So just who do we think qualifies for any COVID-19 vaccine?

Steven Schwartz

09 July 2020 | THE AUSTRALIAN

How should we allocate scarce medical resources?

In Rob Roy’s Grave, poet William Words­worth summarises the ancient rule governing the sharing of ­society’s scarce resources. It’s a simple plan: “They should take, who have the power. And they should keep, who can.”

To prove this rule is still in ­operation, the US government’s acquisition of almost the entire production line of remdesivir for the next three months is a perfect case in point. The antiviral drug developed by research-based biopharmaceutical company ­Gilead Sciences is one of the few treatments available for COVID-19. The US government is willing to pay Gilead a high price to ensure a supply for its citizens.

Gilead has licensed pharmaceutical companies in Third World countries to manufacture and sell remdesivir at a lower price. But there is a catch. To maximise its profits, Gilead permits these companies to sell the drug only in developing countries. Rich countries, such as Australia, will have to pay the full price when remdesivir becomes available in October.

At present, Australia has a strategic reserve of remdesivir, which the federal government says is ­sufficient to meet the present ­demand. The reserve is reassuring — for now — but COVID-19 cases are surging again in Victoria and this could spread nationwide.

What happens if the need for remdesivir exceeds the supply? How will we decide who should receive the drug and who should be left to cope without it?

Similar questions will arise if scientists manage to create a vaccine that is effective in preventing COVID-19. Initially, at least, there will not be sufficient doses for everyone. Who will get it first?

Healthcare workers have a strong claim to be at the front of the queue; we need them to care for everyone else. We may also wish to prioritise older people, who are the most likely to die if ­infected. Assigning precedence to the elderly would save many lives, but the lives saved would be relatively short. Focusing our efforts on younger people could save fewer lives, but each saved life would last longer. It may be more humane and better for the economy to give young people a chance for a long working life than to protect the elderly who are mainly retired.

Age is not the only relevant criterion for deciding who receives priority. Some may argue that convicted criminals should be relegated to the back of the queue, along with substance abusers, tax cheats, and hypocritical anti-vaxxers who have a sudden change of heart.

Religious leaders — and they are not alone — are shocked by such callous calculations. They insist that all lives are equally valuable and everyone should have the same access to treatment.

Given that there may not be enough drugs or vaccine for everyone, equal opportunity would require a lottery to decide who gets priority. A lottery would treat everyone equally, but it could produce unacceptable outcomes. If we rely on the luck of the draw, we could wind up treating criminals while police remain vulnerable. Some health professionals would be denied care when we need them most.

It seems strange that a person’s contribution to the common good should play no role in deciding who winds up at the front of the COVID-19 treatment queue.

Thus far, our political leaders have made all the decisions about what to do in this pandemic. Not surprisingly, their choices have sometimes been political. For example, under lockdown, elective surgery became a scarce resource. At least one state leader suggested allocating access to elective surgery not according to how sick ­patients were but on whether they were “public” or “private”.

We should not leave the decision about who gets immunised entirely to our political leaders. Each state could wind up with a different allocation policy chosen to ensure that some favoured group of voters is kept happy.

Rather than engaging with the thorny issues of how to allocate drugs and vaccines, we may be tempted to leave it to doctors, but this could also lead to unacceptable outcomes. Doctors can tell us how people with different conditions will respond to treatment, but they have no unique insight into who should get cared for first.

Allocating health resources is not a technical issue; it is an ethical and moral problem. Its solution must reflect our values as a society.

During the pandemic so far, ­decisions have been made without public consultation because events have moved too rapidly for such discussions to take place. COVID-19 treatment and the hoped-for vaccine is different.

We know hard decisions may lie ahead. By harnessing the communications technology that we have learned to use in quarantine, we can encourage extensive deliberation.

Initiating such a debate need not be left to the government. Think tanks, civic organisations and educational institutions could take the lead. We must not delay.

The time to address the allocation of care is now — before shortages arrive and the pressure to act quickly will, once again, undermine rational planning.

Steven Schwartz is senior fellow at the Centre for Independent Studies, was the vice-chancellor of three universities and is a former executive dean of medicine.

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