Pandemic Ethics: Where Do We Go from Here?

WENDELL WALLACH: Welcome to our discussion on "Pandemic Ethics: Where Do We Go from Here?" This event is sponsored by three esteemed institutions—Carnegie Council for Ethics in International Affairs, which is also our media host; The Trebuchet, a higher education consultancy, founded by one of the event organizers, Sherman Teichman; and The Hastings Center. For those of you who are not aware of The Hastings Center, it has been around since 1969 and has been a leader in discussions of medical and research ethics and is a go-to forum for discussions of the latest ethical issues arising around the pandemic.

My name is Wendell Wallach. I am a Carnegie-Uehiro Senior Fellow, and at the Carnegie Council I co-direct the Artificial Intelligence and Equality Initiative. I am also a senior advisor to The Hastings Center.

Few crises have underscored such a breadth of ethical issues and the near-term consequences of our making good choices as the COVID-19 pandemic. We become aware of the fragility of our social systems and how their effectiveness can be undermined by politicization, of our reliance on unpaid workers who are taking great risks to serve our needs, and of questions of prioritization in the distribution of vaccines and around richer countries hoarding vaccines. Social justice considerations, security, and end-of-life issues all enter into the mix.

We have a wonderful and informed panel of speakers today. I am going to introduce each one of them before they speak, but I also want to tell those of you who are participating to feel free to put in comments or raise questions in the Chat, and we will get to that before the end of our event today.

Jonathan Moreno is the David and Lyn Silfen University Professor at the University of Pennsylvania.

Jonathan, you wrote this book with Penn president Amy Gutmann called Everybody Wants to Go to Heaven but Nobody Wants to Die: Bioethics and the Transformation of Healthcare in America. It sounds like a verse for a country and western tune. You wrote the book in 2019, and the paperback is just now coming out, and you and Amy decided you wanted to add a new afterword called "Pandemic Ethics." Tell us a bit about the book, what the book was intended to do, and why you pivoted to add in this new afterword.

JONATHAN MORENO: Thank you, Wendell, and thanks to the co-sponsors for letting us all be together in this remote fashion. Like my good friends and colleagues on the side I do wonder if funders will be bringing people together in person after this or if we will be doomed to Zoom, but that is a topic for another day.

As you said, Amy Gutmann, a political philosopher and president of Penn, former chair of the Obama Bioethics Commission—on which Nita served and Jason also had something to do with that—and I published this book in 2019, in the old world. The idea of the book was to provide a framework for a popular conversation about bioethics.

We started with a couple of historical chapters. The basic trajectory of the little field of bioethics that has become sadly so prominent in the last year in the public health sector is: How did we get started in the field in a way that did not lead us to—and what I am going to say might be contentious, but I'll say it any way—give a high priority to the ethics of public health?

I think it is fair to say that traditional medical ethics is a field that Ulf especially studies in the European setting and is what some people have called "doctor-oriented" ethics. For various reasons—the emergence of new technologies and the emergence of civil rights movements; The Hastings Center, one of our co-sponsors, was very much a part of that in the late 1960s and today—the focus was on the patient, on the individual. We see this in just the standard list of bioethics principles—respect for autonomy, beneficence, nonmaleficence, and justice—where respect for persons or personal autonomy is the "first among equals," as some have said, and justice is much less well defined.

By the time that our little field of bioethics got started at The Hastings Center and at the Kennedy Institute in the late 1960s and early 1970s it really looked as though the era of infectious disease was behind us. As a matter of fact, there was an urban legend that I believed for a long time that an American surgeon general actually said that in 1971, that the era of infectious disease is behind us.

That was an urban legend; it's not true. But it felt true. It felt as though we were somehow over the worst of the terrible epidemics and pandemics that had plagued humanity for millennia. It is really interesting that by 1980 you have the eradication of smallpox. The whole "narrative," a term that we tend to use a lot these days, seemed to be "been there, done that."

Then of course in the early 1980s you have the emergence of HIV/AIDS, a catastrophe for so many people, that I witnessed up close when I was working at an inner-city medical school in Brooklyn. But the HIV/AIDS epidemic did not really orient us back to a more public health-oriented view of bioethics. It affected people who were having intimate sexual contact, it affected IV drug users, it affected people who were receiving blood or blood products.

I think while it is certainly true that there are many people who came to specialize in public health ethics because of HIV/AIDS, it did not really change the trajectory of the field. Important work was still being done on rather high-tech issues. I will say that I am responsible for some of that as well. We were focusing on brain science and on genetics and so forth to the extent that when I started teaching—before there was electricity—there were textbooks in bioethics for these experimental bioethics courses in the 1970s, the ethics of public health and the ethics of resource allocation, tended to take at a theoretical level the form of "lifeboat" ethics exercises: Who gets to stay in the lifeboat? And to the extent that it was policy-oriented, the case in question tended to be set on organ transplants or who gets the dialysis machine. We did not have very much of a public health focus in the field.

Although you didn't ask, Wendell, about how did I react to this in February and March—by the way, the last time that Wendell, Nita, and I were together, the last actual in-person conference I attended in ethics and science, was one that Nita organized at Duke. I felt at the time—early February, if memory serves—and I think a number of us felt that something ominous was lurking, but we didn't know the shape of the beast.

I spent the first month or two in this room in my house kind of breathless. The first few weeks I said: "This is the stuff that I should have been thinking about and writing about for years, decades in fact, and I missed the lifeboat. I didn't get it."

When Amy and I wrote the book, when we were getting ready for the paperback, and both of us said at the same moment, talking on Zoom: "We really need to write a postscript now on pandemic ethics." We were writing that, of course, still very much in the beginning of this event.

What we tried to do in the postscript is identify some of the themes that had already emerged. Since then of course there are more. I think we did pretty well in getting the big themes as they were last summer and early fall, and I think we have captured some of them, and we will be talking about them today perhaps: the failure of our public health system to adequately address a situation like this, particularly in the United States and the lack of leadership.

I did spend a month or two last year when this was unfolding, as my own kind of academic form of self-therapy, reading histories of epidemics and pandemics that I should have read and that my colleagues had read that I had not read. One of these historians said: "If you've seen one pandemic, you've seen one pandemic." There are so many different variables at play.

We are still sorting this out, but I do think—and I will stop with this—there is a kind of reckoning that needs to take place in our field, in bioethics. We need to rethink our orientation, and that is going to be a little painful. That is especially going to be a challenge for younger folks, who will have to live with the theoretical frameworks that we develop coming out of this, but I do think we are in an important conceptual turning point in thinking about the field of bioethics and traditional medical ethics.

WENDELL WALLACH: Thank you, Jonathan. I think I am going to come back with a question after we have had each of our introductions.

Nita Farahany is the Robinson O. Everett Professor of Law and professor of philosophy at Duke Law School. I think it is fair to say that Nita is really a leading figure internationally in the ethics and law of emerging technologies.

I know that one of the topics that has concerned you, Nita, has been the public trust in science. Perhaps you can talk a bit about that in the context of the pandemic.

NITA FARAHANY: Thanks, Wendell, and thanks to both of my fellow panelists and also to the sponsors of this conversation, which is both timely and important.

I do want to talk about public trust in science, and it builds really from what Jonathan was talking about, the fact that bioethics, especially within the United States, has been very individually autonomy-focused, and the conversations that we have had, the rhetoric that we have had, and the way in which we have fashioned bioethics, has traditionally focused very much on the individual. When we find ourselves in the middle of a global pandemic, which is not about individuals but is about the community and the global community as a whole and requires concerted effort on the part of a global community as a whole to be able to address it, it is particularly problematic to not have any of the structures in place, any of the rhetoric in place, or any of the ethics in place that enable that kind of coordinated global response.

Part of what I want to focus my remarks on to just start the conversation as fodder I hope for continued conversation is the fact that one key element of both the fact that this rhetoric has not existed, that the ethics and the ethical analysis has been missing in a lot of the field, is the role of the public institutions in being able to bring people together and to establish trust to enable that kind of coordinated effort. Here in this global pandemic, particularly within the United States, public trust in science has been deeply undermined at a time when it is essential that it be high and that our trust in public institutions be high.

There are a few reasons for that. One of them, and a really important one, is the politicization of science. That is, rather than having science be this kind of objective set of information which is based on facts and grounded in facts, it has been a tool that has been used by political parties to be able to advance their objectives.

Jonathan I think will be able to speak well to this idea. He wrote a terrific book called The Body Politic: The Battle Over Science in America, which looks at the interesting alignments that exist on science, which are not your traditional alignments around Republican and Democrat as we understand them in the United States. In fact there are some odd bedfellows who find themselves together when you talk about issues that are divisive within science.

One of those issues that has been incredibly divisive ties into this question of bioethics, this individual-versus-community ethics, the idea of: Should we be acting just to advance our individual interests, or do we need to be acting to advance the interests of society as a whole? So, one has been politicization of science.

The second importantly has been misinformation, intentional spreading of misinformation, which at a time when misinformation is an issue across every dimension, misinformation in science and misinformation in the middle of a global pandemic means that people don't know whether to trust the information that is being given to them by public officials, by anyone, what they read in the news and whether or not it's accurate, whether or not it's true, and we are all isolated from one another, where you rely so heavily on what you read and what you hear in the news, having misinformation and intentional misinformation becomes even more deeply problematic. It becomes even more of an issue with respect to developing public trust in science.

The third big issue has been the lack of transparency. The way in which you fight misinformation but also develop trust in science—and this has been true throughout science, regardless of whether or not it's public science or scientific publications—has been ensuring that data and information are widely available and are transparent.

When information instead is kept hidden, when information is intentionally clouded in misinformation or news sources and there are repeated references to things like "fake news" and you are not giving people accurate and true information, it becomes even harder to be able to develop the kinds of public trust that you need in order to be able to advance the community ethic that we need to be able to emerge from this kind of a pandemic.

There have been a number of missteps as well, some of these unintentional, some of these quite intentional, that feed into each of these previous ones. For example, there was a claim on Twitter that was made that masks don't protect individuals: "Stop buying masks. They don't help."

It becomes then so deeply problematic just a little while later to say: "No, no, masks work, and everybody should wear them."

The right answer at the time should have been to say: "Look, masks work, but there is a shortage of them. We have a massive shortage, and here is the problem with individuals acquiring those masks versus having those available to health care workers. If they don't have them when you go to the hospital, there will be nobody there to treat you. Our frontline workers are essential."

That kind of misinformation and intentional misinformation made it incredibly problematic for us to be able to get this pandemic under control.

The result means that there was in the beginning and still today a poor uptake of mask wearing in public in the United States, and that is in part because of this idea of, Well, if I'm not personally at risk, why should I have my liberty infringed upon, without an understanding of the community ethic that is needed but also the implication of interdependence of individuals to stop the spread of the virus.

It also meant that there was an undermining of trust in the data. It allowed for conspiracy theories to grow. It allowed for this kind of belief that perhaps things aren't as bad as people say they are, and the other kinds of conspiracies that grew during the pandemic and continue to exist during the pandemic.

Most critically right now with an undermining of public trust it means that there is still mistrust in vaccines, and right now we have this moment of hope and this moment of essential need, which is we not only have a hope for people to be able to get vaccines but a need for people to become vaccinated because in order for us to get out ahead as much as we can of the mutations that are happening with the virus we need as many people to be vaccinated as possible.

There is some encouraging information that I will just say as a backdrop with this. Pew Research issued a study in September of 2020 looking at public trust in science, and they found that there are, of course, some public divides over science and that there is some partisanship but that there still is a high degree relatively of trust in scientists, even if there has been an undermining in the trust of public institutions. The trust in practitioners like medical doctors is stronger than that for researchers in this field, but the skepticism about scientific integrity is really widespread. This, which is the thing that most boosts trust in scientific research findings, is making data openly available.

So right now we have this opportunity to really turn things around. We have a new administration in the United States that is in office. We have a new moment with widespread—hopefully—distribution of vaccines, and that moment is the moment at which we should be making as much scientific information publicly available as possible.

That's why I think the moves by companies like Pfizer and Moderna that made their protocols widely available and transparent was a very good move. Those are the kinds of moves we need right now to make as much transparent data available as possible to be able to move toward a place of restoring public trust and restoring public leadership in science to be able to help us navigate through this pandemic.

WENDELL WALLACH: Thank you very much, Nita.

Ulf Schmidt is a fellow of the Royal Historical Society, and he is a professor at the University of Hamburg.

Ulf, I am sure you have a lot to say about differences between what has happened in the United States as far as public trust of science and what is happening in Europe, but I would also like to emphasize your work as a historian specializing in the history of medicine and medical ethics. I particularly want to ask you: How important is historical contextualization in understanding aspects of the pandemic?

ULF SCHMIDT: Thank you, Wendell, and thank you to Carnegie Council for hosting this event.

I might preface some of my comments. Historians are generally rather cautious in talking about the present and even more about the future, but I do think that in this particular case I might add the odd additional dimension to this conversation.

What I think is interesting in just following and listening to both Jonathan and Nita is that most of the issues which have been raised by both speakers and also within the public domain are not new and that past societies and past governments and states have grappled with them and tried to find solutions. If anything, it does potentially indicate that humanity does not seem to be particularly good at learning some of the lessons at least from past mistakes.

As far as my own work is concerned, I think what is interesting here—I think Nita already addressed this—even in my own work there has been a considerable focus on the individual in the past. I looked at the history of Nazi medical experiments. I looked at the development of Nuremberg, particularly the Nuremberg Code, in which key ethical principles for human experimentations were formulated after the Second World War, and which started the beginning of some of the debates in terms of human rights and human experimentations and ultimately also were particularly important in developing the bioethics field as a whole.

What is interesting when we contextualize these developments is that the backdrop to these developments is a new response in the postwar world, particularly in Europe, to the catastrophe and the destruction of the Second World War and the horrors that went along with it. So we are having a context in which there is a serious moment of reflection going on as to how it could have been possible that science was involved in some of these ethical violations, whilst at the same time there is a genuine attempt to rebuild Europe and the world into a better future.

That also involved—and I think this could be important for our discussion—major changes in public health and public health systems and also in terms of international organizations collaborating to ensure that certain diseases would be eradicated—we are thinking of malaria, at least that was an attempt in the 1950s; we are thinking of polio later—and all sorts of international linkages which were established in that period in order to ensure that the degree of nationalism and the degree of antagonism between countries which brought the world to its knees in the 1930s and 1940s would never happen again. That is just as a preamble.

In my own work I have been interested also in terms of looking beyond what we would call the "Western narrative" of bioethics, but looking at other places, for example, in Eastern Europe, to what extent medical ethics and health played a particular role. I think what is interesting already coming out of that work is that we see a general sense that in the postwar period health is of enormous importance for societies at various levels. It also becomes indeed a propaganda tool that societies wanted to show the extent to which their infant mortality rate was declining faster than in other countries, for example.

So public health was not understood in any shape or form in a negative form as it is sometimes being seen as a bigger state or even attached to socialist or ideological ideas. It was seen to be very much imbued with a kind of positive narrative in order to improve the health of the people as part of what one could consider a general understanding for the common good.

If I sketch this in very broad strokes, one could say that over the last two to three decades, certainly from about 1989 onwards—and that has to do with politics, that has to do with a form of neoliberalism, and I think that was already touched upon—the role of public institutions, and that means also the role of the state, the role of welfare, all these bigger ideas including international organizations—and I think the fact that the United States dropped out of the World Health Organization (WHO) during the Trump presidency is only the end of that development—signified a kind of battering of these broader ideas to keep the world together.

To put it crudely, public health was not sexy. It was far more interesting to invest in researches like individual, personalized health, to look at individual rights, and to look at all sorts of aspects which were more interesting rather than the field of public health. I think we are to some extent paying now the price for having not invested and put enough resources into that.

I want to conclude with one aspect of this debate. When we are looking at these very broad strokes here and we are looking at institutions and societies I think we also need to look at the whole level of experiences. We are looking often at quite abstract levels and forget that there are different generations involved here, including the generation of children, for whom the pandemic is now over one year old. In the whole debate I would wish that we also consider some of those dimensions as well.

WENDELL WALLACH: Thank you very much, Ulf.

Jason Schwartz is an assistant professor in the Department of Health Policy and Management at the Yale School of Public Health.

Jason, you previously trained in the history of medicine and public health, and I wonder if there are lessons you have learned from past mass vaccination programs that have informed how this one has been designed and carried out so far.

JASON SCHWARTZ: Sure. Thanks, Wendell. Thanks to our organizers and co-sponsors. It is great to be here with our colleagues on the panel.

Yes. I think as Jonathan noted, no two epidemics are the same and no two pandemics are the same. This pandemic has absolutely caused us to write a new playbook in terms of what we are thinking about in terms of how we gather evidence, how we marshal evidence, and how we put that evidence to work in terms of thinking about policy responses.

I want to talk a little bit about that in the context of vaccination programs, which is an area in which I spent a lot of my work in the past and certainly in the last six or nine months or so thinking a lot about, thinking about the ways in which evidence gets gathered, marshaled, deployed, and translated into regulations and policies in public health, particularly around vaccines. Clearly what we are living through every day is a lifetime's worth of work to start thinking about those interfaces and to contribute to some of them as I have done. I will say a little bit about this as we go along.

One of the things I have also been interested in in the topic of our conversation this afternoon is the ways in which ethical considerations, ethical determinations, and value judgments are often latent in the development of policies and regulations and the consideration of scientific evidence. I have always been fascinated and maybe even a little frustrated I could say in the ways in which sometimes there is lots of ethical work happening in terms of how we think about medical technologies, how we think about health policy decisions, and how we think about the regulation and promotion of vaccines in particular, but often that ethics work is not brought to the surface, it is not made explicit, and it is sometimes papered over as "objective" scientific evaluations.

The issues that are flagged or coded as "ethical" sometimes get sent off to another group, another committee, another commission, or another panel to say: "Oh, this is an ethical issue. Bring in the ethicists." So I have always been interested in the ways in which ethics is absolutely unresolvably entangled—in a good way, in an important way—with the ways in which scientific officials, health officials, and experts of all stripes, think about the work that they are doing.

I want to say a little bit about how that can help us think about what we are seeing with respect to these vaccines about which we are seeing news every day in the newspapers in the United States and around the world. I think we can disavow this idea that the ethical work of science and medical policymaking and regulation are somehow able to be disaggregated from one another. And I will pick up on a few points that our previous speakers, really all of them, I think have amplified and just bring them to this particular site around vaccine efforts here in the United States from the work that happened over the summer and fall and the work that is continuing with respect to the data collection and evaluation of the clinical trial results for these vaccine candidates, first the two that are available in the United States, and we have a process that is ongoing right now, even as we speak, for a third vaccine, and a few more in the pipeline.

Throughout the summer and fall there were questions and discussions about process for one, to Nita's point about transparency, in terms of how the data would be collected, how the data would be shared, how the data would be deliberated upon publicly by the expert advisors of the Food and Drug Administration (FDA). I think a really important asset to the review of these vaccines was the fact that there has been a considerable amount of data—not all the data, to be sure, but a considerable amount of data—that was made public for the scientific community and for the medical community to think about with respect to those vaccines in keeping with this importance of transparency and public confidence in the vaccines, which we know is always a challenge for vaccination but a particular challenge at the moment we have been living through with the concerns about the role that interference could play in the prior administration's decision to deploy these vaccines.

So there was one. Certainly the transparency piece showed up in that evaluation area, but it also I think shaped a lot of those questions that the FDA, thinking historically for a moment, has faced throughout its history, this balancing act that it encounters with any intervention that it is reviewing or considering, this balancing act where it is often criticized at one extreme for in some cases having too many requirements, too many demands, too many expectations, and too complicated a process that could needlessly delay the interventions that can save lives or prevent disease from becoming widely available. That has been one set of critiques of the FDA throughout its history.

At the other end of the spectrum, there are obviously concerns when there are issues that emerge with a medical product after it is introduced and made public if something goes wrong. If we find a new safety issue, then clearly there are often alarms that the FDA has failed to live up to its consumer protection obligations. And everywhere in between.

So the FDA has always faced this balancing act between speed and rigor, not that those are in conflict with one another, but along that spectrum of how it does what it does. And it has encountered that with respect to these COVID-19 vaccines in terms of the requirements, the expectations it has set for manufacturers to give the kind of data that would give the medical and public health communities confidence in these vaccines but not creating procedural hurdles or hoops to jump through or additional requirements that would encumber the sort of swift introduction of these vaccines once a critical amount of evidence is made available, is evaluated, and is disseminated.

We see that. We have seen that just in the past day or two looking at the news. We have this very favorable initial report about the Johnson & Johnson vaccine that we may be seeing here in the United States as early as this time next month, and there are already some eyebrows being raised that the key advisory committee that will review these vaccines and will look at the safety and make sure we have confidence to deploy this vaccine on the scale of tens of millions of doses is not going to meet until the end of the month. There have been some cynical observations from public commentators and editorialists that say: "Boy, you know, there's a global pandemic going on here. Maybe they could move things a little more quickly." However, those of us who study vaccine policy would say this is "warp speed"—pardon the unfortunate phrase—in terms of how the FDA would actually review a submission in a matter of weeks and duplicate the data analyses, generate the reports, and generate the discussions.

But it's a balancing act. And clearly, god forbid, if there were to be a safety issue that emerged after these vaccines have been introduced—and thankfully the story we have seen so far is an incredibly favorable one—the repercussions, the second-guessing about the pace of the FDA's review would clearly be under the microscope. So it's one point in which the scientific advisors, the policymakers, are absolutely balancing this role of consumer protection, of minimizing risks, but also recognizing the great benefits that come from accelerating these vaccines as quickly as possible and trying to find that sweet spot in their work.

When we think about the vaccine rollout, the deployment of these vaccines, the ethical issues are even more apparent and I think again have shown the ways in which they are inseparably connected from the questions of public health, deployment, and the optimization of our public health strategies, and we have seen that I think in two interconnected ways that I want to spend the last few minutes of these opening comments reflecting on.

The most obvious has been the incredibly difficult and challenging discussions around our allocation frameworks, these prioritization groups. We have had a bevy of learned panels and bodies offering guidance in terms of how we can think about allocating our limited vaccine supplies during these initial months, where our supply is clearly inadequate to meet the need and demand for these vaccines. We have had groups from the National Academies of Science, Engineering, and Medicine that issued some guidance, some framework for thinking about the ethics of these allocation issues as early as last summer.

But we also had the work from the Centers for Disease Control Immunization Advisory Committee that makes the vaccination schedules, these science-based schedules, that have guided vaccinations in the United States since the 1960s. They have offered their own prioritization frameworks. That's where this Phase 1a and Phase 1b and Phase 1c, the sort of Lake Wobegon effect where everyone is in Phase 1 but we are just continuing to slice that in ever-thinner increments.

Then we have states that ultimately are the arbiters of thinking about how they should deploy the limited vaccine supply they are receiving. Here in Connecticut, where I live and work, our governor has a vaccine advisory committee, on which I serve along with a number of other health professionals, community leaders, and elected officials, that are then also thinking about how to allocate these scarce vaccine doses.

What are we trying to optimize? Are we trying to save the most lives? Prevent the most hospitalizations? Recognize the increased risks that certain individuals encounter because of their occupation, because of their health status, because of their age, or some combination? The answer is clearly all of the above, but that is a difficult set of principles to weight and then translate into: Okay, which subgroup should get these vaccines now, and which subgroup should wait when there are large percentages of the population that have an important public health and ethical claim to receiving some priority in this vaccine rollout?

These are all activities where of course ethical analysis, ethical insights, and ethical arguments are clearly helpful in helping us think through these issues, but by no means have they been carved out and saying: "We are going to create an ethics committee to sort these out." But I think it has been recognized that they are unmistakably inseparable from the scientific, clinical, and public health issues that relate to the success of this vaccination program.

For the last point I want to come to the equity concerns, which are part and parcel with allocation and prioritization, but they also raise more cross-cutting issues in terms of how we think about our health care system. We know that COVID-19 has not affected all communities equally. We know that communities, particularly with respect to race, ethnicity, and socioeconomic status, have been particularly severely affected by COVID-19 hospitalizations and deaths. We know the structural disparities in our health care system that help explain some of those inequities, and I think we know from the White House on down that we cannot allow those inequities to be reflected in the ways in which these vaccines are distributed.

We are seeing already frankly troubling signs in cities around the country that show that the disparities we see elsewhere in health care are manifest in who is getting vaccines in these early weeks of the vaccination program. Here is a case where I think there is clear understanding that there is an important problem that cannot be allowed to happen.

There are a lot of strategies to try to address it. There is no single magic bullet for sure to addressing equity in our vaccine access programs, but there is a clear recognition from everyone, from the ethicists to the scientists to the elected officials to the public health officials, that ensuring that our additional effort—the additional programs, the additional initiatives—to make sure that these vaccines reach our historically underserved communities that have lots of barriers—transportation, language, and access—to health interventions is both a public health imperative and a moral imperative, and that's what groups like our state committee is working on. The White House has an Office of Health Equity to try to translate those ideals into action, and I think that will be one of the many arbiters of the success of this vaccination program in the months to come.

With that, I will throw it back to you. Again, I am grateful to be part of this wonderful group this afternoon.

WENDELL WALLACH: Thank you, Jason, and thank all four of you for the breadth of issues you have already raised for us.

Jason, you mentioned the Johnson & Johnson trials which were just announced last week, and I think they have gone today for expedited approval. I also wanted to bring to the attention of those listening in that within a day of that announcement Jonathan Moreno and two of his colleagues already had an analysis of the research findings up on The Hastings Center Bioethics Forum. Again, that is a go-to source for those of you who want really quick responses and quick analysis of some of the latest ethical issues that have arisen.

Before I ask each of you a question I also want to remind those of you who are attending this discussion that we do have a Chat box open for you to put in your questions or comments. That is being monitored by one of my colleagues, and I am going to turn it over to him in another 20 minutes or so.

First, Jonathan, I hate to be expanding this canvas even more broadly, but in much of your previous work you have had a lot to say about national security. Can you make some links between your concerns around national security and pandemic ethics?

JONATHAN MORENO: One of the items I have been thinking about for the last few weeks is the way that we in the United States at least—and maybe this can help to tee off an exchange with Ulf—consider that what falls in the category of a "natural disaster"—this is really for the lawyer in me. Natural disasters, in our system at least, are physical in nature—hurricanes, floods, tsunamis, and earthquakes. Interestingly biological disasters are not considered in our regulatory scheme, in our government scheme, to be natural disasters. I think it is very clear that this is one, and it is very clear that it does have national security implications.

In the early weeks of the pandemic the U.S. military made a number of adjustments that are not well publicized, but one that was identified in March was a decision by the U.S. Army not to let people cycle out on schedule and not to move them around to new deployments because you don't want to move the bodies around if you can avoid it. And messages were sent, I think we can be assured, to U.S. adversaries that we were still focused on the work of defending the nation. So there is no question but that we need I think to take another look at the way in which we integrate worries about public health into our national security system.

Now there is a very powerful objection to that from many political scientists, which is: "Oh, great. Let's just extend the reach of the state now"—this is called "securitization"—"into everything, and let's use a pandemic as an excuse to do that." This is, by the way, part of what I would call the more thoughtful objections to some of the prescriptions of public health officials, in this country at least, and worries about moving into a surveillance state.

I want to say one other thing that I think everybody also has alluded to, and it is going to give me an excuse to get into this and maybe again a kind of trans-Atlantic conversation as well. The fact that the leading government public health official, Dr. Fauci, has played such a bizarre iconic role in this situation—this is somebody I have known somewhat for decades—there is a deeper analysis to be done, and if you will forgive me, public health and politics can't be disentangled. They are both about bodies and how bodies interact.

In the U.S. political system our two political parties, like all parties, are coalitions. In the Republican Party the coalition between commerce-oriented internationalists and social conservatives had held together quite well, partly because of the fact that Ronald Reagan somehow seemed to satisfy both veins in the party.

This I think began to change with the end of the Cold War, when there was not a common enemy to unite those veins of the party, an anti-communist orientation, and you see people like Pat Buchanan and Ann Coulter beginning to appeal to the populist vein.

Nita alluded to the anti-science sentiment or the skepticism of science, and as she says I have written about this. If you think about it, the far-right conservative movement in this country, right populism—there is also left populism in terms of anti-vaccination—which is particularly on our minds now is a reaction to elites.

Let's face it. Academics tend to be on the left. The entertainment industry tends to be on the left in terms of cultural orientation. Technology tends to be on the left, or maybe those people are libertarians. It's hard to tell. And science is seen as an elite institution. Much of it takes place at our elite institutions, the universities, in the United States and Europe.

So I think part of the breakdown we have seen in the last year has been "tearing off the Band-Aid" of something that has been festering for a while, an emerging populism of the right that is skeptical about elite institutions, that feels left out, and that doesn't trust the values that are being transmitted by professors like us to the sons and daughters of America's parents. That I think has manifested itself a little differently in Europe than it has here, but I think it is essential to understand that this is a several decades old shift in the nature of the political coalitions that we call our parties.

WENDELL WALLACH: Thank you ever so much, Jonathan. All of us on this panel are scholars in one form or another, and as scholars we are all aware of the great amount of energy that goes into writing an article, and therefore we are pretty careful which articles we select to write.

Nita, particularly given your breadth of expertise and interest, I am fascinated by the fact that you chose to write one particular article in relationship to the pandemic, called "Proof of Vaccination Will Be Very Valuable and Easy to Abuse." Can you share with us what the intention of that article was and why you chose to focus on it?

NITA FARAHANY: One thing that was pretty clear to me as soon as the vaccination campaign started and as soon as companies and others started to jump on the bandwagon of creating things like digital passports, and of course even earlier in the pandemic as people talked about the concept of immunity passports as people recovered from getting COVID-19, was the potential for abuse of this system.

As Jason discussed in some of the distribution politics and the challenges that we have faced, not just with respect to things like respirators but also with the distribution of the vaccines, the plan that we have come up with with respect to distribution of the vaccines is based on where we are in the pandemic. If we were at a very different point in the pandemic, we might not have chosen to vaccinate the most vulnerable, for example, first. It might have been that to stop the spread of the virus it would make sense to first vaccinate people who are younger and more likely to spread the virus. It reflects the moment that we are in. It doesn't reflect necessarily anything other than that.

As a result, it also doesn't reflect the ways in which the pandemic has affected people socioeconomically. The people who have borne the greatest risk and the greatest impacts socioeconomically are not necessarily the ones who are going to have access to the vaccine anytime soon. In fact, we are seeing quite the opposite. We are seeing lots of people gaming the system even, people who have access to resources or to technology or know how to make appointments quickly or have connections are figuring out ways to get the vaccine sooner.

I wrote that article with a recognition that as people started to see the vaccine rollout and started to have things like—I'll just flash this quickly. This is my vaccine card, which shows that I have been vaccinated because I was part of the Moderna study, as part of the clinical research study, and as an unblinded participant now I know that I received the vaccine. That vaccine card should not be my entry ticket back into society, at least not right now. We do make vaccination an important consideration for things like attending schools and other issues once it is widely available and it has full regulatory approval.

But I was concerned that first it would raise significant equity issues to condition people's reentry into society based on whether or not they had a vaccine card or existing immunity and that jobs and availability of resources, the ability to go to a restaurant, the ability to be able to attend a venue or an outing or a concert, if it relied upon your access to a vaccine card and there is maldistribution already of the vaccines, that that would further create this divide that the pandemic has only exacerbated.

The second is that I worried that there would be a significant risk that people again would misunderstand. One thing that we still do not know the answer to, and there is some evidence on both sides on this, is: What does it mean to be vaccinated for other people? If I'm vaccinated, my risk of severe disease has gone down drastically, but does it mean that I am not going to spread it to other people while I remain asymptomatically potentially infected and able to infect other individuals?

If we reopen society based on this lack of understanding, it would exacerbate these problems I was talking about earlier, undermining public trust but also returning us back to this place that is really based on an individualized ethic rather than a community ethic. My behavior hasn't changed much because the rest of my family isn't vaccinated. My children aren't vaccinated. My husband was also in the Moderna study. He wasn't vaccinated. He was given the placebo. So my behavior is based on the risk to the other people that I can come into contact with. Or my parents, who weren't vaccinated until recently.

The third was creating this black market. Once you start making it contingent for people to gain reentry into society based on things like a vaccine card, you create a significant risk of forgeries, of people who are bartering these types of cards. I think that creates a black market, and that is problematic.

I will just say as a side note: Given that I am so concerned about public trust and transparency, it is important to remember that while there is very good data on these vaccines, it is still limited in time. That is the reason why they have Emergency Use Authorization and not full regulatory approval yet. Requiring people or conditioning participation in society on taking a vaccine that does not have full regulatory approval yet I think further undermines public trust in science and creates a greater degree of mistrust, particularly among the communities where that mistrust has been so deep and so problematic, like minority populations throughout the United States.

I personally wrote that article because I thought: This is a moment in which people are going to make some serious missteps ethically about conditioning participation in society based on vaccination status. I am all for people getting vaccinated if they want to get vaccinated, and I hope that vaccines will be as widely available and accessible to everybody who wants them and for everybody who needs them. But I certainly don't want to make people's ability to participate in society right now, when that is not the case, conditioned on whether or not they have a vaccine card.

WENDELL WALLACH: Great. Wonderful.

Ulf, you have already been primed by Jonathan for some input on the security perspective from Europe, but I also know that you are interested in investigating the origins of the pandemic. I wondered if you could talk about the importance of that and where you see the role of ethics in this.

ULF SCHMIDT: Historians like to go back to the beginning, and I do think at some point, maybe not now but once the dust settles a little bit and once we have recovered mentally and physically from this, it will be necessary to look very closely at how the world got into this position, and I think it will be necessary to look at many levels. We need to look at our regulatory levels, governance levels, how science operates, and I think the scientific community and indeed the public needs to be part of that conversation which will have to happen. This is not just for experts, but I do believe that there will have to be a period of very serious reflection.

I will just give you a couple of examples to illustrate that. I wrote a chapter which I call "The Limits of Altruism," in which I looked at the history of medical ethics over the last 50 to 60 years, and I also looked at some of the commissions operating in the United States since the 1990s. Most of you will be very familiar with those commissions, including the Presidential Commission on Bioethical Studies, which looked at experiments which had been conducted in Guatemala after the Second World War.

As part of this conversation at the time, there was a full review of how research is actually being conducted in the United States, how it is being funded in public institutions, and what do these public institutions actually know about the work they are funding? What was interesting I thought was when they wrote the report—and Jonathan can speak probably much more authoritatively than I can; it was called "Ethics Impossible" if I remember correctly—they made 18 recommendations to public institutions and organizations of what needed to be addressed. Organizations, for example, needed to have an idea where the research is being conducted, on how many people experiments were being conducted, that they had some grasp about it, which they hadn't at the time.

What was interesting is that the people who wrote this report and who submitted it also included a feedback loop. They wanted to know whether these recommendations had actually been implemented. It probably won't surprise you to find out that of these 18 recommendations, only two—which were the softest ones and really not particularly important—were implemented. All the other 16 were ignored. What I am basically trying to say is that we will have to look at how our systems, how our structures and public institutions, actually operate, and whether we are actually willing to take quite a hard look at this.

Coming back to your question about the origins, we will have to have a look at how science is operating. At the moment there is a big debate in the science community about what is called "gain-of-function" research, which some people will be quite familiar with. We will have to look at the scientific communities who were working with viruses over the last 10 to 15 years in laboratories, high-risk research, and actually study it very carefully.

I'm not saying there is a conspiracy here that this virus escaped from a Chinese laboratory, but I do feel that research has to ask difficult questions and that we have to allow for these questions without being pushed into a kind of conspiracy corner.

There will have to be calls for greater transparency, including China, to allow this kind of work to look at this. I think it is just not good enough to simply say: "Oh, this escaped from a cave, and now we are all dealing with the consequences." I do feel that we as a world community should actually have the courage to investigate this without fear or favor and have a look at this in as an objective and even-handed a way as possible once the dust has settled.

This should not be about nationalism. This should not be about a blame game. This should be clearly about trying to understand on the best available evidence which we then have at our disposal to get a reasonably good idea what could have happened because only then will we be able to learn some of the lessons so that this will not happen in the future.

WENDELL WALLACH: There are a lot of lessons to learn.

Jason, you don't claim to be a prophet in any way, shape, or form, but I wonder if you can look at your crystal ball for a moment, and if there are ethical issues related to the vaccine rollout that you see looming on the horizon which have not received widespread public attention yet.

JASON SCHWARTZ: Sure. I will note one or two, not that they aren't issues that aren't already starting to bubble up a bit, but I think we will hear much more about them as our vaccination program expands and continues. I think right now understandably the interest is on capacity, vaccine supply, pace, and speed of course, while also collecting additional data about safety and effectiveness, but I think we are in this stage right now where we are still thinking about those issues in the vaccination program.

Other issues that are already simmering and will gain I think more attention as spring turns to summer and summer turns to fall are: One is touched upon in that piece that Jonathan and Angela Shen, our collaborator, and I wrote for The Hastings Center Bioethics Forum that the Johnson & Johnson vaccine signals but does not quite get at I think what we might be encountering with respect to those interconnected ethics and policy issues as we see additional vaccines that really do look different from one another with respect to their performance.

We don't need to get into the granular details about the Johnson & Johnson vaccine, but, yes, it looks a little different in terms of its overall efficacy, but it does seem to be really protective against the hospitalizations and deaths, so the degree to which this vaccine might be treated differently than the Pfizer or Moderna vaccines I think remains to be seen. But what we are hearing from the Dr. Faucis of the world and elsewhere is that it is seen as another nearly-as-good tool in our vaccine toolkit, and that may be very well how it is deployed.

But it could certainly be the case as we learn more about our existing vaccines and we gather new data about their performance in different populations, we learn more about their ability to prevent transmission, not just disease, and we gain additional vaccines, that we might see some very stark differences that cannot be generalized when we look across vaccines that might raise very difficult questions about how we strategically deploy particular vaccines for particular populations to maximize particular benefits in terms of reducing deaths, mortality, transmission, or if there is a vaccine that does have a rare adverse event.

I think there are going to be these, let's call them "higher order" deployment questions that we are going to encounter just as we learn much more about our existing vaccines as well as those that are being developed and we think about where we are using those vaccines, as Nita said, in the context of what the pandemic looks like at the time. So that is something I am really interested in thinking about and watching and understanding again how the data and the policy and ethics converge as these cascading complexities unfold likely over the coming months. That's one issue.

The second one that is already certainly getting some attention—Nita touched on it as well—is we have to keep very clear focus on the issue of vaccine hesitancy. It isn't getting a lot of attention right now because right now there is this incredible desire that we are seeing from individuals to get vaccines as soon as they can, and we are not able to meet that pent-up demand, and we won't be for some time. But even in our long-term care facilities, where vaccine hesitancy among staff has always been a concern, particularly around flu vaccines, we are seeing it with respect to the rollout of COVID-19 vaccines here in Connecticut and around the country, individuals who have doubts and questions about these vaccines overlaid with the perennial skepticism, hesitancy, and lack of confidence that some members of the public have for vaccines in general.

So I think we need to realize that as this vaccination program goes on, it will not simply be handing out vaccines as quickly as individuals line up to get them. We are going to have to think in very sophisticated ways about the roots of vaccine hesitancy, the kinds of responses that are necessary to resolve concerns or questions around the vaccines, how those need to be tailored to particular communities, and the particular questions and issues they raise.

And from that sort of ethics policy matter we are going to certainly start hearing increasing discussion around measures to ensure high vaccination rates. The one that gets the most attention and generates the most controversy is the role of vaccination requirements, vaccination mandates. You already hear questions sometimes at press conferences to our federal health officials and to our state health officials about: "Will this vaccine be mandated and when and for what groups? For health care workers? For students? For teachers?"

The questions I think will continue to gain attention. It is premature right now. We need to have our supply in order. We need to exhaust our ability to get those vaccines to those who are eagerly pursuing it, but there likely will be a time to reach the vaccination rates that we are aiming for to do a lot of work with hesitancy, and then you will hear much more discussion about the role that school entry requirements or other types of vaccine mandates might play in this long-term pursuit of vaccination goals.

So I am interested in that. I think we will hear much more about both of these in the months ahead.

WENDELL WALLACH: Beautiful.

Before we turn to the questions and comments in the Chat, I want to push all of you to think a little bit beyond Europe and America and our approaches to vaccine distribution. Here at Carnegie Council for Ethics in International Affairs, we have been particularly concerned about the ways in which emerging technologies exacerbate structural inequalities and even create new forms of inequities. Therefore we created this Artificial Intelligence and Equality Initiative.

Now we have this miracle of vaccine creation, and I think all of us do see it as a miracle, not only in the speed at which traditional forms of vaccines are appearing, but here with Moderna and BioNTech-Pfizer we have actually a totally new approach to the development of vaccines, and that turned out to be the quickest approach.

But we also have a rather difficult situation internationally. According to an international consortium of nongovernmental organizations, people in the 70 poorest countries have roughly a 9 or 10 percent chance of getting a vaccine in 2021, whereas America and Europe are looking to having all their citizens vaccinated in this year.

There are these questions about whether people should be jumping the line or not, but I noticed in a conversation with Peter Singer where he actually felt that at least from his utilitarian analysis it might even be acceptable to allow the rich to bid to have early vaccines if the money that they contributed went to ensuring that the poorest among us were vaccinated.

But even in that context, Gavi, which is collecting funding to vaccinate the rest of the world has roughly a $37 billion budget, and it has only been able to raise a fraction of that, even in the midst of an analysis that suggests that there will be a growth of $1 trillion in worldwide productivity, most of it going to the richest nations if we can get everybody vaccinated. I just wondered whether any of you want to comment on that or perhaps have a little discussion about the challenge of distributing vaccines for the rest of the world.

NITA FARAHANY: I'll jump in for a moment just to say this of course is not a new problem. It is a problem that we see particularly acutely right now, but if we were to look at the same issue, which is the distribution of lifesaving medications, this is the problem we have worldwide, which is that there is a significant difference.

One thing I will note that is different here is a recognition that with an infectious disease it is actually problematic and even in the interest of the countries that are likely to vaccinate all of their own to actually figure out a solution to this problem. With other kinds of medications and lifesaving medications, countries have not been well enough incentivized to think about this as a global problem, but in this instance when you see variants that are evading vaccines or substantially reducing the efficacy of the vaccines and we recognize that the biggest reason why the virus is mutating as quickly as it is is because it is a virus left unchecked worldwide, there should be a recognition and a need for collective action that every country should recognize the self-interest even in doing so.

So my hope is that will actually motivate a difference in response than the kind of response that we see generally with the maldistribution of medications, of technology, and of all of the global inequities that we see in healthcare and in the distribution of care. In this instance at least—it is perhaps jaded of me to look at it this way—there is a good incentive for collective action that will lead to a different response I believe in this instance than in every other instance where we have those problems.

WENDELL WALLACH: Does anyone else want to weigh in?

ULF SCHMIDT: I am happy to make a couple of observations. I think particularly on this vaccine debate, there obviously is a lot about it, and as you rightly said it is a very impressive development on the one hand, but I do think we also have to contextualize things a little bit and relativize them.

This is not all about vaccine as a silver bullet. That is not the solution. I think what is most interesting here, and I think again when we look at history and the history of pandemics, what these kinds of "health crises," as we could call them, often do is they exacerbate and throw into relief existing social, economic, and political tensions. They highlight injustices more than anything, and they can in some cases—examples are the cholera epidemic in places in Europe in the 19th century—lead to positive change and improvements.

Just to focus now on vaccines, vaccine distribution, and vaccine effectiveness in a sense would narrow our perspective potentially too far. We need to make sure, I think, to keep the bigger picture in perspective: What actually has this pandemic shown us about our way of living, how we live as a world community or family of nations, how we treat each other? They are fundamental questions about us individually and collectively, how nation-states operate between each other. Nita was saying that.

I cannot emphasize it too strongly. International collaboration and international organizations have been enormously weakened over the last two decades. If you look at the funding of something like the World Health Organization, which is partly funded by the Gates Foundation, on soft money, and partly by nation-states, but if you would look at the actual amount, it is probably less than a day's work of Mr. Bezos. It is pitiful.

It raises questions about whether we as a world community are basically set up for events like that. Those are the bigger questions, and Nita was saying that. We need to look at it in the perspective of access to medicine, access to health care, and I think those are the bigger questions. We need to look at broader questions of inequality and opportunities in education. All those are the bigger questions in which all of this is actually part of the story, and I think we should not forget about it.

The final point is that there are countries in the developing world which actually have responded quite well to the pandemic without enormous resources. Why? Because they have had experiences of epidemics, and they learned lessons from them. Because much of what we are talking about are issues about basic hygiene and basic issues of public health, and these kinds of issues they have learned the lessons to implement quickly. It is not only about resources and vaccination distribution. It is a much bigger issue here which we are addressing when we are actually moving away from just our Western perspective.

WENDELL WALLACH: Let me turn to my colleague, Alex Woodson, who has been monitoring the Chat.

Alex, perhaps you can underscore a few of the points there and see if there are some responses from our panelists.

ALEX WOODSON: We have three questions that I am going to read right now. I think they are mostly things that we have covered but may bring up some new points to finish the discussion.

From David Tsang: "Does the need for vaccination undermine the idea of consent in any sense?"

From Rachel Svetanoff: "What also is going to be a concern is the fraudulence or counterfeiting of vaccines and/or vaccine cards. Has that already been considered in other discussions?"

From Richard Wilson: "Is the WHO up to the task of coordinating vaccine requirements for the Third World? What are the responsibilities for the most developed nations that have the capacity to develop the vaccines?"

WENDELL WALLACH: Jonathan, do you want to come in on that first piece?

JONATHAN MORENO: I will just tell you a story that the late D. A. Henderson told, who was one of the leaders of the WHO smallpox vaccination campaign. The story goes essentially: A team is in the Subcontinent in the 1970s. They are going from house to house. They walk into a home that is presided over by a woman, and there are children. They say, "We need everybody now to hold out their arms and get this jab."

The woman says: "Where's the food?"

"Oh, the food's coming. The food's coming. It'll be here in a few minutes."

There was no food. I think we need to accept that public health at this scale is not necessarily pretty, and the eradication of smallpox, like the fact that we still don't have polio eradicated in some parts of the world—I was in Karachi 15 or 16 years ago and talked to some people from WHO who were going out to some of the tribal areas in Pakistan.

We have to come to grips with this. This is part of what I think we started talking about in this session. Consent issues don't fit neatly into a public health crisis.

WENDELL WALLACH: Nita, Ulf, do you want to jump in here?

ULF SCHMIDT: I can jump in a little. I think it was addressed already. It depends what you are looking at. First of all, for example, historically in East Germany vaccination was compulsory. You had to be vaccinated, and young adults would receive up to 20 vaccinations when they were 18. Even today, as some of our previous speakers said, if you want to go to school, you have to have a certain vaccination in certain places. So actually having the requirement to be vaccinated in certain historical periods and times is not completely unusual in the first instance.

But there is obviously a bigger issue here. If you are making vaccination a requirement for taking part in society, meaning if you want to go to the cinema or if you want to travel on the train, then you are entering into a difficult territory. I think that is where we will have that debate. I think we need to be quite specific about the places and the circumstances in which we might require people to be vaccinated.

Otherwise, I think it is important that people can have the choice to take part in society without having to vaccinate if they do not feel they want to go down that road. I think we need to be very careful here in getting the balance right.

WENDELL WALLACH: Jason or Nita?

NITA FARAHANY: I will just say I agree with that. We have seen in the United States in particular the response to government mandates and government lockdowns, and it has not been pretty. It has not been pretty for a number of reasons, including the lack of public trust, but also that is not the historical approach that this country has taken.

One of the questions I saw in the Chat here is this question: "How does the state response and our knowledge of the pandemic redefine citizenship in America?" It has fundamentally, I think, reshaped the way people see their relationship to the state and the way that they see their relationship to each other. There is probably a renewed understanding of what the federal government can and cannot do and what states can and cannot do and how the variation among states may track much more closely to politics than they do to science.

The result I think is that we do have to tread carefully, to Ulf's point, when we get to the point where we can take a breath from this pandemic, where we can step back and have the luxury of reflection. Right now we are still very much in crisis mode, but when we can have the luxury of reflection that is one of the questions that we fundamentally have to ask: What is the relationship between individuals and states? What is the role of government? What is the role of states versus national coordinated efforts? What are the powers of national governments to be able to enact uniform, potentially liberty-stripping measures that are essential to public health in the common good rather than for the individual good?

We will have that luxury I hope, and when we have that luxury these are all the fundamental questions that we will need to be asking: What is the right balance between individual liberty and autonomy and community ethics and community response in the name of the common good?

JASON SCHWARTZ: Wendell, I will jump in. I don't have anything to add beyond what I said previously on the consent question, but in that series of questions we heard there was one about the global vaccination issue, which I didn't comment on previously, and the question was: "Is WHO up to the task of coordinating vaccines for developing countries?"

I think that is a hard question to answer, and the answer is probably not on their own. As with so many other issues where there have been critiques of the World Health Organization, yes, to some degree that is an indictment of the WHO itself, but it is really an indictment of the global community, the member states who support, who fund, who bankroll, and who give the WHO not just its budget but its mission, its mandate, and its resources. We see the failings in epidemics and pandemics and other health issues around the world where a strong robust World Health Organization I think could be a tremendous asset to efforts and certainly to this vaccination program.

What has emerged in that—I don't want to say a "void" but to supplement what the WHO can't do on its own are absolutely the global health organizations heavily supported by the Bill & Melinda Gates Foundation that are likewise collaborating with this vaccination effort. You can't tell the story of global health without the story of the Gates Foundation, and that raises really interesting profound issues about this question about democratic governance for global health versus a landscape that has the fingerprints of a foundation that is shaping so much of our global health agenda and committing I should say obviously the resources to support that vision.

So we have with this global vaccination effort the consortium—the World Health Organization, Gavi, the global public/private partnership that does tremendous work with childhood vaccines typically, and we have another Gates-supported organization like Gavi, the Coalition for Epidemic Preparedness and Innovation (CEPI) that jointly are supporting this COVAX facility that, Wendell, you noted is trying to be the global coordinating body to procure and deliver vaccine doses, particularly for low and middle-income countries.

But as you have noted the fundraising—meaning the donations from member states, particularly high-income countries—has come below the targets that are clearly needed to vaccinate large numbers of the population in these low and middle-income countries. The estimates for the numbers of individuals that could be reached, just from a supply perspective, not just the distribution issues, are staggering. What the estimates tell us is that we are talking well into 2022 or beyond for the vast majority of residents in low and middle-income countries having access to these vaccines. Of course, think about how that would be acceptable if we heard that from elected leaders in the United States or Western Europe.

So there is a lot of work to be done. Clearly I think this is a case as the questioner asked where there are such strong arguments, whether it is for global solidarity, whether it is self-interest, as Nita noted, and for leadership and contributions from higher-income countries. We are starting to see that. I think the fact that we will see that here in the United States with the Biden administration back in the World Health Organization, joining this COVAX facility, which the prior administration had decided to sit out, are steps in the right direction, but I think that something—and one of those other issues we absolutely need to keep our eyes on because the challenges, the barriers to making this vaccine rollout look anything close to equitable globally are just immense, and we know enough from past experiences to know how short we could fall as this work moves along.

WENDELL WALLACH: Our time unfortunately has just about run out, but we did start a few minutes late. I wonder whether any of the panelists have a last summarizing comment that they would like to make.

JONATHAN MORENO: I like the fact that Ulf ended by mentioning the kids. I know that all three of my fellow panelists have small children at home. Mine are big and out. That is good and bad.

We do need to keep in mind the intergenerational problem, the social, psychological, and emotional effect that this is having. From my colleagues on the panel and other friends I have, I see how hard it is.

I said to my Zoom class last fall, my last remark when we were focusing on the pandemic and other global bioethical issues: "I'm sorry on behalf of my generation. We screwed up."

Wendell, it was your fault as well. We didn't do well, and I think, as all the panelists have said, we need to come to terms with some fundamental mistakes we made and look at them honestly. Since I will go into my dotage imminently, I can afford to do that and take the blows as they come, but we do need to grapple with the fact that we have in so many ways in this particular topic failed the kids.

WENDELL WALLACH: Ulf, Nita, Jason?

Then just let me thank you all in conclusion. This has been really a remarkable and broad-reaching discussion. I think the fact that if we haven't failed the next generation, we will have failed them if we don't act on some of the precipitous issues that have been underscored by this pandemic and will be revealed over the next few years or so, but many of us have been talking about how this is an inflection period in history, whether that is due to climate change, exacerbating inequalities, or the onset of emerging technologies that are radically destabilizing the world as we have known it, we still have this charge of whether we can bequeath the next generation with a world worth living in.

If there is a good side to this pandemic, it has given us a little bit of a timeout to reflect on what we have created and perhaps more importantly underscored some of the truly egregious issues that we have not attended to.

Again, thank you all ever so much.