COVID-19 Vaccine: From Ethics of Early Access to Payments for Risk

COVID-19 Vaccine: From Ethics of Early Access to Payments for Risk

Promising results from ongoing trials have raised hopes that the first vaccines against COVID-19 could be approved for use in the beginning of 2021. However, as vaccine doses available initially will not be sufficient for every one willing to get vaccinated, prioritisation becomes imperative. On the other hand, when a vaccine is widely available, should vaccination be mandatory?


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Vaccine Access Regulation

"This process [of prioritisation] serves to decide which persons or groups of persons should have priority access to which vaccines. However, prioritisation should not be based on medical-epidemiological findings alone," according to a joint position paper, How should access to a COVID-19 vaccine be regulated?of the Standing Committee on Vaccination (STIKO), the German Ethics Council and the German National Academy of Sciences Leopoldina.


Prioritisation must also take into account ethical, legal and practical considerations, the paper points out. It is for this reason the authors have developed a framework for action for the initial prioritisation of vaccination measures against COVID-19.

The framework includes these key concepts and recommendations.


  • Prioritisation must comply with medical, ethical and legal principles. Self-determination (‘autonomy’) of each individual should be respected – i.e. informed, voluntary consent is required for vaccination. Therefore, prioritisation criteria must be presented to the population in a comprehensible way. Ethical principles of non-maleficence or protection of integrity, justice, fundamental equality of rights, and solidarity must also be given importance in prioritisation decisions.
  • Vaccine distribution is aimed at achieving vaccination goals: prevention of severe courses of COVID-19 (hospitalisation) and deaths; protection of persons with an especially high work-related risk of exposure to SARS-CoV-2 (occupational indication); prevention of transmission and protection in environments with a high proportion of vulnerable individuals and in those with a high outbreak potential; maintenance of essential state functions and public life.
  • Identify and minimise vaccination risks at an early stage. A system for the timely recording and evaluation of adverse events must be established in parallel to vaccination. As such, the product-based recording of COVID-19 vaccinations in a central database is necessary, as this can also help in determining vaccination coverage rates.

According to the authors, governments and public health authorities should provide transparent information and education so that the population will be encouraged to trust in the safety, efficacy and proper rollout of vaccination. These efforts will help to increase people's willingness to be vaccinated.


This document should also show policy makers and other stakeholders which structures have be established in order to be able to implement its recommendations, the authors say, noting that uniform and transparent distribution of vaccines will inspire confidence and ensure acceptance.


Mandatory Vaccination or Payment for Risk?

In the meantime, an article published in the Journal of Medical Ethics (Savulescu 2020) compares the alternatives of mandatory vaccinations and a system of payment for risk in vaccinations.

According to the article, mandatory vaccination requires four conditions to be met:

1.      There is a grave threat to public health

2.      The vaccine is safe and effective

3.      Mandatory vaccination has a superior cost/benefit profile compared with other alternatives

4.      The level of coercion is proportionate.

However, the author argues, due to the vaccine’s novelty the level of (perceived) risk is high, therefore “it would be practically and perhaps ethically problematic to introduce a mandatory policy, at least initially”. He further defends a payment model arguing that its advantage is that “people are choosing voluntarily to take it on”, noting that payment per se does not make a vaccine riskier. Despite the existing attitude that paying people is coercive, the author argues that an option to receive payment for being vaccinated is not coercion, especially if an opportunity for altruistic vaccinations is given, such as to donate any cash payment back to the health service. He concludes that when risk is high, payment for vaccination may be an option ethically superior to mandatory vaccination.


Image credit: claraveritasvia iStock


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Savulescu J (2020) Good reasons to vaccinate: mandatory or payment for risk? Published online: 5 November. Journal of Medical Ethics. doi: 10.1136/medethics-2020-106821

Published on : Wed, 11 Nov 2020

COVID-19 Vaccine: From Ethics of Early Access to Payments for Risk

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