Ethical allocation of scarce vaccine doses: The Priority-Equality protocol

BACKGROUND: Whenever vaccines for a new pandemic or widespread epidemic are developed, demand greatly exceeds the available supply of vaccine doses in the crucial, initial phases of vaccination. Rationing protocols must then fulfill a number of ethical principles balancing equal treatment of individuals and prioritization of at-risk and instrumental subpopulations. For COVID-19, actual rationing methods used a territory-based first allocation stage based on proportionality to population size, followed by locally-implemented prioritization rules. The results of this procedure have been argued to be ethically problematic. METHODS: We use a formal-analytical approach arising from the mathematical social sciences which allows to investigate whether any allocation methods (known or unknown) fulfill a combination of (ethical) desiderata and, if so, how they are formulated algorithmically. RESULTS: Strikingly, we find that there exists one and only one method that allows to treat people equally while giving priority to those who are worse off. We identify this method down to the algorithmic level and show that it is easily implementable and it exhibits additional, desirable properties. In contrast, we show that the procedures used during the COVID-19 pandemic violate both principles. CONCLUSIONS: Our research delivers an actual algorithm that is readily applicable and improves upon previous ones. Since our axiomatic approach shows that any other algorithm would either fail to treat people equally or fail to prioritize those who are worse off, we conclude that ethical principles dictate the adoption of this algorithm as a standard for the COVID-19 or any other comparable vaccination campaigns.