Fair allocation in times of pandemic

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Alena Buyx heads the Institute for the History and Ethics of Medicine at TUM and

Alena Buyx heads the Institute for the History and Ethics of Medicine at TUM and has been Chair of the German Ethics Council since Spring 2020. Image: A. Heddergott

Medical ethicist Alena Buyx: Consider differences in efficacy when allocating vaccine

At present Germany’s elderly are being given priority for Covid-19 vaccination. But what happens when only minimal research data is available on the effects new vaccines have on the elderly? Such circumstances should play a role in ethical considerations of fairness in distributing scarce medical resources, says Alena Buyx, Chair of the German Ethics Council, in the Technical University of Munich (TUM)’s "Covid-19 Lecture Series". Buyx is professor for Ethics in Medicine and Health Technologies at TUM.

"The whole world wants a vaccine. And at first - as was to be expected - there isn’t enough to go around. A situation like this where the vaccine is absolutely scarce calls for proper prioritization," said Buyx. The vaccines against Sars-CoV-2 approved in Germany are therefore being allocated according to a five-tier prioritization model. Since the risk of a severe or fatal Covid-19 infection is 500 times higher for people over the age of 80 than for the young and healthy population, the elderly are currently very high on the allocation list. However, allocation in practice could change in case of new vaccines.

,,The ethical difficulties are often a matter of detail."-- Prof. Alena Buyx

Buyx said that there are enormous challenges involved when it comes to practically implementing the ethical guidelines she has carefully formulated together with the members of the German Ethics Council, the Standing Committee on Vaccination (STIKO) and the Leopoldina German National Academy of Sciences. One example is the vaccine from AstraZeneca approved on Friday by the European Medicines Agency (EMA). According to STIKO the available data on the vaccine’s efficacy for those over 65 years of age are insufficient. Buyx said that possible differences in the efficacy of a vaccine for different age groups have to be considered in vaccine distribution.

The medical ethicist went on to say that the reason primarily the elderly are being vaccinated is the basic principle of recognizing under the law not only the equality of all people, but also their differences. "An individual with an entirely different risk level may also receive different treatment," she added, noting that nevertheless the practical guidelines resulting from legal-ethical prerequisites require constant adaptation and ongoing further development - especially when important medical data are not yet available. "The ethical difficulties are often a matter of detail," said Buyx.

,,We’re in a very steep learning curve."-- Prof. Alena Buyx

The lack of reliable data is however also relevant in another context, as when it comes to the fair distribution of vaccines, she said. Buyx noted for example that at present it cannot be assumed with certainty that vaccinated individuals will not nevertheless infect others with the virus. If it was certain, she said, that by being vaccinated younger people could protect older people against infection, the fact would also have an impact on prioritization. "We’re in a very steep learning curve," said Buyx. She pointed out that the most important factor in vaccine allocation is that it has to be transparent, robust and understandable; this can in turn inspire trust. Of course, it will never be possible to design the allocation process so that everyone will be satisfied, she conceded.

In her lecture Buyx also spoke on triage, i.e. the prioritization of patients requiring acute treatment in cases where medical capacities are inadequate. While triage happily still remains a theoretical consideration in Germany, the German Ethics Council and its Chair Alena Buyx are developing recommendations for vaccine allocation as the basis for current policy decisions. "I find the situation in part fairly bizarre," said the medical ethicist. During almost 20 years working with the allocation of scarce medical resources, Buyx said, she has often been asked why she was dealing with such a theoretical topic. But since early 2020 the topic has become highly relevant and could hardly have a more pragmatic focus.

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