Priority is Not a Proportional, Fitting, or Fair Return for Vaccination

This article refers to:

Rationing, Responsibility, and Vaccination during COVID-19: A Conceptual Map

Two questions emerge from the target article about reciprocity as a priority principle for health resource allocation: (1) whether we owe people priority for scarce and potentially life-saving health resources as a reciprocal return for their contribution to a common or public good—e.g., accepting vaccination to reduce disease transmission; and (2) whether people who have not contributed to that good—e.g., the unvaccinated—should be deprioritized for those resources as retribution for failing to do their “fair share.” The answer to both of these questions should be “no.”

Park and Davies (2024) note an important distinction between reciprocity both as an instrumental and a non-instrumental value in the context of resource scarcity. As an instrumental value reciprocity might be important to incentivise certain types of behavior. For example, we might try to motivate health care workers to come to work during an infectious disease pandemic by offering them priority for ICU beds or ventilators should they become unwell; similarly we might try to boost vaccation rates by offering the vaccinated that same reciprocal benefit. As a non-instrumental value we ask what is owed to people as a reciprocal return as a matter of justice rather than what it is useful, or desirable, to provide (Fenton 2021).

Lawrence Becker’s non-instrumental account of reciprocity is grounded in the norm that “good be given for good received” (Becker 1986). A distinctive feature of this account is that it does not require that benefits in a reciprocal exchange be roughly equivalent. Rather, a reciprocal return must be “appropriate” in that it sustains a system of reciprocity the goal of which is to maintain “the sort of social equilibrium that makes productive social exchange possible” (Becker 1986, 106). Maintaining this equilibrium requires that reciprocal returns meet two conditions. First, a return must be fitting, that is, it must be something that the recipients will perceive as a return, and as a good. Second, a return must be proportional, that is, sufficient relative to the good received. The goal of proportionality is to produce a “balanced exchange.” These conditions apply both to exchanges between individuals, and exchanges that happen in the context of collective goods, like public health. In this context what is critical is that people contribute their “fair share” to the collective institutions they want to sustain, where a fair share is “a fitting and proportional return for the benefits provided by social institutions we want to sustain through reciprocity” (Becker 1986, 115).

One argument that might follow from this notion of fair shares in the case of vaccination during a pandemic is that those who get vaccinated are contributing their fair share to the collective good of public health, from which we all benefit. On this argument vaccination itself is the reciprocal return for receiving the collective benefit of public health. But those who argue for priority for treatment interventions for the vaccinated go one step further, arguing that reciprocity requires that the vaccinated receive a further benefit in return for doing their “fair share.” It is far from clear that reciprocity requires this, since the vaccinated are already receiving the benefits of a system that protects public health. Certainly this is not an individual benefit—it is not a “tit-for-tat” exchange. Yet on Becker’s view that is not what is required for reciprocity in relation to collective goods. We do not need to reciprocate only for goods that we voluntarily and explicitly accept, but should rather cultivate a disposition to reciprocate in order to sustain collective goods that are critical for human wellbeing, or goods that everyone needs, regardless of whatever else they want (Becker 1986).

So one response to the argument that those who get vaccinated should be given priority for treatment in return is that no further reciprocal return is needed in this case—i.e., a reciprocal return is not owed to the vaccinated as a matter of justice. However, suppose we accept the argument that those who contribute their fair share in this way should receive a reciprocal return for that contribution, we can turn to the further argument that priority for scarce and potentially life-saving resources, such as ICU beds, ventilators, or medical interventions, is an “appropriate” return. I suggest three reasons for why priority for these resources is not an appropriate return.

First, priority for potentially life-saving interventions is not a proportional return for vaccination, nor is depriority a proportional cost for the unvaccinated. This is because the vaccination of any one person is a small, though important, contribution to the collective good of public health or reduced disease transmission. Priority for potentially life-saving interventions, on the other hand, is a disproportionately large benefit, or cost, for an individual to receive, potentially the benefit of life over death, or the cost of death over life. We must also ask, if the vaccinated should be given priority as a reciprocal return for contributing their “fair share” to the collective good of public health, who owes them this return? It could be argued that all the beneficiaries of public health owe them this return, but the people who will actually be making this return are those who are also competing for the scarce resource. It is these people who are making the return by giving up their chance to access the resource. So the vaccinated benefit from the return, but those making the return (everyone who benefits from the collective good) are not the ones paying its costs. Similar arguments can be made about why health care workers should not be prioritized for scarce, potentially life-saving resources (Fenton 2021). Priority is too large of a return relative to the contribution of vaccination, and a disproportionate share of the burden of making that return falls only on some of the people who received the benefits. Priority for scarce resources is not a proportional return for vaccination. In Becker’s terms, it fails to produce a “balanced exchange.”

Second, since vaccination status does not, by itself, determine which health resources a person will need, priority or depriority for those resources is not clearly a fitting return, either for contributing or failing to contribute to the collective good of public health and reduced disease transmission. This is similar to what Park and Davies (2024) call the “proximity condition,” or “which behaviors should count as proper reciprocation, and how closely connected they need to be to the reciprocal result.” The problem in the vaccination case is that it is not always clear whether or how closely vaccination status is connected to the need for the scarce resources. It is at least possible that both vaccinated and unvaccinated individuals might need higher levels of care for reasons that are unconnected to their vaccination status. In these cases, priority or depriority for these resources would not be a fitting return.

Finally, vaccination status is too crude a measure of a person’s contribution to the collective good of public health or reduced disaese transmission to ground reciprocal returns of this magnitude. As others have noted, “people are far more than their vaccination status” (Parker 2022), and may choose to contribute their “fair share” to public health and reduced disease transmission through other actions, such as mask wearing or isolating. In this case, offering priority for scarce resources solely in return for vaccination, or deprioritizing in return for not vaccinating, fails to recognize the extent to which those alternative actions also contribute to the collective good. If vaccination is not the only way in which people can contribute their fair share, then it should not be singled out for reciprocal returns, especially returns that may confer life-saving benefits.

It might be argued that vaccination should be singled out for reciprocal returns because it has greater value as a more effective way to protect public health, or because those who get vaccinated assume a higher level of risk (though still minimal) than those who choose to wear masks or isolate instead. Such value judgements about the worth of people’s contributions are difficult to sustain, however, especially in the face of life-and-death priority determinations. Vaccination status does not capture a person’s worth, nor the risks they may have assumed in order to make a variety of contributions to public health or pandemic response. Resource-allocation principles should not depend on these kinds of value judgements.

Priority and depriority for scarce and potentially life-saving resources might have some instrumental value as tools to increase vaccination rates. But they are not appropriate as returns owed as a matter of justice. To argue that there are reasons of reciprocity, and not merely instrumental reasons, to prioritize the vaccinated because their contribution to public health is more valuable introduces the “arbitrariness and bias” of relative value into potentially life-and-death decision making (Rothstein 2010). Vaccination is itself a reciprocal return we can all make for the benefits of the collective good of public health and protection from infectious disease. It is our “fair share.” But it should not determine whether we live or die.

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