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  • Reverend James Squire

The Last Shall Be First

Updated: Feb 13, 2021



Questions loom over us now that the approval of vaccines is on the horizon. We are confronted by a significant bioethical question that matches the difficulty of discovering the vaccines in the first place. Who gets the vaccine first? How is that decided? The Advisory Committee on Immunizations for the CDC set forth a process to answer that question. Ethics has taken a central role in their decision making and contains two ingredients that I have taught my Ethics students over the years. First, we tolerate (not necessarily agree with) that which we understand. Hence, a good deal of the ACIP’s reasoning had to make sense to the rest of us. Two, the people that are most affected by the Pandemic or any other bioethical issue should have the most to say in the decision. The ACIP’s decision was to give voice to those people.


The words of Jesus in Matthew 19:29-30: “The last shall be first.” is at the core of this bioethics decision. “The last” here refers to those who have been the most vulnerable to the disease. Wealth in our country usually has dictated access, and access is a key in bioethics decision making. “Who has access to what we all need and when will we get it?” is the important “driver” of the discussion regarding the distribution of the vaccine.


Currently we are in the final approval stages with AstraZeneca which has the greatest flexibility to be transported and Moderna and Pfizer. ACIP has employed the ethical system of Utilitarian belief to their process. The central guiding principle of that system is the greatest good for the greatest number of people in each group in line for the vaccine as opposed initially to the group being the entire United States.


Currently their phases of ranking are as follows for various groups: The first group to receive the vaccine are the doctors and nurses on the front lines because they are the most vulnerable as well as minorities and those with lower income. Long term care residents would be part of this first wave. The next group would be firefighters, police, educators, food service people, and those who work in the area of energy. This group is placed there because, among the issue of their value, they cannot do their jobs at home. The next would be those with underlying health issues and people who are over the age of 65 and those in congregate settings such as jails, and homeless shelters. Research shows that young adults tend to be the super spreaders so they would follow. Middle Age people in self-contained working situations would be next. The remaining people would follow these categories.


It is important to note how Bioethics is based in Situation Ethics as well, meaning the situation dictates the approach taken. The ethical language applied to the above groups is the Machiavellian Notion of the “ends justifies the means”. The ends in the Pandemic decision making for groups is based in vulnerability and value to the whole nation. The nation becomes the final group as the greatest good for the greatest number in our entire country. “The last defined as those most vulnerable shall be first.”


This is a very different Bioethics decision-making process than what occurred at Memorial Hospital in New Orleans during Hurricane Katrina. Keeping in mind Situation Ethics and how the situation dictates the process, the process at Memorial Hospital divided people into two basic groups with the knowledge that they couldn’t get everyone out of the hospital alive in terms of the time and resources. They chose the patients who they thought had the best chance of surviving to be taken out first. They were the group identified as last with the most likely chance of surviving. The others came next in a group.


I write this post as we are in the midst of another spike of the virus. Already we are seeing hospitals that can’t take all of the patients. Some of the patients could be taken to other facilities, but the fear is that we will run out of space and medical personnel to care for the need. How do you determine who is treated and who is not? That is the kind of question bioethicists have to address. Do you do first come first served, do you look for a precedent that is like this or…? I took a group of 24 faculty From EA to the Penn Center for Bioethics for a two weeks intensive course on bioethical decision making taught by Drs. Caplan and Sisti. After the two weeks I asked the teachers how they felt. Their response was “depressed and stressed” as this kind of decision making is tough. The title of one book, Come Let Us Play God! captures the tension.

We are not done here yet. There are other important issues to address. We know who will have access to the vaccines, but we also know that not everyone will risk taking a vaccine. One group feels that vaccines have been politicized and therefore rushed and inaccurate. Black people are already suspicious of government funded projects because of the Tuskegee Experiment. This was a study of untreated syphilis in African American males sponsored by the U.S. PUBLIC HEALTH SERVICE between 1932 to 1972 to observe the terrible consequences of untreated syphilis. They were told they were getting free health care from the government. As a result of this travesty, laws were introduced where consent had to be given for any further medical treatments or surgeries in our country. That trial is still in the cultural psyche of black people in our country. In addition we have the anti-vaccine groups who are opposed to all vaccines of any kind.


There is one other serious ethical decision that must be made. I have been privileged to travel to many different foreign countries. One thing that you learn as an American is that the United States is not the center of the universe. I talked about utilitarian theory and identifying your group first in the decision-making process. We share one planet. We are one global community. We are one global group. What countries should get the vaccine and in what order? What we will do when that question is raised if we follow Bioethics guidelines is to look at other global health crisis like AIDS, Malaria, Polio, and others. I am of a certain age where I remember getting the polio vaccine in a sugar cube at my elementary school. Precedents should be examined regarding ethical approaches used in the past to address pandemics in the same way that judges and lawyers look at precedents in law cases to make a decision.


In my opinion that would be the best way to start, but we need an ethical guideline for those conversations. I would suggest for consideration the words of the Gospel of Luke: “To whom much is given, much is expected.” That verse is one of the two core values of the Gates Foundation. I would put it simply as, “Those who have much have a moral obligation to those who don’t.” That is what makes human beings different, the ability to be forward looking with moral guidelines to address global challenges. Other primates can’t do that.

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