The current state of coronavirus affairs is a little like the famous Trolley problem.
If you’re unaware, here’s the quick version.
There is a runaway trolley and up ahead are five people tied on the track. You are standing some distance off in the train yard, next to a lever. If you pull this lever, the trolley will switch to a different set of tracks. However, there is one person tied on that side track.
You have two options: Do nothing and allow the trolley to kill five people, or pull the lever, diverting the trolley onto the side track where it will kill one.
What is the right thing to do? It’s a problem that has plagued ethicists for decades; there’s no right answer.
In many ways, our governments and health departments are standing in the train yard, with a whole bunch of levers to pull with regards to the coronavirus. But to make matters worse, they’re operating on a foggy day and can barely make out some people on the tracks.
To put you in their shoes, we’re going to walk you through three real coronavirus dilemmas. Ask yourself, if you had the ability to pull the lever, would you?
One dose or two doses?
Let’s say you have two elderly grandparents. And let’s say you have only two doses of the Moderna vaccine — you’ll probably get more, but you’ll have to wait a couple of months.
The dilemma: Do you vaccinate grandpa and schedule his second dose as recommended in four weeks, or do you vaccinate both grandpa and grandma with one dose now and hope to schedule their second doses down the road?
You know the Food and Drug Administration’s recommendation is to give one grandparent two doses, about four weeks apart. That’s because the trials for the vaccine all were with a two-dose regimen — those are the results that have been peer-reviewed and confirmed. Those trials showed that the Moderna vaccine was 94.1% effective; really darn good.
And yet, there’s a tantalizing subset of the data involving those who had only one shot. In that subset, there were 39 coronavirus cases in the placebo group, and only seven in the vaccine group. That would mean the first dose was 80% effective, all by itself.
It makes sense to take the 80% odds of keeping both grandma and grandpa healthy instead of the 94% chance of keeping one healthy, right?
There are problems, though. First, that’s not a very big sample size. Also, the competing vaccine from Pfizer using a similar technology has data showing the first dose was 52% effective by itself. And there’s a possibility even that level of effectiveness would decline, lending to a false sense of security.
And then there’s worry about mutations. What if the halfway-effective vaccine means millions of grandparents have pretty weak antibodies against the virus — not enough to kill all of it, but enough to give the virus a better chance to mutate rapidly to avoid the vaccine? If such a new variant spread, we might have to develop a whole new vaccine.
But wait! As grandma pushes to be vaccinated at the same time as grandpa, she raises some good points. These mutations might be more of a product of how long the pandemic is lasting than immune system strength, but we really don’t have great data on this with regards to coronaviruses. Antibodies after weak infections last for months, so it is probably true that the weak vaccination antibodies would last for months, too.
And, well, grandma doesn’t want to reenact the devastating first 10 minutes of Pixar’s “Up.” Grandma wants to stay healthy now, too.
The United Kingdom has made the move to one dose over two, leading to real questions now for state and federal lawmakers. But the U.S. is not making that move, and officials from the Utah Department of Health say while they’ve been following the situation in the U.K., “They have not made any decisions to adopt a similar approach, and would not without some sort of consensus or direction at the national level.”
So if it was up to you, what would we do?
Save lives or stop spread?
Let’s say you’re a doctor with one dose of the vaccine on hand, and you’re pretty sure you’ll get a second dose in four weeks. In your waiting room are two patients:
• One is relatively healthy 85-year-old man. He lives at home with his wife of a similar age, but they don’t get out often. His son calls a couple of times a week but rarely stops by. They get groceries delivered. If he got the coronavirus, the odds of him dying are roughly 10%.
• The other is a relatively healthy 35-year-old college professor. She teaches math to about 250 total students — two large seminars in a big hall with about 100 students, and to two smaller seminars with about 25. She is unlikely to die — her odds are about 1 in 10,000 — if she contracted the virus. But, thanks to her teaching job and the way she has to shout to make sure those in the back of her class can hear her, she could be a superspreader.
The dilemma: Do you give the vaccine to the elderly man or the college professor?
There are two goals of the vaccine: to prevent death and to prevent the spread of the virus. These goals are sometimes, but not always, aligned.
This is a debate about 30 Utahns are having right now with consequences for all of us. Already, the Health Department’s prioritization advisory group has decided to move from an approach focused on essential workers (in our case, the professor) to prioritizing those over 75 over (hi, grandpa!). Now, they’re discussing more how to prioritize the vaccine within those groups.
Back to our hypothetical.
Giving the vaccine to the elderly man is more likely to directly prevent a death. But the ongoing chain of coronavirus infections caused by one college professor might end up creating more risk of death down the road, if the virus spreads from the professor to her students, and then to their family members, multiplying each time.
Or perhaps it won’t — maybe the professor’s most contagious period, right before her symptoms begin, will fall on a weekend. Mask-wearing changes the math, too. But we don’t know what kind of mask the woman wears, and that can have a huge impact.
There are also lots of complications due to COVID-19 to consider, for both the elderly man and the college classes. What is the likelihood of hospitalization, or of long-COVID symptoms? How many hours of work or school will be missed due to quarantining? And what impact will sitting out have on these students’ education?
Of course, you can replace the college professor with any number of professions, from:
• Those who work in jails, homeless shelters, hotels, youth centers, etc.
• Postal workers, grocery store clerks, fast-food employees, bank tellers, and many more in the service industry.
• Those who were willing to risk their health to be a part of the scientific trials for the vaccine, only to get a placebo.
If you were on Utah’s vaccine committee, whom would you argue to prioritize?
Which activities will require vaccination?
Let’s say our 85-year old grandpa doesn’t drive anymore, instead he uses public transit. He’s already been vaccinated long ago, but he knows his vaccine is only 90% effective. And he knows there’s a 10% chance that if he contracts COVID-19, he will die. Combine the odds, and if he takes a seat on the bus next to someone with the virus, there’s about a 1 in 100 chance he will die.
He knows there’s a big anti-vaccine crowd and the virus is still getting passed around, probably will be for years. So under the thinking that he shouldn’t have to face the odds of death similar to skydiving 2,000 times in a row in order to leave his home, he asks the transit agency to impose rules.
The dilemma: How far should the government go to keep grandpa safe?
Requiring people to prove they are vaccinated isn’t exactly new: Many African countries require you be vaccinated for yellow fever before visiting, and all U.S. states have vaccination requirements for attending schools. But it is new for most U.S. adults, and there are real ethical questions.
Enacting vaccination passports serves to protect the health of those who are vaccinated, and limits the rights of those who aren’t. So midway through a public vaccination process, how many rights are reasonable to restrict? Is there a right to fly on an airplane or ride that bus? Should vaccination be required for certain jobs, or to attend a concert or sporting event?
How fair would it be to restrict access depending on people’s status in a vaccination queue they have no control over? Knowing the world, that probably creates a black market for vaccinations, or simpler, fake vaccination IDs.
On the other hand, it’s also not super fair to restrict access to a full life for those who have already had a vaccine?
And even once the vaccinations have been administered to all who want one, there are still concerns. Look around, a huge group of people aren’t going to react responsibly to being restricted. They aren’t acting especially responsibly in the pandemic’s peak. Giving police responsibility to check vaccination status is a recipe for stop-and-frisking, which has been used in discriminatory ways. Also, how do you track vaccination status?
It’s possible that governments will largely just bypass these questions by doing very little either way; this has been a consistent theme of the American response to the pandemic. A proposal in Utah would ban the government from requiring vaccines, but would let companies do it.
And some companies will. The CEO of Australian airline Qantas has said that the company will require passengers to be vaccinated, and that he expects other airlines to follow suit. Delta has an agreement with Italy on special flights from the U.S. that require four separate negative coronavirus tests; once the vaccine arrives, it’s easy to imagine them swapping that out for proof of vaccination.
So if you were in charge what, if any limits, would you impose on those who haven’t been vaccinated?
With all of these dilemmas, there’s one thing we know: Anyone who tells you that the answer is a no-brainer isn’t to be trusted. These are hard decisions in a field that we have limited data and experience in — we can make guesses as to what would happen if we gave one dose instead of two, or the vaccine to one group or another, or required proof of immunization for various activities, but we don’t know what would happen. And yet, decisions must be made.
Now, it’s time to squint through the fog as best as possible. You’re standing in a train yard, next to a box full of levers. Which ones do you pull?
Andy Larsen is a data columnist. He is also one of The Salt Lake Tribune’s Utah Jazz beat writers. You can reach him at firstname.lastname@example.org.