The Ethics of Global Vaccine Distribution, Part One, with Cécile Fabre

ALEX WOODSON: Welcome to Global Ethics Review. I'm Alex Woodson from Carnegie Council, the world's catalyst for ethical action.

In this podcast series, we'll be connecting Carnegie Council's work and current events with our senior fellows, senior staff, and friends of our organization. You'll hear from leading experts on artificial intelligence and technology, migration, public health, and U.S. foreign policy and global engagement.

This week's podcast is the first in a series on the COVID-19 pandemic and the ethics of global vaccine distribution.

As we enter the summer of 2021, some nations, like the United States or the United Kingdom, are seeing vaccination rates of around 50 percent, effectively ending the imminent threat of mass hospitalization or death due to COVID-19. Other nations—including many in Latin America at the time of this recording—have vaccination rates around 10 percent or lower and are still facing public health emergencies. These states simply do not have the same access to vaccine doses.

In recent weeks, the Biden administration has put in motion a plan to help distribute tens of millions of doses to some of the neediest nations. Though many have applauded the move, there is less consensus as to whether it goes far enough.

Given the existing global inequities, what are the responsibilities of vaccine-rich countries to the rest of the world? What ethical considerations should guide policymakers’ thinking on these issues?

To start to answer some of these questions and to understand the ethical underpinnings of some of the policy choices we are seeing play out, I spoke with Dr. Cécile Fabre. She is a senior research fellow at All Souls College, Oxford and professor of political philosophy at the University of Oxford. For more on the COVID-19 pandemic, the vaccine, and ethics, you can go to carnegiecouncil.org.

I'll be back in the coming weeks with much more on this topic, but for now, here’s my talk with Professor Cécile Fabre.

Professor Cécile Fabre, thank you so much for speaking today. I am looking forward to this.

CÉCILE FABRE: Thank you for having me.

ALEX WOODSON: Or course.

I want to ask a question or two just to make sure we are all on the same page with our audience with some terms and some of these ideas. Just to get started, as a philosopher what do you see as the major moral considerations when you think about ethical global vaccine distribution? What are some of the issues that come up for you?

CÉCILE FABRE: One of the main issues if not the main issue is whether or not national and political borders are morally relevant, whether the fact that a person is born on one side or the other of a border or is a citizen of this state rather than that state makes a difference morally speaking to whether or not that person should have access to the vaccine, which is a lifesaving resource. Some people frame this as a debate between vaccine cosmopolitanism on the one hand versus vaccine nationalism on the other hand. I don't really like the term "nationalism" in this context. It has very negative connotations. I prefer to speak of priority for residents.

To illustrate the issue, I am French, as you will have gathered from my accent. I live in Britain. I am a long-term resident of the United Kingdom. So the question really is this: Does the fact that I am a long-term resident in the United Kingdom mean that the British authorities should give me priority when it comes to access to vaccine, or are they morally required to send vaccine doses abroad to help people from other countries?

The radial cosmopolitan would say that borders are completely irrelevant morally speaking, so the fact that I am a long-term resident of the United Kingdom in that view does not give me greater priority of vaccines, which are within the control of the British, than if I were born and lived in a completely different country. The radical nationalist will say that the government of the United Kingdom is morally obliged to give me absolute priority over someone who resides in a different country. It is not just that they are permitted to give me priority; they are morally required to do so.

So the first answer to your question really is: Are borders in that sense morally relevant? In between those two extremes there is a range of views obviously.

ALEX WOODSON: I would like to get into some of those views, and maybe a way to get there is that you said you don't like the term "nationalism" in this context.

CÉCILE FABRE: That's right.

ALEX WOODSON: Maybe we can start there and talk about some of these views. Why don't you like the term "nationalism" in this context? What is a better term that we can think of?

CÉCILE FABRE: The term "nationalism" has a very dark history. The darkest, most negatively connotated way of framing the radical nationalist position consists in saying that residents of a given country—in fact, even worse, people who share the same ethnic origin and who live in the same country—have ties that bind them which justifies and indeed mandates giving one another priority over people who are not members of this particular group.

But I think there is a better, more plausible radical nationalist position which makes no reference at all to the often sometimes rooted racist connotations of nationalism, which is, well, no, it's the relationship of residency. So, by dint of living together under the authority of the same state, other residents of Britain and I have something in common that obliges us to give priority to one another over, for example, someone from Kenya who lives in Kenya.

ALEX WOODSON: So one of the ideas to deal with this issue is the Fair Priority for Residents (FPR) framework. I was hoping you could explain that.

CÉCILE FABRE: In a nutshell, this particular framework, the FPR framework, says the following, that governments are morally allowed to retain vaccine doses which they are able to procure for their residents up until the point at which their society no longer experiences crisis-level mortality, bearing in mind that to help reduce mortality levels those governments can at the same time impose reasonable public health restrictions. This raises at least four separate issues.

First of all, so far I have spoken of residents and not citizens. According to the Fair Priority Model, as I understand it and as I subscribe to it, priority has to be given up to a point to residents of the relevant political community and not just to citizens. That is a very live issue. I would, in other words, include illegal or, as you might say in the United States, "undocumented" immigrants.

It is a live issue—for example, as recently as March of 2021 the British authorities had to explicitly reassure immigrants who were present illegally in the United Kingdom that they could register with a medical practice and be vaccinated without risking expulsion, and I understand that it is a live debate in the United States as well. Some countries have said explicitly that they were not going to include all residents in who has access to the vaccine but only their citizens. So that is the first point that I want to make clear about the framework: It is residents and not just citizens.

The next issue is: What is it that I mean when I say, "You can keep the vaccine doses that you have been able to procure until you are no longer experiencing a crisis-level of mortality?" The first point to note here is that the metric is mortality, or death. It is not other harms, such as long-term disability and so forth. That is because death is irreversible. It is the worst possible harm that people can experience.

My colleagues and I who are working on this thought from the very beginning that, given that we had to choose one metric, we had to choose the most severe harm that we could experience, and that would be death. It is also important to note that other harms occurring from COVID-19 are elevated when non-crisis-level mortality is reached. So we used mortality as the metric as a proxy generally.

I also mean mortality from COVID-19 and from reduced access to health care as a result of the pandemic, and this is really crucial. When we consider what is the right, ethically speaking, way of distributing vaccines globally and when we think that the principle must include mortality as a metric, we don't simply mean people who die from COVID-19. We also mean people who die not from COVID-19 but, for example, from cancer, where the reason why they die during the pandemic from cancer is because hospitals are so overwhelmed by COVID-19 patients that they simply do not have capacity to treat other illnesses.

We also need to think about what we mean by a "crisis-level" or a "non-crisis-level" of mortality. Here it seems to me that the most fruitful way to think about it is to have in mind familiar public health threats. A good comparator is the flu. Here the thought is this: At the point at which COVID-19-related mortality reaches the yearly mortality of a worst-than-average but not terrible year for the flu, that is the point at which you cannot hold onto vaccine doses. You have to distribute to other countries which are still experiencing crisis levels of mortality.

The third important point is what counts as "reasonable health" in a restriction. Remember, the model says you can keep vaccine doses up until the point at which you are no longer experiencing crisis-level mortality, but bearing in mind that there are two ways of reducing mortality: Vaccines are one, and public health restrictions are another. So as long as you can continue to reduce mortality by taking reasonable health restrictions such as social distancing, imposing the wearing of masks, and installing HEPA filtration systems in public buildings, then at that point you have to give away your surplus doses. That is what the framework says.

The rationale for the framework is that it is a compromise between radical cosmopolitanism on the one hand and radical partiality for fellow residents on the other hand. The framework should go some way towards pleasing, as it were, those who believe that governments are morally obliged to show preference for their residents because the framework says explicitly: "You may keep doses up until the point at which you are no longer experiencing crisis mortality." But it should also appease the radical cosmopolitan, or at least cosmopolitans who are a bit less radical, because it says you cannot hoard. There is a point at which you are morally obliged to give spare doses of vaccines.

In that view, the United Kingdom, for example, would not be morally entitled to say: "Well, we know there are still people who are dying of COVID-19 in another country, and we know that this country is experiencing crisis levels of mortality, but we are not going to give them surplus doses because we want to live under no public health restrictions whatsoever." The framework says, no, that is morally wrong. The sacrifice for every single one of us in the United Kingdom of having to socially distance and wear masks in close spaces, is not burdensome enough to justify allowing crisis mortality levels in other countries. That is roughly how the framework works and why my colleagues and I think it is justified.

In this interview I do not speak on behalf of my colleagues with whom I have written a couple of papers about this. I speak on my own behalf, and on my own behalf I just want to say this: I endorse the framework. I think it is a good framework, but I have very strong cosmopolitan leanings. I am actually tempted to endorse fairly radical versions of cosmopolitanism.

However, even a radical cosmopolitan must be realistic, and that takes us back to some of the moral considerations we need to think about when dealing with this topic. Even a radical cosmopolitan must accept that given the way the world is by and large the best institutions for delivering and administering vaccines to a given population will be the national authorities of that country. So that is the first point.

The second point is that the radical cosmopolitan has to accept that equality of access to vaccines is only one value. There are other competing values, and one of those competing values is the need for governments to be seen to have legitimacy in the eyes of the citizens and residents, and the framework allows for that. A government that would say, "Oh, well, it shouldn't matter to us that people in our country are dying in excess of normal levels of mortality, we are going to distribute wherever in the world"—that government would not be seen to have legitimacy by its citizens, and that would have very, very detrimental consequences at the time for the effective delivery of public services. Whereas others who work on this believe that the compromise that the framework reaches is the first best principle, I tend to believe that it is the second-best principle, which makes more room for disagreements about the conditions under which governments are legitimate and so on and so forth.

Does that answer your question?

ALEX WOODSON: Definitely, yes. It gives me thoughts for more questions too.

I want to talk a little bit about the concerns, but first I am just interested to hear—you say that you have a radical cosmopolitan view on this, and maybe some of your colleagues don't. What would that mean? If you alone were deciding this framework, for example, what would you be doing differently to fulfill this radical cosmopolitan view?

CÉCILE FABRE: I am not sure that the principle in its detailed articulation would be very different. The key difference has to do with the rationale for the principle.

Some of my colleagues in general, more in political philosophy, both in academia and outside academia, believe that there is something which is profoundly morally meaningful to the relationship of co-citizenship or of co-residency, meaningful such that if I were, for example, standing in front of a burning building and had to choose between saving the life of a fellow French or fellow British—I have dual nationality—on the one hand and someone from Madagascar on the other hand or Colombia, then I am, in the views that I am describing and which I reject, morally allowed to give priority to the life of the fellow French or fellow British over the life of the person from Madagascar or Colombia. Indeed, on a stronger view, I am morally obliged by dint of that relationship of co-citizenship or co-residency to give that life priority.

I do not have that intuition. I never have had that intuition. I don't remember a time since I became aware of thinking about these things when I have not held the view that those lives I should regard as strictly equal. On that view, which is a radical cosmopolitan view, the relationship of co-citizenship or co-residency does not make a difference to life and death.

There is an even more radical view, which says that that it shouldn't make any difference even to the distribution of non-life-saving resources. That is even more radical. But with respect to life and death it should not make a difference.

The disagreement lies in how one justifies the framework. When you have three broad positions on the table, I can imagine some people saying: "Well, the framework is in fact, morally speaking, the right balance between the demands of cosmopolitanism on the one hand and the demands of acceptable nationalism on the other hand." Others will say: "Well, it's not actually, morally speaking, the right thing to do. It is a compromise solution," and it is a compromise in the sense that we have no choice but to defer to the nationalist intuition. That tends to be the view I have there.

ALEX WOODSON: Okay. Moving on to some of the objections, you touched on them a little bit in one of your previous answers. I think a lot of them come down to "My country was better prepared than others. I made social and financial sacrifices to deal with this disease. This country is a better state than your country because of this." I believe you said that you don't think that is burdensome enough to justify not distributing the vaccine, but if someone were to push you on that, how would you respond to that?

CÉCILE FABRE: I think it is a very important objection. It comes in different guises, and it has to be dealt with properly.

The first thing I would say is that this is not I think an objection to the Fair Priority for Residents model, and that is because the countries which are in such a position that they can buy lots of vaccines are already at the head of the queue, and the framework says very clearly you can keep your doses until they reach non-crisis mortality levels. So the objection really has to be: "Well, even beyond that level, because of the financial sacrifices I have made or my country has made, we are not under any obligation to help people from different countries. It is our wealth. It is through the proceeds of our taxes." I have a few thoughts there.

When someone says, "Well, look, you know, we are better prepared because we have made lots of effort, we have contributed a lot," we need to know what "better prepared" means. It could mean, for example, that we have invested more in research and development, or we have a health care system which is better able to cope with the pandemic, and the only reason, the argument goes, why our healthcare system is better able to cope is because we pay more taxes."

My response to that is to say: "Well, but these are global collaborative processes. There is no pure British research and development in that field. In fact, if you look at the nationality makeup of vaccine manufacturers, these are global enterprises." But being better prepared in that sense does not overlap neatly with national borders.

Relatedly, national health care systems—the British health care system is a very good example—have very often relied on immigration from abroad. The National Health Service (NHS), which is the national health care system in the United Kingdom, has a substantial number of non-British citizens amongst its workforce. That is costly for other countries. It is the well-known phenomenon of the brain drain. It seems to me that any argument to the effect that "We are entitled to hold onto the vaccines we can buy by dint of the fact that we have paid our own taxes to have the NHS," has to be sensitive to the cost for other countries of our having the health care system that we have.

I also worry a little bit about any argument that will say that wealth is decisive when it comes to life and death allocations of resources. A lot of people, including people who are sympathetic to the objection you raise, would balk at the idea that as between someone who needs a liver transplant which would save his life and is wealthy enough to buy one and someone who needs a liver transplant that will save his life but is too poor to buy it, the liver should go to the former, when I think a lot of people have the intuition that need is the right basis for access to lifesaving medical resources and not ability to pay.

Finally, I always want to know where does the wealth come from? In the United States you have a longstanding debate about past injustices, in particular reparations for slavery. In Britain and in Frances the debate is partly about slavery, but it is also about colonialism. Here the argument is: "Well, if you look at the processes by which national wealth has been accumulated, you are likely to find enormous amounts of injustices, including injustices committed against the ancestors of populations nowadays which are desperate for the vaccine doses." This sorting here is why it's so clear that national wealth unquestionably belongs without restrictions to the people who happen to have it.

ALEX WOODSON: These are for me very persuasive arguments about the need to distribute these vaccines globally, and I fully take your point that countries like the United States, the United Kingdom, and other high-income countries have a moral obligation.

How do you respond to the argument that you might be giving these countries millions of doses of the vaccines, but they are not prepared to distribute them effectively? How do you respond to that issue?

CÉCILE FABRE: Again, that is a very important objection. It is easy to dismiss it as well. It is not really a moral objection. It is just a question of implementation.

I think it is easy to dismiss it in those terms, but it is a mistake to dismiss it in those terms. It really is a profoundly important moral question. If vaccines, once they are distributed to countries in need of doses, are not distributed to the people who ought to have them, it's a waste, so we might as well have sent them elsewhere. We should never forget that it is a matter of life and death.

There are different ways it seems to me of responding to that objection. The first way looks at: Okay, so on what basis do we make the judgment that a government will be ineffective at distributing vaccines? Not so much nowadays, but a few months ago you would hear people say, "Well, they have made such a mess of dealing with the pandemic up until now that we cannot trust them to deal with the vaccine effectively."

The United Kingdom is a very good counter-example to that argument. In the first year it did not deal with the pandemic very well, but I think it is unquestionably true that the vaccination campaign has been a major success. So, the first response to that objection looks to the evidence: What is the evidence, we are asking, that this government will not able to distribute the vaccine effectively?

A response to this would say: "Well, the governments in countries X, Y, and Z have a track record of extremely poor management of aid in particular." So the effectiveness objection paralyzes debates in the ethics of international development about aid conditionality.

Here the response would be: "Well, even if it is true that by the look of it they would distribute the vaccines very ineffectively or indeed even very unfairly, the fact is it is still likely that the doses of vaccines that are delivered would save lives." So, for us to say, well, no, we can't give the vaccine to them might be tantamount to almost punishing the population for the misdeeds of the government.

The second response tries to be a bit more creative with institutions and says: "Well, but there is a way of bypassing governments, by distributing vaccines to local nongovernment organizations (NGOs). Might this be a way of getting around the effectiveness objection?"

The "headline news," if you will, or the take-home point from that particular problem is: Before we rush to judging that distribution to this particular country will be ineffective, we have to be a bit more clear as to the evidence that we marshal in support of that claim, and before we decide that the evidence is good enough that we must desist from distributing, we have to think about alternative mechanisms for getting the doses where they ought to go.

ALEX WOODSON: This brings up another issue that I can think of, not really an objection to the plan but maybe just a different way to look at it, and that is that countries like the United States are somewhat dictating this process because they are in possession of the vaccines, and we see that millions of vaccines are being distributed—we have seen Biden's plan about that—and the concern is that this just reinforces global health inequities for the United States and the big Western nations saying, "This country can have the vaccine and this country can't, in this country we are going to give it to the NGOs." How do you think about that? Does that concern you as you work through this process?

CÉCILE FABRE: Of course it does. I think it should concern anyone who is committed to—if not full, because that is utopian—global health equality, at least to reducing global health inequalities. One solution, which is a very imperfect one, lies it seems to me in the establishment of and ongoing support for a time of robust international institutions with different voices around the table and not just in the wealthiest countries in the world with enforcement mechanisms. This is where some people might say, but that too is a very utopian line of thought, but I don't really see any other way, to be honest, at this point. The path to building such international institutions, as we know from the United Nations and the International Criminal Court, is long and rocky, but that alone is not a reason not to start walking down it, as it were.

ALEX WOODSON: I want to go back and speak a little bit more about how you have approached this over the past year and a half since we have been dealing with this pandemic. When you started looking into this, was it useful for you to look at previous pandemics and previous vaccination campaigns? The two that come to mind for me are the 1918 flu epidemic and the polio vaccine campaigns in the 1950s. Did anything like that inform your work and change your thinking about this process?

CÉCILE FABRE: I think that is a very good question. In my case, not really—there is a sense in which it is a sad admission to make—because I have not worked on global health justice before now, and if I had, I think that would have been my default mode—oh, let's look at previous cases.

In addition, I always get a little bit worried when we start thinking, Oh, what lessons can we learn?, for example, from the 1918 flu pandemic or the polio vaccine campaign because the cases are so different.

I want to know: What is the proper baseline for comparison? If you look at mortality, well, as things stand, the COVID-19 pandemic is dwarfed by the 1918–1919 flu pandemic. If you look at a pandemic that put a stop for a long time to social and economic life across the globe, I think this one is unique as far as I can tell. Due to my previous research, both due to my distrust and wariness about these comparisons, I have not tended to think about it in those terms.

What got me into this was the work I have done for years of the different contexts on cosmopolitanism. That for me was the hook, if you will, on which I hang my thinking over global ethics for vaccine distribution, for at least this particular vaccine.

ALEX WOODSON: How did that work inform your thinking? You have written books, Cosmopolitan War and Cosmopolitan Peace. How did thinking about war and peace and some of those issues inform your thinking about this?

CÉCILE FABRE: The thread is cosmopolitanism. When you think about war, in effect by and large you have to think about the ethics of killing and the ethics of saving lives. Here the similarity between the two questions is this: In war we have to decide whether the lives of our compatriots are more important than the lives of enemy civilians. The principle of noncombatant immunity, which prohibits deliberate targeting of enemy civilians, in effect says you may not deliberately kill enemy civilians in order to save the lives of your compatriots. At the heart of the ethics of war, but particularly the principle of noncombatant immunity, which is a cornerstone of the ethics of war, there is a very strong cosmopolitan principle.

So it is not a huge step from there to think: Okay, that is interesting. We have a life-saving resource, which is the vaccine. Does the cosmopolitan intuition that I find and defend in my work on war carry over into this particular issue? That is one point of connection between those different strands of my research.

Over the last year or so I have begun to see other connections. Some people think that war is a state of emergency par excellence, that you need different normative principles to deal with states of emergency compared to the normative principles that you need in order to deal with ordinary life. So again, it is not a giant step to move from that view to the view that the pandemic as we know it is a state of emergency. It is a global crisis, so we might need completely different principles.

As it happens, I don't believe that war is morally exceptional, that it is a state of more emergency. I don't believe therefore that the principles that ought to regulate war are radically different from principles that ought to regulate ordinary violence. I am inclined to think that the same goes with access to vaccines during a pandemic, but I have to do more thinking about that.

ALEX WOODSON: Final question. I want to look to the future a little bit. I have done a little bit of reading, and scientists think that they are better prepared for the next pandemic because they have done so much work on this vaccine. They think they could have for a new coronavirus a vaccine ready to go. I am wondering if that is the thinking with the Fair Priority for Residents framework too, that this could be a template for—hopefully we won't have to deal with it for a very long time—whenever the next pandemic emerges, that something like this is in place to have the world get back on track a little quicker than it did this time.

CÉCILE FABRE: I would hope so because the concerns which the Fair Priority for Residents framework tries to handle, that is, how do we balance the needs of our fellow residents and citizens with the needs of distant strangers against a background of enormous inequalities in wealth between different communities? Those concerns are not going to go away. In fact, those concerns are not unique to the pandemic that we have been witnessing for the last year. A good deal of moral and political philosophy over the last 40 years has been concerned with precisely that question.

When or if we are hit by the next infectious disease pandemic such that only a vaccine together with public health restrictions will do, we are going to have to grapple with the same concerns. So I would hope that—what lateral revisions are required by changes in context—the model could still be useful.

ALEX WOODSON: Professor Cécile Fabre, thank you so much.

CÉCILE FABRE: Thank you very much. I really enjoyed that.