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CDC guidelines give the unvaccinated substantial priority for antiviral treatments for Covid

Brian Leiter

MOVING TO FRONT FROM YESTERDAY–INFORMATIVE DISCUSSION IN THE COMMENTS!

This seems surprising; an excerpt:

Current therapies such as Sotrovimab, a monoclonal antibody with activity against omicron, and the oral agents, Paxlovid, and Molnupiravir, exist in very short supply. Already the demand has far outstripped our capacities raising the specter of rationing and a host of medical, social and ethical issues. 

The use and administration of these therapies — funded by the federal government without cost to the end user — are governed by the Centers for Disease Control and Prevention (CDC) and state prioritizations. Although immunosuppressed patients are appropriately atop the list, most unvaccinated patients will be granted the next highest level of priority.  

For example, a 35-year-old unvaccinated former smoker with asthma gains priority over a 66-year-old vaccinated cancer patient. Similarly, an unvaccinated 25-year-old smoker with depression takes precedence over a 64-year-old vaccinated patient with chronic pulmonary disease. Indeed, the highest priority on the CDC list does not include a single profile of vaccinated patients other than the immunosuppressed, regardless of other comorbidities. Based on current supplies, unvaccinated patients will receive most of these lifesaving medications.  

Beyond its inherent unfairness, the decision to prioritize unvaccinated patients for scarce therapies is based on assumptions regarding risk factors, and the data regarding which risk factors contribute to a poor prognosis is weak at best. It is this very paucity of evidence that explains the lack of clear prioritizations in the initial vaccine rollout. 

I'm curious what readers, and especially those working in and around bioethics, think about this.

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20 responses to “CDC guidelines give the unvaccinated substantial priority for antiviral treatments for Covid”

  1. Balazs

    I'm not sure there is an "inherent unfainess" in prioritizing patients according to a comparison of risks of short-term lethal outcomes of treatment/no-treatment scenarios based on the total available information at the moment of the care decision (assuming that risks can be plausibly ascertained, which is of course in many cases highly questionable).
    My intuition says that the real inherent unfairness lies in not mandating unvaccinated people to pay a health insurance premium which is comparable to the expected additional health care cost they generate due to their decision to not vaccinate. (In the ballpark of Average_treatment_cost_for_Covid * P(needing_treatment | getting_infected) * P(getting_infected). The current €100/month figure in Greece seems reasonable.)

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  2. A Sharon

    Practical considerations likely outweigh the ethics. According to the latest reports I could find the demographics of those still unvaccinated do not align with the popular impression of a leftwing/rightwing schism. Overall, minority populations still have a lower vaccination rate than do whites. The gap has narrowed over time. The unvaccinated are more rural and poorer. Financial penalties will only make things worse. Doesn't is make sense to see vaccination refusal as aligned with other health problems in that population? I will search for studies that have looked at this. I would guess the unvaccinated are also the same people that experience a variety of other unhealthy conditions. I bet many are smokers, have poor diets, depression, substance abuse, domestic violence and lack health insurance. In summary, the same people that suffered from economically-induced poor public health before covid are suffering the most from covid. In hindsight, we are a country filled with people that do unhealthy things that lead to a lot of death. Why would we believe covid would change that?

    https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-by-race-ethnicity/

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  3. Laurence McCullough

    The guidelines reflect long-accepted ethics of triage: minimize mortality in the patient population when resources are not adequate to treat the entire population. (This is population-based, beneficence-based clinical reasoning.) The goal is to identify and deploy criteria based on an organizational culture of quality: evidence-based prediction of risk of mortality; reliably measurable basis for this prediction; and easy to apply clinically (using a decision tree). A triage officer is assigned to make these clinical decisions, removing the patient's physician from the loop. Periodic review is conducted to identify and reduce uncontrolled variation, using accepted tools to do so (such as Shewhart control charting) and aiming for professionally responsible variation.

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  4. Leslie Glazer

    How many unvaccinated persons would get vaccinated if they knew they would have to incur the cost of treatment? While we need to be compassionate toward all, we need to find a way to incentivize responsible behavior.

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  5. Laurence McCullough

    Leslie and colleagues: The problem with a differential payment system based on responsibility for one's clinical condition was pointed out back in the 70s (in an article the details and author of which I cannot recall). The article went like this: It would be fair to introduce a differential payment system for those who make an informed and voluntary decision to engage in behaviors that are reliably predicted to result in the clinical condition in question. The challenge becomes how to fairly identify these folks. Examples: Smoking-related diseases: Smokers tend to start in their teens and are often not well informed and some smokers were issued cigarettes during military service. Alcohol addiction: defined as having taken alcohol one is not able to prevent subsequent exposure. First-time drinkers do not have this information. Not being vaccinated: some individuals are making decisions based on false beliefs that they may not have voluntarily adopted. Then comes the clinical challenge arising from the commitment to quality of care: making the distinction between informed and voluntary non-vaccination vs. somewhere along continuum to non-informed and non-voluntary free of bias. This is a major problem: patients with self-destructive behavior evoke strong emotional responses among healthcare professionals, as I saw again and again as a philosopher-medical educator and of which physicians are taught to be aware. How to manage these two challenges professionally, which, if poorly managed, will result in uncontrolled variation (which is the definition of poor quality)? Avoid them by following a reliable triage protocol, which protects professional integrity and therefore protects patients.

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  6. David Wallace

    Laurence McCullough is absolutely right about the ethical case against differential payment. But in addition: the COVID vaccine is free, has no significant downsides, and offers very strong protection against a potentially deadly and extremely prevalent virus. That's already a ridiculously strong incentive to get vaccinated. But those people who are nonetheless deciding not to take it don't think it's a sufficiently strong set of incentives, so why think a hypothetical future financial penalty if they get sick is going to move them much?

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  7. Brian Leiter

    Just in response to David's last question: employer mandates or vaccination have worked quite well, and these involved a serious financial penalty for failure to comply. That doesn't answer the practical or ethical problems Laurence McCullough identifies with imposing such penalties at the point of care.

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  8. Roger Albin

    There may be a reasonable pragmatic rationale for this priority list beyond reducing mortality. While these therapies have limited availability, the most limited resource is ICU beds. Unvaccinated status definitely increases risk of serious illness and this may be a reasonable approach to mitigating the shortage of ICU beds. As Brian points out, however, there isn't certainty about risk factor strength. This is an area where some decent modeling might be useful.

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  9. Robert C Hockett

    Apparently the current rationing scheme prioritizes those who are immunocompromised, for many of whom vaccination itself is contraindicated. I don't know precisely what percentage attaches to that 'many,' but if it is sizable the policy would seem to make at least some sense.

    What definitely does *not* seem to make sense is the fact of the short supplies themselves. Ditto for supplies of antiviral pills. The same means employed to lever-up vaccine production (not to mention war production in the 1940s) – viz. rapid public expansion and construction of manufacturing facilities – could be readily employed here.

    That we are not dramatically accelerating production of antibody drips and antiviral medications, not to mention masks and tests, along *with* vaccines seems to me publicly insane now that some variants are 'breaking through' to sizable numbers even of people thrice or four times vaccinated.

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  10. Dean C. Rowan

    I don't think this is the article referred to by Dr. McCullough, because it doesn't quite track his recollection, but it seems relevant and it might be that the article he's trying to recall is among those cited.

    Robert Crawford, You Are Dangerous to Your Health: The Ideology and Politics of Victim Blaming, 7 Int'l J. Health Servs. 663 (1977).

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  11. David Wallace

    Point taken, but there’s a difference between an actual immediate financial penalty and a hypothetical future one that only arises if you get seriously ill from a disease you don’t really believe in anyway. (Put another way: the hypothetical fear of death from COVID doesn’t seem to move vaccine skeptics, but I imagine being executed for noncompliance would still be a strong incentive for them!)

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  12. Allen Hazen

    So, suppose it's 2025 and some new virus is rampaging through the world, and a vaccine is introduced and everybody is sternly told to get vaccinated. And vaccine hesitant people say to themselves, "Better not– I might yet come down with the new disease, and there might be a treatment for it, but on the evidence of three years ago, if I get vaccinated now they won't let me have the treatment." (The whole thing is very complicated with numerous ethical problems: this seems like ONE possibility that ought to be considered. The military, in order to work out strategy, plays war-games: perhaps the CDC, etc, should play pandemic games… and give prizes to the staff members who come up with the most off-the-wall considerations the makers of the rules for the first version of the games had overlooked.)

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  13. V. Alan White

    I never really thought the Darwin Awards would soberly play out in reality to the extent this has.

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  14. J. Bogart

    Well, for the untreated vaccinated, they may be consoled by recollection that virtue is its own reward.

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  15. Balazs

    Re David Wallace, Laurence McCullough etc.: note that upon bringing up differential health care insurance costs I invoked neither the idea of penalizing nor the idea of incentivizing behavior, but I did invoke the idea of fairness. The expected treatment cost difference between vaccinated vs non-vaccinated individuals is quite significant, and this is a known fact. At this point the health risks involved in taking the covid-19 vaccine are well known to be minimal for almost everyone, and the decision to get the covid-19 vaccine can be regarded as well informed as any decision in human history. There are no addictions involved in taking the vaccine and thus this case is not analogous to alcohol, tobacco, etc. type examples.

    I find forcing ("mandating") people to vaccinate to be contrary to my general liberal world view ("you shall be free to do as you please as long as consequences of your actions do not significantly burden others"), but I don't think it is unfair to ask the unvaccinated to bear the brunt of their decision, in fact I find it unfair not to ask them to do so, because in the end the cost of maintaining the health care system needs to be paid, not to mention the direct health costs the vaccinated needs to face due to not being able to get treatment for their other diseases due to hospitals being filled up with unvaccinated covid patients. (It maybe worthwhile to note that I live in a country with universal health care where health care costs are automatically deduced from salaries, with limits on how much low-income salaries can be effected.)

    Would people who object to differential health care costs in the covid-19 vaccine case (where, again, reliable information regarding the decision is readily available, and there are no addictions involved) also object to, say, a differential cost for a travel insurance depending on whether it includes coverage for extreme sports? After all one could also be misinformed by reading only facebook posts of friends about the amazing time they had during wall climbing, and deciding not to google the health care risks of wall climbing before attacking El Capitan.

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  16. John Turri

    Would you mind elaborating on the reasoning behind this claim: "The decision to get the covid-19 vaccine can be regarded as well informed as any decision in human history"?

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  17. Barney W.

    In reply to J. Bogart (#14)…

    How sure are you that getting vaccinated is an act of virtue? It my own case, it felt more like an act of self-interest.

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  18. J. Bogart

    7

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  19. Justin Fisher

    This seems to be a case where what maximizes short-term consequences (prioritizing unvaccinated people for limited treatment resources saves the most lives over the short run) may be different from the policy that would maximize longer-term consequences (making clear that vaccinated people will, ceteris paribus, also receive higher priority for limited treatment resources might motivate many more people to get vaccinated for this and future diseases, curbing the spread of this and future diseases, thereby saving even more lives over a longer run). I can get myself in a mood where the latter, long-run maximizing, policy seems quite reasonable, though I'd feel better about this if this had been a clearly announced policy from the beginning, and if we'd done better at ensuring that traditionally underserved populations would have easy access to vaccines (including safe transportation and time off work).

    In some ways, this feels akin to the old fire-fighting schemes where people who contributed to the fire brigade would get top priority for limited fire-fighting resources. It's pretty easy to get oneself in a mood where it seems right that people who have done their part to contribute to our collective welfare (by getting vaccinated or by contributing to the fire brigade) should, ceteris paribus, receive higher priority to limited societal resources when it turns out that they need assistance. (Of course, this is compatible with saying that, when limited resources don't force us to make triage decisions, the fire brigade should probably help put out other fires, and treatment should probably be provided for unvaccinated people.)

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  20. Dan Dennis

    'Unvaccinated man denied heart transplant by Boston hospital'
    https://www.bbc.co.uk/news/world-us-canada-60132765

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