‘Take me first’

If a deadly bird flu pandemic ever materializes, who should be the first, second and third in line to get a potentially lifesaving dose of vaccine?

Most ordinary people might yell impulsively, “Take me first.” But medical experts agree it is only logical for health care and other emergency workers to get priority.

It is over the next group – the general public – where the disagreements occur.

Dr. Ezekiel Emanuel, chairman of the department of clinical bioethics at the National Institutes of Health Clinical Center, incited a hearty debate recently when he argued in the journal Science that healthy Americans between ages 13 and 40 should be the next up to get a shot after key emergency workers.

His argument is simple: Those between early adolescence and middle age should receive a high priority, as they have survived childhood and have many productive years ahead of them. Society has a clear interest in protecting its most productive members during a pandemic.

But that position is countered by two U.S. advisory groups that have said people with high-risk health conditions – young children and the elderly – should be next in line for vaccine. Society should protect its most vulnerable members.

The debate has divided top ethicists and ultimately could have real life-and-death consequences.

We spoke with Emanuel by phone from his office in Bethesda, Md. We also spoke with Dr. G. Caleb Alexander, a University of Chicago assistant professor of medicine focusing on health-care allocation.

Here is an edited transcript of their diverging perspectives:

Dr. Ezekiel Emanuel

Q: You have taken a position that is a pretty hard sell politically. You are essentially saying one person’s life is more valuable than another’s.

A: We (he and co-author Dr. Alan Wertheimer) thought about this long and hard. In a pandemic where potentially millions will die, the question is whether you should focus on the sickest and oldest people or the healthier young people.

There are a lot of good ethical reasons to focus on healthier, younger people. Just naturally when a young person dies, you hear people say things like they had not had a chance to live their lives yet or that they were just on the brink of something.

Why should the life of someone who is 65, who has 15 years left to live, be of the same value as someone who is 15 and has 65 years yet to live?

Q: But your recommendations also would put not only older adults but the very young further down on the list of vaccine recipients. You zero in on those aged ages 13 to 40, but what about a child who is 2 or 3 years old?

A: We talk in our research about the idea of life investment. A person who is a late teenager or in early adulthood has put a higher investment in their life than a 2- or 3-year-old, and that person still has a long life ahead of them.

I know these are tough choices. But in a situation of scarcity of a vaccine, there is no neutral position in this.

You will always favor one group or another. It is just a matter of which one.

Q: Some experts also argue that you cannot make blind choices on vaccine allocation when you don’t know ahead of time how a pandemic will affect certain age groups.

A: I don’t think those (experts) are taking seriously what a pandemic would look like. We won’t know who is at highest risk in the middle of a pandemic when there could be pandemonium and confusion. It would be like trying to make changes in the evacuation policy in the middle of Hurricane Katrina.

There would be a lot of social disruption, so it would be hard to make these decisions on the fly.

Q: U.S. Health and Human Services Secretary Mike Leavitt recently said the states ultimately would be responsible for making decisions about who would receive a potential vaccine. Some have said the federal government is passing the buck, leaving the difficult choices to state officials. What is your reaction?

A: I think this is an extraordinarily complex issue, and assuming all 50 states will have the resources in terms of skilled officials with knowledge and experience is optimistic. And it is not clear to me at least why the same exercise should be conducted 50 times rather than once at the national level.

Dr. G. Caleb Alexander

Q: After emergency health-care workers and a few others, there is a sharp difference of opinion regarding who should be next on the list to receive a potential vaccine. What is your take on the issue?

A: What matters most to me is that attention needs to be paid early and often to the numbers and information that would be coming in about who is being affected if there is ever a pandemic.

So there has to be fluidity and flexibility in the policy to make sure the highest number of lives are saved.

For example, if we knew that a 40-year-old had no chance of dying and an 80-year-old had a really high chance of dying without the vaccine, I don’t think anyone in their right mind would suggest that all the vaccine go to 40-year-olds first. So from an ethical standpoint, the question is who is affected.

With these sorts of dilemmas, the devil is in the details. So we will need to track and respond to information as fast as we can.

Q: But Dr. Emanuel is arguing it would be difficult to make changes in the midst of a crisis and, more importantly, the larger issue is who is saved, not the just the highest number.

A: There is something compelling about that idea, and it does have an intuitive appeal. But for me, the most important question is how a pandemic would affect some age groups more than others.

Q: So you believe that the number of lives saved is most important?

A: Yes, but I also think there would be a role for altruism, although it is difficult to define public policy around altruism. Some people who are eligible to receive the vaccine may forgo it, for example, if they are elderly and ask that it be given to a younger person.

It could not be a targeted donation like organs, but there could be a role for altruism. In these sorts of public health emergencies, there is often tremendous heroism.

Q: Every decision about vaccine allocation seems particularly weighty and fraught with potential unexpected consequences. Can the public feel safe?

A: The public should be reassured that health experts and others are working together to make sure good plans are in place. But this does not mean that if there were a pandemic, there would not be significant challenges.

It is almost impossible if the worst scenario were to take place to be totally prepared for something like this.