Flu Vaccines, Ethics, and Order of Delivery

[Lagmonster]

With all the talk of upcoming pandemics, a lot of attention is being paid towards how to protect populations in the event of pandemics such as H5N1 where vaccines or treatments might be rare or expensive and a significant percentage of people are expected to die. For this case, assume we're talking about an avian influenza vaccine available in limited quantities (and as an aside, screw ducks. Let's all hope H5N1 doesn't get into pigs).

Traditionally, people determine who is at the greatest risk and treat them first - meaning that after the medical community and the military, the elderly go first, then the kids, then the adult population. This works as long as you don't go around automatically sticking the old folks when the greatest risk of mortality are the young adults (see 1918).

When you actually ask people, however, they always say they would give the shots or the hospital beds to their kids, rather than themselves. There's a concurrent line of thought which suggests it is right to save those who have the most time left to live. This would place sick elderly folk at the bottom of the treatment list and the adults second, but fails to take into account the greatest risk category or need, based almost entirely on a person's emotional response.

Another idea is that there should be an implied social value; that policemen, firefighters, engineers, medical practitioners and scientists should be given first priority in a case of limited treatment supply. The thinking here is that people should be saved in the order of their value to a recovering and repopulating society, and also in terms of how much has been invested in their lives. This puts kids and the elderly on the bottom, with the 25-40 category largely first in a carefully selected line. People who swing this way quote 1918 as well, reminding us that it's important to consider the epidemiology of the disease.

Any thoughts on how would you decide to prioritize your treatment efforts?

[Boyish-Tigerlilly]

I think age, utility, and other criteria, such as development status, are mentioned in the "duty to die" concept, and it seems somewhat similar to what you mention above. It's pretty complex and is predicated upon having enough time to organize the distribution.

According to the duty to die, I would look at the usefulness to society, investment, the level of cognitive development and age. I would certainly agree with you that it would be the right thing to do, if we had limited supplies to distribute the vaccines according to utilitarian bioethics--a type of triage. That means, as you said, in a case of limited supplies and time, resources should go first to those who will give society the biggest bang for the buck and are most important to society. It would be horrible if we didn't have enough and we decided to bypass medical pracitioners, scientists, and other key members of society's infrastructure.

It can be difficult to weigh each and every case, though, since I am not sure that every particular scientist is critical to society, so it might have to be administered via a general utility rule instead of case-by-case calculations. Sometimes it could get too cumbersom if we break down treatment by each and evey degree field.

When the first priority is taken care of (this assumes you have some time to do the above anyway), then it would be most appropriate to give the vaccine to the general populace and based on criteria such as age, development etc. Depending on age and development, I would think the utility of fulfilling some interests would be the same as if we fulfilled others (or at least the weight we give to them). For example, adults usually contribute to the economy, they work, they do jobs. They also do have a fair bit of life left to experience. Society has invested a lot of resources in them over time, more so than the small children, so prima facie, I would prefer that most adults (save perhaps for the extremely elderly) would get the vaccine.

In the case of terminally ill and the extremely elderly, again, if resources are limited, I would think we would do more good giving to children and adults over them. The same would go for the severely mentally ill who are perhaps in late stage dementia. IF they cannot be saved anyway, and if they have lived a good deal of their life (and if they are not key to society), I would think we should put them last on the totem poll. I think we could do more general good by giving it to people who can be saved and have a fuller life to live.

So I guess it would be in this order.


Key personnel (medical, infrastructure, irreplacables).
Adults
Children
Elderly/extreme cognitive deficiency
Terminally ill

[Wyrm]

There's also getting the most immunization bang for your buck, as it were. I've seen arguments that children should get high priority for flu vaccinations because "they are the vectors." If you immunize a few people who are at high risk to spread disease, then it's equivalent to immunizing a larger number of lower-risk individuals.

Although I have no data about this, I'd say it would make sense to throw in their potential to spread disease other members of society into the mix of critera for vaccination.

[Lagmonster]

There's also getting the most immunization bang for your buck, as it were. I've seen arguments that children should get high priority for flu vaccinations because "they are the vectors." If you immunize a few people who are at high risk to spread disease, then it's equivalent to immunizing a larger number of lower-risk individuals.

There was another big impact flu - not like 1918, but big - in the late 1950's that hit the US, and the old folks got hit hard, but not the kids, because they were all home for Christmas vacation.

[Jalinth]

Although I have no data about this, I'd say it would make sense to throw in their potential to spread disease other members of society into the mix of critera for vaccination.

You would also need to factor in quarantine plans into the risk of spreading issue. Any truly severe epidemic should logically incorporate some type of quarantine plan. The plan itself should vary depending on how the disease spreads and the ease of spreading. This might mean that delivery people and others who must travel to deliver fuel, food, etc.... should be just below medical personnel just to limit the spread of the disease.

[Wyrm]

There was another big impact flu - not like 1918, but big - in the late 1950's that hit the US, and the old folks got hit hard, but not the kids, because they were all home for Christmas vacation.

I can't account for the attack plans of major flu epidemics.

As with all things, spreadability is a factor to be considered in the immunize/don't immunize decision.

[Broomstick]

Another idea is that there should be an implied social value; that policemen, firefighters, engineers, medical practitioners and scientists should be given first priority in a case of limited treatment supply. The thinking here is that people should be saved in the order of their value to a recovering and repopulating society, and also in terms of how much has been invested in their lives.

Don't forget the plumbers and electricians.

Whenever folks start talking about the valuable members of society they all too frequently forget the blue collar guys, but you can't run modern civilization with the plumblers, electricians, truck drivers, and steel mill worker types. In fact, in the aftermath of a disaster, a construction worker is more valuable to society than someone with a PhD in math.

In the normal course of events, you vaccinate the elderly, very young, frail, etc. because the average healthy adult will fend off the disease or not catch it in the first place. With a pandemic with high mortality, though, what you really need to save are the healthy, breeding-age adults.

That's a real hard thing for the average person to wrap their heads around. It violates a lot of parental instincts to not protect the kids. Our society is used to heroic life-saving efforts, not to allowing the frail to die because we can only save X number of people, and going forward we really do need manual laborers and breeders more than 80 year grandpa with his walker. You can logically reason out such a course of action, but emotionally most folks just won't get it and it will be hideously painful and awful to live through such a time.