The Ethics of Scoring a Covid Shot

The ethics of scoring a COVID vaccine shot

in Community

A shot in the arm jabs the conscience when there’s not enough vaccine for everyone.

With Covid-19 vaccine hard to come by, unease, even guilt, that they may have done something wrong is affecting those who got the vaccine. And those who didn’t.

To begin, consider this intimate account of obtaining the vaccine, my own.

I do not know the private individuals responsible for me getting the Pfizer/BioNTech Covid vaccine on Jan. 26. It was unclear at the time whether I qualified. It was administered by a health care organization of which I am not a member. My health care provider was not offering shots at the time, for anyone, let alone the target group of healthcare workers and those over age 75.

My spouse had received a vaccination appointment through her health care provider. It had come to her through someone who knew of the availability of the vaccine and shared the information privately. Even so, I was vaccinated ahead of my spouse, who had obtained an appointment 10 days before I received an email from the friend of a friend and would get the shot 10 days after I got mine.

This story was originally published in the March edition of Climate Magazine.

An Ethical Dilemma

Did I do the right thing? Or did I, as San Mateo County Health Officer Scott Morrow, M.D. put in his lengthy and emotionally charged letter to the public of Jan. 19, “jump the line” and receive a dose that could have saved the life of “some 89-year-old widow”?

I fit vaccine guidelines when I received my shot, but, still, it’s a devastating indictment. Conversations with others who stressed over if and when and where they might receive the vaccine show many have faced or are facing it, too.

Experts looking back in hindsight in the future may be able to resolve the issue, but in the moment, in a period of changing medical guidelines, fluctuating rates of disease and inadequate supply of vaccine, it’s impossible.

Of the many stories about scoring the vaccine, few are the same. Those who succeeded in the prescribed way — submitting an online form or calling published phone numbers — appear less common than those who got lucky, or who happened to be in the right place at the right time, or who happened to know people.

If it sounds chaotic, it’s because chaos at the top is forcing those at the end of the line, the counties, to adapt to chaos.

Epidemiologists at the Centers for Disease Control and Prevention made the first critical vaccine decision when they were forced to choose: vaccinate to minimize deaths or minimize spread? Lives of tens, if not hundreds, of thousands depended on whether priority went to preventing deaths, in which case age would be the determining factor, or spread, in which case age would not be the dominant factor. They chose to minimize deaths: People over 65 account for most hospitalizations and over 80 percent of Covid-19 deaths.

Priority by Age

Because vaccine supplies were limited, the age range was set at 75 and above unless sufficient vaccine were available to vaccinate those 65 or older. Healthcare workers also got priority in the effort to keep hospitals open.

This was the setup: Under its 1a guidelines, the federal government would buy all vaccine and allocate it to states, the states in turn would allocate to localities — in California’s case, counties. Frontline vaccinators would receive doses in the allocated quantity directly from the federal government.

In San Mateo County the setup created three vaccine streams.

One stream inoculates veterans, the elderly in long-term care facilities and healthcare workers. The Veterans Administration and two pharmacy chains, CVS and Walgreens, receive vaccine to inoculate that population. This channel, especially the VA, has operated without much public complaining, presumably because it has been efficient.

The second channel allocates to San Mateo County itself. The county is the community safety net, the healthcare agency of last resort. Its stream goes to the most vulnerable population, to the county hospital and to small community clinics usually run by nonprofits.

The third allocation goes to “MCEs,” multi-county entities, the major community healthcare providers. In San Mateo County, Kaiser, Sutter/Palo Alto Medical Foundation, Dignity Health and AHMC/Seton comprise this group. Long-term, the plan is to give MCEs the largest number of doses, but for now they receive sometimes a quarter of what counties get.

Puzzling Numbers

Each MCE tries to match up its vaccine supply with its members, leading to some neck-snapping discrepancies. In mid-February Dignity Health had enough supply to vaccinate 65 and older, while Kaiser had enough only for 75-plus and Sutter had not even begun vaccinating.

Complaints about long telephone hold times or websites that crash or have no appointments available probably concern one of these MCEs.

At the delivery end, once it’s in hand the vaccine reverses the official dynamic. Where the CDC guidance is to vaccinate the elderly and healthcare workers, state guidance can vary week-to-week — partly because it has little advance information about how many doses it will receive. When it arrives locally, the supply is unevenly distributed among the supply streams. On the front lines, if vaccine becomes available and the choice is use it or lose it, the 1a age guideline appears to be holding, but the healthcare worker guideline is slipping.

Having vaccine to spare in a vaccine desert happens.

Even casual conversation turns up many people who secured a vaccination appointment, found another because it was sooner or closer and did not, or could not find a way to cancel the first.

For whatever reason, a west side medical facility last month at the end of the day found itself with 40 no-shows and 40 unclaimed doses. The physician contacted churches, who in turn passed the news about the doses to whomever they chose, however they chose.

The physician confirmed the essentials of the account but declined to be identified and demurred when asked for additional detail except to say the 40 shots found arms. In most cases, background for this story came from individuals the same way: Use the information but don’t use the name. Covid vaccine nervousness, shyness — or guilt — may be misplaced, but it also may be justified.

Avoiding Waste

The state of Texas asked Houston physician Dr. Hasan Gokal to set up a vaccination site with instructions to dose those in the 1a category and not waste vaccine. At closing, one vial remained. A last patient arrived and the seal on the last vial was punctured, which meant Dr. Gokal had six hours to find arms for the 10 doses left in the vial. At midnight, after hours of hustle, he’d found nine patients with 15 minutes to go and no one left in line. He gave the tenth to his wife, who had a medical condition making her vulnerable but who did not meet the age guideline.

Dr. Gokal was fired and the Houston district attorney filed charges for misuse of the $135 vial of vaccine. The judge threw out the charges, but the state did not give him back his job, claiming he had violated the federal guideline on equity: Too many recipients had Indian-sounding names.

Fundamentally, vaccination is an equity equation, equity being a pillar of the federal government’s Covid response. A select Advisory Committee on Immunization Practices aligned the CDC’s guidelines with an ethics pledge to “maximize benefits and minimize harms, promote justice, and mitigate health inequities.”

“Equity” as a goal runs throughout the program from Washington on down — San Mateo’s Health Department declares three banner vaccine program principles: Safety, Transparency and Equity.

Inequity can be simple to detect. Consider the vaccination appointment process. It can take just a phone, if one is willing to spend 10 hours holding, waiting to be told no appointments are available, as happened to one source. But it still takes a phone.

Deciding What’s Equal

Online registration takes a computer, internet access and, depending on the website, substantial technical skill. Some application processes require an ID image or a picture of a vaccination or health record. For that one needs a smartphone or even a digital scanner at a minimum.

The county works hard to reduce inequality, discloses data consistent with its transparency principle and reaches out to bridge ethnic and racial gaps where it can. It publishes volumes of data proving Covid kills minorities and the poor, particularly Hispanics, disproportionately.

The graphic shown here takes a different approach. Is any one area getting disproportionately more vaccine? If so, what may account for that? We looked at how age of population and wealth correlate to what percentage of a city’s residents received vaccination.

Age and household income track — young populations haven’t had long enough income-earning careers to catch up with retirees or those in career primes.

Vaccinations do not. Portola Valley has two percent more residents in the 70-79 age range as Half Moon Bay but twice the vaccination rate. Atherton’s proportion of those aged 70-79 is nearly the same as Millbrae’s, but its vaccination rate also is double.

The graph, which was put together from county information, is not perfect. It does not track another possible variable, proportion of population who are healthcare workers. Charting populations of doctors and hospital workers might be illuminating.

Note: The county website at is a trove of Covid information with links to many resources, including performance data and mass vaccination and testing sites and schedules.