This supplement to The Hastings Center’s “Ethical Framework” aims to help structure time-sensitive discussion of significant, foreseeable ethical concerns in responding to Covid-19 and to support collaboration across institutions throughout pandemic response and recovery. It is designed for use by county health systems and by hospitals, community health centers, and other health care organizations responsible for patient care or preventive health, including vaccine education, vaccine distribution, and vaccination. This document aims to support formal and informal convening and policy work within the same geographic region, such as a municipality, county, metropolitan area, state, or multistate area, led by public health authorities, health care institutions, or other groups involved in vaccine allocation. The document’s scope is limited to the ethics of vaccine distribution within the United States; it does not address the ethics of international cooperation and sharing vaccines versus focusing solely on ensuring vaccine access in one’s own nation (“vaccine nationalism”).

The focus of this document is the middle tier of vaccine allocation and the ethical challenges arising in the U.S. in the first half of 2021. This focus reflects general consensus and ongoing implementation concerning highest-priority vaccination of two populations: frontline health care workers and residents of long-term care facilities (the groups constituting “Phase 1a

in recommendations from the Advisory Committee on Immunization Practices [ACIP]).The ethical justification for prioritizing these populations was their high risk of contracting the virus, of passing it to others at high risk of severe disease, and, in the case of long-term care residents, of dying of severe Covid-19. Additional justifications include the relatively small size of these initial cohorts, the relative ease of locating them and providing the vaccine, and the value of public trust created by witnessing health professionals receiving the vaccine. There is also broad consensus that vaccine allocation to the general public—people without major risk factors and who can reasonably protect themselves through masking and physical distancing—should occur only after the vaccination of groups at high risk of infection or at high risk of severe illness or death if infected. This document therefore does not address the final stages of vaccine distribution to lower-risk members of the public.