Who Gets to Get the Vaccine? - Issue #9
Conservative media outlets tried to scare older adults by mischaracterizing remarks by Biden Covid task force appointee Ezekiel Emanuel. Turns out they got Emanuel’s utilitarian ethics all wrong.
Welcome to Issue #9! Fitz here! This week, Jason is buried in grading as our abridged semester winds down so I’m rolling solo. My main contribution is an essay considering how the Coronavirus vaccine might be distributed in light of utilitarian ethics. After that, I have a brief reflection on my dad, who would’ve turned 78 today. That is followed, as usual, by music and book recommendations—Jason’s and mine—featuring a viral Dolly Parton cover song (“Vaccine” sung to the tune of “Jolene”) by my friend Ryan Cordell. I hope you enjoy!
Last week, my neighbor, a woman in her 80s whom my family has come to adore, asked if I’d heard the news about the vaccine. We have a lot of conversations that begin with this “have you heard the news” framing and they generally don’t go well. For all her loveliness, my neighbor spends a lot of the day watching Fox News. This time, the news about the vaccine that she was referring to wasn’t that Pfizer and Moderna have what appear to be two highly effective vaccines, but rather that one of the doctors that President-Elect (feels so good to say!) Joe Biden picked for his Covid taskforce said that old people shouldn’t get the vaccine. “They should just be happy with their life and die,” my neighbor told me the doctor had said. I told her I hadn’t heard that, and I didn’t think that it was true, but she insisted that she saw him say it on TV.
We left it there. She asked if I could help her with her iPad and I said I’d visit her in the morning. Then, I immediately went inside and started Googling to see if I could figure out what she was talking about. The following story emerged: Ezekiel Emanuel is the doctor in question, and six years ago he wrote an essay for The Atlantic titled, “Why I Hope to Die at 75.” Of course, when Biden tapped Emanuel (he is the brother of Rahm, former mayor of Chicago), several conservative media outlets resurfaced the Atlantic story and attempted to draw conclusions about what Emanuel might do as a member of the Covid taskforce. They also noted, with feigned horror, that Joe Biden will be 78 when he’s inaugurated…so, over 75! Anyway, this turned into, as my neighbor gleaned from Fox News, the idea that Emanuel “once argued it’s not worth living past 75.” This is not what Emanuel argued, of course, but the nuance of Emanuel’s essay is lost on Fox News. On the same day, Republican senator Tom Cotton tweeted Emanuel’s article, calling him “a lockdown enthusiast” and writing “Americans want our country opened up, not creepy bioethicists who enjoy playing God.”
In fact, in the Atlantic article Emanuel goes to great lengths to assert that he was not writing a prescription for others. He writes, “I am not saying that those who want to live as long as possible are unethical or wrong. I am certainly not scorning or dismissing people who want to live on despite their physical and mental limitations. I’m not even trying to convince anyone I’m right.” In fact, he notes that he advises patients past the age of 75 on “how to get the best medical care available…That is their choice, and I want to support them.” So it seems like a pretty clear cut example of selective reading by some on the right in an effort to paint Emanuel as a kind of ageist extremist.
Well, yes, except there’s this: Emanuel writes that he won’t get flu shots past the age of 75 either, arguing, “Certainly if there were to be a flu pandemic, a younger person who has yet to live a complete life ought to get the vaccine or any antiviral drugs.”
It is this line, taken in chorus with the article’s glaring headline about not living past 75 that has people like my neighbor, and the talking heads she watches on Fox News, nervous about Ezekiel Emanuel’s role on Biden’s Covid taskforce. Of course, I decided to keep digging, in part to get to the bottom of this particular issue, and also, practically, because I’m teaching a class on Ethics in which many of my students are in training to enter various medical professions—one of my students, a working nurse, Zooms in to class from her workplace in her scrubs—and this is exactly the kind of practical application of theory that professors like me live for.
It turns out that Dr. Emanuel largely takes a utilitarian view on the distribution of medical supplies and, eventually vaccines, in the midst of the Covid crisis. More pertinent to understanding his thinking than the Atlantic article from six years ago are essays he’s written and published during the pandemic. Back in May, he was lead author of an article titled “Fair Allocation of Scarce Medical Resources in the Time of Covid-19” in The New England Journal of Medicine and in September he was again lead author on “An ethical framework for global vaccine allocation,” published in Science. Before either of these, back in March, he and two of his NEJM coauthors penned an op-ed for the New York Times titled “How the Coronavirus May Force Doctors to Decide Who Can Live and Who Dies.” It was this latter—and most accessible—article that I brought to my class for discussion.
Before even addressing the specific argument that Emanuel and his coauthors make, it is fascinating to read prognosticating from March and to see how events have, unfortunately, gone just as bad as the authors feared. (And, in one very significant way, it’s gone worse—predictions of the number of deaths from Covid back then were between 200,000 – 240,000; this week we surpassed a quarter of a million.) When it comes to distribution of resources, Emanuel and his coauthors are unequivocal: “The priority should be health care workers; police, firefighters and other emergency workers; and those who keep water, electricity and other necessary systems functioning, because they can save the lives of others.” Note the important “because.” This is a utilitarian argument, which seeks the greatest good for the most people. In fact, the articles states this explicitly, “The goal should be saving as many people as possible, and treating those who are likely to get the greatest benefit from care.”
Normally, medical resources are allocated on a first-come-first-serve basis. Think about it: if you fall off a ladder and break a leg, you go to the emergency room and expect to be admitted and treated. Nobody looks at your broken leg and says, “actually, your leg is just fractured in one place and later today someone might come with a multiple fracture, so we’re going to hold off.” In terms of the coronavirus, Emanuel and his coauthors write, this might mean not treating a person with a “grave, or even hopeless, prognosis” in favor of a patient with a good prognosis if treated.
The authors note that “All patients deserve maximum treatment” and yet if resources go scarce, utilitarian ethics suggest, “The goal of maximizing benefits and survival for the many should take priority over the goal of treating the patient who happened to get sick and come to the hospital first.”
Nearing the end of the article, Emanuel and his co-authors directly address the issue that has the conservative news media up in arms: vaccine distribution. It would seem, given what we’ve read thus far of Emanuel’s views, that here, too, those with a worse prognosis (many of whom would be older adults) will be on the losing end, but not so. Emanuel and his coauthors write, “One point that may seem to contradict the others is that distribution of any vaccine that is developed to prevent disease should prioritize older patients and those with serious underlying health conditions who are at greatest risk.” This is because, the authors explain, older people have “an elevated risk of dying.”
While this seems logical, does it violate Emanuel’s otherwise utilitarian view? It might, if the motivation here was simply care for persons, but it’s not. Even this move is about “maximizing the benefits of a vaccine for society.” See, if older adults become sick they are likely to need and utilize larger amounts of the already scarce resources. Thus, vaccinating older adults first is less about saving their lives and more about saving resources for others who have a better chance of survival.
Granted, utilitarianism is not warm and fuzzy, but it is clear that Dr. Ezekiel Emanuel does not want to let older people die—quite the opposite! I’ll grant that the reason to keep them alive is perhaps more instrumental than many of us are comfortable with. This is, in fact, one of the greatest arguments against utilitarian ethics—the way it considers people as means to an end, integers in a solvable math problem.
Immanuel Kant’s Categorical Imperative, on the other hand, an example of deontological ethics, explicitly states that persons must only ever be viewed as an end in themselves. What would this mean for vaccine distribution? If, as deontological ethics suggests, we should be motivated only by doing our duty—by doing what is right—how do we decide who gets a vaccine when (at least initially) there won’t be enough to go around? In this case, the right thing to do is more about honoring the right to life of each individual person with less emphasis on people in general—a not entirely satisfying answer when we are dying by the thousands.
Thus, we might not like the way it sounds, but a utilitarian approach seems to win the day. Even my nurse-student noted that healthcare professionals should be toward the front of the line for the vaccine so that they can do their jobs and save more lives. Another utilitarian view explored in the most recent issue of Wired considers giving the vaccine not to those most in need or most vulnerable, but to those most likely to interact with others and thus spread the disease. This idea, which originates in network theory, suggests that these “super-spreaders” are likely to do the most harm if infected, so we should vaccinate them first. It might seem like a reward for being overly social at a time when keeping our distance is imperative, but, again, the greatest good for the most people is the focus. It’s just that rather than preventing death primarily, preventing spread is the focus.
Given what we know of Ezekiel Emanuel’s approach to medical ethics, should we expect that as a member of Biden’s Covid task force he’ll advocate for withholding the vaccine from older adults and letting them die? No! To do so, according to Emanuel, would lead to a costly waste of resources. It would not promote the greatest good for the most people. This may not make my neighbor feel recognized for her intrinsic value as a person, but at least she can know she won’t be sacrificed to Coronavirus in the name of utilitarianism.
The views expressed in the above essay are solely those of the author.
On a personal note, today would be my dad’s 78th birthday. I’ve been thinking a lot about Dad this month. I’ve been thinking about how fortunate it was that he passed away right before Covid hit, on March 2, 2020 (and I’ve been thinking about how strange it is to think that). In the weeks before he passed, my family (and especially my sister Jen) spent so much time at the nursing home where he was staying. We basically moved in for his final weekend, and we would not have been able to do that if he’d stuck around just one week longer (as Jen says, Dad died and the whole world shut down). On the other hand, of course, I miss him. And this is going to sound bad I suppose, but I miss him so much more than I ever thought I would. Now that he’s gone, I find myself thinking about him all the time. We didn’t talk that much on the phone—he always just handed it over to my mom, but now I think of things I want to tell him every single day. A couple of weeks ago, Jen and I got new iPhones and it felt wrong not to be ordering one for Dad too; he always had to have the latest and greatest (which is, of course, where we get it!). So, today, on his 78th birthday (which, by the way, he shares with President-Elect Biden), I celebrate his life. Happy Birthday, Dad. I miss you.
What We’re Listening To:
Fitz: Two things… First, as I’ve been thinking about my dad and the last weeks he was here with us, I’ve been listening to the album Marigold by Pinegrove, because I listened to this nonstop during those weeks when I drove from campus to the nursing home in Gloucester several times each week. The chorus to “Dotted Line,” the record’s opening track says, “‘Cause I don’t know how / But I’m thinking it’ll all work out.” Those lines, and so many others sewn throughout the album, got me through. Here’s “Dotted Line.”
But also, my PhD advisor and friend, Ryan Cordell, went viral this week when he recorded a version of Dolly Parton’s “Jolene” with new lyrics about the “Vaccine.” The lyrics were written by Gretchen McCulloch in celebration of Parton’s contributions to vaccine research. Anyway, this is one of those things I would’ve called my dad—country music fan that he was—about.
Jason: For some reason, I’ve never used Spotify. For some other reason, I did decide recently to pony up $9 a month to get YouTube Premium. The lack of ads is nice, but the real draw is that you automatically get their proprietary music app, which is a very, very good app. Anyway, I was going down some playlist rabbit hole last week, and “New Slang” by The Shins came on. I was never into The Shins when they were the indie darlings of 2004-5, but that track hit hard in November of 2020. I actually said aloud, somewhere around the one-minute mark, “Gosh, this song is lovely.” I’ve listened to it maybe 100 times since. So what I’m trying to say is that I’m right on the vanguard of the indie rock scene circa 16 years ago.
Oh, also, I’m pretty sure the shot of the band in the water at 0:23 is an allusion to the album cover art of Slint’s Spiderland.
What We’re Reading:
Fitz: We Ride Upon Sticks! I mentioned this one a few weeks ago and I’m about halfway through now and it’s tons of fun.
Jason: Student essays. Still a little Stephen King at bedtime, too.
Thank you, as always, for reading. See you back here next week!