With the UK Covid-19 hospitalisation and mortality figures reaching new global heights and the possible increased severity of the new UK strain, the start of 2021 has not been promising. The only silver lining in this gloomy cloud is the roll out of the vaccination programme. Being the first country in the world to approve vaccines and initiate a national rollout means there is much riding on its success and daily “jab” rates now accompany daily death rates during number 10 briefings, endeavouring to create a mood of hope.
While it is the NHS that has responsibility for delivering the biggest vaccination programme in its history, the decision on who gets the vaccine rests with the government, advised by the Joint Committee of Vaccination and Immunisation (JCVI) . They have produced a series of recommendations over the last few months, the latest on the 30 December.
For what the JCVI now call phase one, their aim – which is admirably succinct – is to prevent mortality and support the NHS and social care system (note the term ‘system’). They argue that as the risk of mortality from Covid-19 increases with age, prioritisation should be primarily based on age. The order of priority for each group in the population corresponds with data on the number of individuals who would need to be vaccinated to prevent one death, estimated from UK data obtained from March to June 2020. There are nine groups:
It is estimated that taken together, these groups represent around 99% of preventable mortality from Covid-19. They suggest that an age-based programme will result in faster delivery and better uptake in those at the highest risk. Indeed, the government aims to cover all four top groups by mid-February. However, the JCVI also acknowledge that implementation needs to involve flexibility in vaccine deployment at a local level, with due attention to mitigating health inequalities, such as might occur in relation to access to healthcare and ethnicity, vaccine product storage, transport and administration constraints and finally, “exceptional individualised circumstances” (whatever they are!).
This all seems eminently sensible and yet it differs from the approach in other countries.
In his recent Covid blog, Professor David Archard, chair of the Nuffield Council on Bioethics describes a discussion with his 99-year-old mother about the vaccination (following the example of the Deputy CMO who encouraged his elderly mother "to be ready"). Professor Archard’s mother said she didn’t think she deserved priority and that it should be given to the young first. He says: “I have no reason to think her reply was disingenuous or confused. Like many of her age she has a sober and realistic understanding of her own mortality and she is cognitively very able. Nor was it a question of being vaccine hesitant. She simply thinks the priority rule is wrong”.
He contrasts the UK guidance to the German equivalent that appeals to a number of underpinning ethical principles, of most relevance here being those of ‘justice’ and ‘solidarity’, in contrast to the JCVI that relies solely on a principle of reducing the overall loss of lives.
An alternative extreme policy has been adopted by Indonesia, which is targeting young people, who are seen as the drivers of infection.
The lack of an underlying values framework in the UK approach is not ethical semantics, but is creating a problem waiting to happen.
The debate has already started. On a daily basis, advocates come forward for groups who are not currently prioritised. Recent examples include the Home Secretary Priti Patel saying that the police should be a priority and the charity Unicef, who say teachers should be.
How should the validity of these claims be assessed?
The expansive language used in the JCVI guidance also means that some groups who you might not expect to be prioritised are eligible, such as back office staff in the NHS.
This, coupled with the mixed messages arounds distribution policy and the increasing concerns over the UK outlier position on the timing of the second jab, means that clarity of messaging to the public is urgently required.
This debate suddenly became personal on Thursday 21 January. I received an invite by text from my south London General Practice to come in for a Covid vaccination. Apparently, I was eligible by virtue of being between 65-68 years old (this is group 5 – outside the top four priority range). It was a friendly text finishing with “we would love to see you tomorrow”.
However, on the day I read this I was listening to the Today programme on Radio 4, where the disparity across the country of vaccination rates was being debated with rates as low as 30% for the top four high-risk groups in some parts of the country. The night before I had heard on the PM programme the NHS London Medical Director Dr Diwakar being horrified to learn that some unscrupulous people are using links shared with them to try to falsely book a vaccination appointment. “To seek to do this is denying some of the most vulnerable in our community a life-saving vaccine. Let me be clear about this, it is morally reprehensible to try to jump the queue,” said Dr Diwakar.
I appeared to be being pushed to the front of the queue unwittingly, perhaps because south London GPs are super-efficient or maybe I am what the JCVI describe as an “exceptional individualised circumstance”. I did have a cancer diagnosis five years ago, but am in remission, so do not count myself as in the extremely clinical vulnerable group.
As it happens, I was talking last week at a webinar as part of a research programme on the ethics of Covid, funded by the British Academy. My subject was the role of the public and press in understanding the ethics of Covid. Thinking about my experience I realised I had just become a Covid ethics case study!
I did not have long to ponder the ethical pros and cons as I was phoned on Saturday 23 January by the practice to make an appointment for the next day. I had intended to contact my GP for a discussion, but the speed of service meant that an immediate decision was needed.
I quickly thought through the options. It may be that I was called as there was spare vaccine after all the groups 1-4 has been vaccinated and it should not go to waste or indeed perhaps unlike me, the practice considered me at high risk. My decision making was complicated by the fact that I am currently out of the country.
Taking the ethical and overall perceived risk factors into account I informed the caller that I would like the vaccine, but not now. They accepted this, but warned me that vaccine may not be available in the future. I put the phone down and within five minutes I received a text saying that my appointment had been cancelled and I will receive another text to book a new appointment. I was content that my moral dilemma was resolved and thanked God for the efficiency of the NHS.