The Ethics of Rationing COVID-19 Vaccine for the Sickest Among Us

January 13, 2021 • Posted in Blog
Illustration Credit: Maksim Yremenko

Illustration Credit: Maksim Yremenko

C. Ben Mitchell, Ph.D. Distinguished Fellow of the Tennessee Center for Bioethics & Culture

C. Ben Mitchell, Ph.D
Distinguished Fellow

We must not allow our combined COVID-19 fatigue to prevent us from asking important questions about public health ethics. At the time I am writing this essay, we are just transitioning into Phase 2 of the vaccination plan. I am sure our public health officials are doing the best they can under unprecedented circumstances, so we should give them the benefit of the doubt. But for the sake of clarity in the future, some retrospective analysis will be crucial.

For instance, in our own state, we have abandoned traditional triage ethics in favor of a purely age-based rationing of vaccines. Why? Under the rubric of triage ethics that governs, say, battlefield medicine, after the health care team is secure, those patients who are sickest and most likely to survive get priority. This was the rubric the Tennessee Department of Health (TNDOH) announced in their original plan. After health care workers, first responders, and nursing home carers and residents were vaccinated, the next patients in the queue were to be those with underlying comorbidities that significantly impact their health.

This vaccine distribution protocol not only complies with traditional triage ethics, but follows the recommendations of the National Academies of Sciences, Engineering, and Medicine, which the TNDOH says they are following (see page 11 of COVID-19 Vaccination Plan ( According to A Framework for Equitable Allocation of Vaccine for the Novel Coronavirus by the National Academies, Phase 1 is to include “People with significant comorbid conditions (defined as having two or more)” along with “Older adults in congregate or overcrowded settings.” (see page 109).

Instead of following this recommendation, on December 30, 2020, the TNDOH abandoned traditional triage ethics and the Academies’ direction and began in January 2021 a massive “cattle call” distribution of citizens over 75 years-of-age without respect to comorbidities or other health factors. This decision means that many frail elderly in the state get frog-jumped by those who are more well. (See page 13 of this document.)

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In my own area of the state, the Jackson-Madison County Health Department stopped taking appointments for vaccinations before the first of the new year. On January 1, an open call for vaccination went out for anyone in Madison County age 75 or older, regardless of health status, to get to the Jackson Fairgrounds at 9:00 am on Thursday, 7 January, for a first-come, first-served opportunity to receive 2,000 vaccines.

Allocation of scarce, life-saving resources requires difficult decisions to be made, and as someone has properly pointed out, hard cases usually make bad policy. Nevertheless, our protocols, policies, and procedures must be scrutinized carefully both prospectively and retrospectively. With due respect to my public health friends who are making these often-excruciating decisions, I wonder if on reflection we will find our protocols, policies, and procedures were flawed at best. I hope we can do better in the near future, and I most certainly hope we will do better when the next pandemic arrives.

MORE: See 8 January announcement for a change in vaccine distribution plans here.