Debra DeBruin works on issues in public health ethics and the ethics of health policy, with a focus on concerns about social justice and health equity. She has been a member of a number of working groups relevant to public health in Minnesota, co-directed the Minnesota Pandemic Ethics Project, led the project to develop ethics guidance for Crisis Standards of Care in Minnesota, and now co-leads the Minnesota COVID Ethics Collaborative, which develops ethics guidance for COVID-19 response in the state of Minnesota. She has also served as a health policy fellow for Senator Edward Kennedy in the Democratic office of the Health, Education, Labor and Pensions Committee of the United States Senate, and worked as a consultant to the National Academy of Science's Institute of Medicine and the National Bioethics Advisory Commission.
1. How is a framework for prioritized vaccine allocation decided?
Allocation frameworks provide ethical guidance for how to allocate scarce resources. For COVID-19 vaccines, as for emerging therapeutics available under emergency use authorizations, the federal government initially allocates each state a limited supply, until enough doses can be produced to meet the need. The states have the responsibility for ethically allocating the supply they receive.
There are really two questions here. How should the supply be distributed geographically across the state to ensure that all Minnesotans have fair access? And which individuals or groups should have priority in allocation, when the supply is too small to provide the resource to everyone who is eligible and would like to access it?
An allocation framework answers both of these questions by taking into account three morally important objectives. The first is to reduce morbidity and mortality; the second is to respect individuals and groups; and third, to promote fairness and equity. All those considerations have to be taken into account, and they have to be balanced against one another because, for example, the approach that does the best or most efficient job of reducing morbidity and mortality may also potentially introduce or perpetuate inequities. To be ethically acceptable, an allocation framework should take all of those moral values into account.
2. What should Minnesotans know about COVID-19 vaccine guidelines?
First, the state aims to make sure that it's sending out supplies of the vaccine across Minnesota in a way that's proportional to need. As long as supply is limited, no region will get as much vaccine as it needs, but allocation throughout the state should be equitable. Then we need to think about which groups should have priority in allocation, since there is not enough vaccine to serve everyone right away. The federal government has identified the initial priorities to be health care workers, and people in long term care facilities. We know that the burden of severe illness and death has been exceptionally high in long term care facilities, so there is good reason to prioritize that group for vaccination.
There are two reasons to prioritize health care workers. First, if we can protect them, then we can best protect everyone. We need them to stay healthy, so they can take care of the rest of us. Second, given that they take on risks to provide services to us, we owe them protection in return. It’s important to understand that when we talk about prioritizing health care providers, we don't just mean doctors, we mean everybody who provides critical services in health care facilities. As planning continues to evolve to address subsequent phases of allocation, please know that the COVID-19 vaccine guidelines will continue to take complex ethical considerations into account and try to be as transparent as possible.
3. Why are bioethical considerations needed right now?
People often think about bioethics in terms of ethical issues in research or in the care of individual patients. Also core to bioethics are public health ethics issues, which have received a lot of attention during this pandemic. Public health emergencies require us to work at the intersection of clinical ethics and public health ethics. When there are sufficient resources, health care systems and providers use conventional approaches to patient care, and the standards of clinical ethics guide practice. When there is a strain on the system due to overwhelming need and limited supplies, additional guidance is needed to incorporate population health and equity considerations into health care decision making.
The work that the Center for Bioethics is doing on COVID-19 is an extension of work that we have done for a long time. Our past work in partnership with the Minnesota Department of Health (MDH) established foundational ethics guidance for public health emergency response. We are now building on that established foundation to provide ethics support for MDH and the state’s health systems during the COVID-19 pandemic. We've developed guidance around a number of challenging issues such as allocation of a variety of scarce resources, and how to balance patient needs against provider safety. We also offer ethics consultation at the University of Minnesota Medical Center and in the broader M Health Fairview system, both to help resolve ethical issues that arise in the care of individual patients and to assist the health system in implementing ethics guidance for its COVID-19 response.
About the Center for Bioethics:
The Center for Bioethics helps students, professionals, policy makers, and the public confront and understand ethical issues in health, health care, new biomedical technologies, the environment, and the life sciences. They offer programming to engage the public through their Ethics Grand Rounds, a seminar series featuring noted local, national, and international bioethics scholars lecturing on emerging research of ethical issues in health care. Check out past recordings here.
The Center for Bioethics promotes ethical responses to the COVID-19 pandemic through academic scholarship, media interviews, educational opportunities, statewide collaboration, and institutional implementation of ethical guidelines.