released last week about Iowa’s distribution of the COVID-19 vaccine was the inclusion of ethical experts on an advisory panel that will guide the state’s decisions about how, where and to whom the limited supply of vaccines will be provided.

Kelly Garcia is the director of the Iowa Department of Human Services and acting director of the Department of Public Health. (Photo courtesy of DHS)

Dr. Kelly Garcia, acting director of Iowa Department of Public Health as well as the state human services director, discussed plans to convene an infectious disease advisory council of “external and internal subject matter experts” to provide clinical guidance.

“This council will assist the state in developing COVID-19 vaccine prioritization of populations for early stages of vaccine response when supply is limited,” Garcia said at the governor’s news conference on Thursday.

She said the group “will bring together ethical and clinical expertise from across the state to represent multiple perspectives, including rural and urban populations, hospital administration, infectious disease specialists, vulnerable populations and congregate settings, advocates for aging populations and individuals with intellectual and developmental disabilities and refugees.”

She went on to say: “The reason for this is to minimize health inequities based on geography, poverty and other social determinants.”

That’s really good news, because Iowa’s health care system is rife with inequities based on geography, poverty and other “social determinants” such as race. Even for urgent public health initiatives such as COVID-19 testing, there are clear inequities in the distribution of free tests based on geography and individuals’ access to transportation, for example.

The governor’s office and a spokesman for Garcia didn’t get back to me Friday with more specifics on who would be advising the state on medical ethics and what issues would be the focus. A lot has been written already about the ethics of vaccine distribution and the issues are not always clear-cut. For example, most of us would probably agree in principle that equal access to the vaccine is the most ethical way to distribute a life-saving drug.

But in a rationing situation, as U.S. states will experience as vaccine supplies are initially limited, the federal government has already started making ethical choices in its guidance that health care workers and long-term care residents be prioritized for vaccination. Iowa’s public health department released the latest draft of its distribution plan Friday.

Most of us would likely agree that health care workers who are being regularly exposed to the virus while attempting to save lives should be first in line for the drug. Similarly, most of us would likely agree that the people most at risk for severe complications, including residents of nursing homes, should have priority.

But there are lots of gray areas. For example, should a cosmetic surgeon whose practice consists of elective procedures get the vaccine ahead of a 75-year-old retiree who lives independently but is at risk due to his or her age or pre-existing health conditions? What about the immediate families of health-care workers? Should famous politicians and celebrities be vaccinated ahead of others who may have a greater need so they can show it’s safe?

Garcia correctly stated last week that “transparency is key.” She carved out an exception for some details to be withheld due to security. But, she added, “we also recognize Iowans want to know who will get the vaccine when and we’re trying to strike this balance between keeping everyone informed and ensuring the safe distribution.”

Discussions about the ethical choices related to vaccine distribution should be held in public.

I have a lot of respect for Garcia. Every time I’ve heard her speak, I’ve been impressed with her expression of empathy for the populations her agencies serve, her interest in hearing stakeholder views and her repeated commitment to openness. Others who deal regularly with the agency have said Garcia’s gained their trust. She clearly has the governor’s confidence to manage the Department of Public Health during a pandemic while also overseeing Department of Human Services, one of the state’s largest and most complex agencies. However, her interest in transparency does not always manifest in easy access to public information. The vaccination process is too important for mere lip service in favor of the public’s right to know.

Nevertheless, it’s encouraging that Garcia is publicly elevating the importance of ethics in the conversation about access to COVID-19 vaccines. That conversation should continue beyond the pandemic as the state makes policy and funding decisions about Medicaid, mental health, family planning, EMT services and many other topics that affect Iowans’ quality of life.

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