Herculean Challenges

There is no shortage of issues as the world moves forward to undertake what is the largest mass vaccination effort in history.  Each country has a different protocol, a preferred vaccine, and their own logistical and resource challenges. 

Here in the United States, we have 50 unique state protocols, only two vaccine options available in very limited resources, and widely varying distribution channels.  In Prince Georges, Maryland, the county public health agency is organizing and administering the vaccine. In Titusville, Florida, you get your vaccine at Publix, the grocery store chain. 

The distribution of doses across states and allocation within states is raising legitimate ethical concerns that areas with higher COVID-19 rates and larger populations with underlying health factors are not getting an equitable share of the vaccine. It has been nothing short of a very rough start to the vaccination rollout but still there is optimism as we can see the end of this horrific pandemic and visualize the road to recovery.   

In this spirit of optimism, who expected that this challenge might pull us together? That in these polarized times it might solidify our sense of community, civic obligation, and commitment to a common purpose?  That would not be an unreasonable perspective to have.  We see examples of communities rallying to support public health officials in the distribution of vaccines, reaching out to the vulnerable and those in need, and speaking with a unified message to promote the safety of the vaccine.   

Unfortunately, we are also stunned and perhaps dismayed to hear about the selfish, callous, unethical behavior exhibited by some in our communities.  A paramedic, who cannot legitimately claim ignorance about the potential impact of his actions given his chosen profession, allegedly stole vials of the vaccine entrusted to his care. He reportedly succumbed to pressure by a superior who wanted it for his elderly mother. Shame on his supervisor for creating an ethical dilemma for his direct report.

The principal of a vaccine start-up company admitted on national media that he diverted doses to use for personal distribution. The media reported that he did so on a day when senior citizens who showed up for their appointments were turned away from his venue. A psychiatrist in Kansas was accused of helping friends cut in line by fraudulently vouching that they were her employees and therefore eligible for vaccinations in a phase that covered healthcare workers.

Less attention grabbing but still troublesome are reports of residents “county shopping” in search of an alternative with more availability so that they could procure their vaccine.   Lastly, there are reports that applicants falsified details when registering online in the hopes that when they show up for the vaccine, they would not be denied the shot.

In each case, these individuals are taking something critical that was destined for another person. Most likely someone who has a far greater need.  In what is literally a life and death situation, is that not the very definition of a despicable, unethical act?   Who would do such a thing?  The short answer is that any one of us may be tempted and susceptible. 

Blind Spots

The reality is that we all share the tendency to overestimate our character. There is a gap between how ethical we think we are and how ethical we truly are, and most of us are unaware that the gap exists.   That is the finding of Max Bazerman and Ann Tenbrunsel, two experts in the field of behavioral ethics that seeks to understand how people behave when confronted with real ethical dilemmas.  In their appropriately titled book “Blind Spots” the authors reinforce that we all have blind spots when it comes to making ethical decisions, in part, because we are hardwired to put our personal interests first. “When it comes time to make a decision, our thoughts are dominated by thoughts of how we want to behave; thoughts of how we should behave disappear.” The struggle between “want’ and “should” is constant.

Imagine the intensity of the struggle then when otherwise good, rational people are faced with the opportunity to break the rules and jump the line to get a lifesaving vaccine far in advance of when they thought they could.  

Beyond the danger posed for the individual who is delayed in getting their vaccine because of the unethical conduct of others, if allowed to persist, this conduct will undermine the public’s trust and confidence in the public health system and government.

Four Steps to Building Trust

While many elements of the vaccination process are beyond the control of local government managers, there are four steps that they can take to enhance equity and fairness in the system and perhaps restore the public’s confidence.

1. Lead from the front.  Be the role model for ethical conduct by personally adhering to the protocols as they relate to you and your family. Do not “jump the line” or accept special treatment.  It is true that local governments cannot function effectively without the manager:  you are essential. As is the senior leadership of the organization. That said, if your position and/or personal circumstances do not meet the qualifications for the group designated to be vaccinated, wait until it is your turn.

Reinforce the message with your staff that no one in the organization is entitled to “jump the line.” That will go a long way to offset the informal norms and pressures that exert far more influence on behavior than the rules. Remember that an organization will not act ethically if it lacks a leader who believes in ethical decision making.

2. Emphasize Values. The rules and protocols are so disparate, and the delivery mechanism so flawed at this time, that people lack confidence in the process. Why follow rules if they permit someone else to “jump the line”? Why should I follow rules that allow others in a comparable position to get vaccinated ahead of me? To encourage compliance in the community, focus on messaging that elevates shared values, rather than rules.  A focus on the values that should guide behavior, like the “Golden Rule,"  may serve to elevate the “should” in everyone’s behavior.

3. Adhere to the Rules:  This sounds contrary to the point above but allowing individuals to flaunt the rules will result in more violations and less confidence and trust in the system. If your agency is responsible for administering the vaccine, make sure that your agency has clear standards of proof of eligibility and that your staff know that they are fully empowered to turn away those who are not yet eligible. And that regardless of who challenges the protocols, you will support your staff. Enforcing the protocols reinforces the profession’s commitment to equity and fairness.

4. Fix the Flaws: The limited shelf life of the current vaccine leads us to a false equivalence.   Assume for the moment that you do not meet the criteria for the current tier of people being vaccinated. A meeting takes you to your fire station where county health staff are giving vaccinations to your public safety employees. The station fire chief looks at you and says, “might as well get in line, we had cancellations so have plenty of doses.” What would you do?   

Letting a very scarce, lifesaving commodity go to waste is wrong. But is the ethical choice just to deliver it to whomever is present regardless of need? No. The risk in that approach is that people may rationalize that option rather than resolve the underlying issue. That will in the end lead us to fail in our objective to protect the neediest. Perhaps the first question should be why is there a surplus? And secondly, what is the best approach to address the surplus and achieve our goal?    

Using a data driven approach to enhance their efforts, county health departments are already assessing the “no show” rate and implementing processes to vaccinate qualified residents who signed up for the vaccine.  In Tuscarawas County, Ohio, the health department launched the “No Waste Waitlist” enabling residents who sign up to accelerate their access when surplus vaccines are available. As vaccine distribution evolves, scarcity must be balanced by the overarching need to inoculate those most deserving, not necessarily those most accessible.

Absent a process to logically distribute the day's surplus vaccine, the default for the staff member, especially if he or she is the manager, should not be to step in line. Best to think before acting, in both reflective and analytical ways. Focus on the values that should guide next steps. Do a scan to determine whether there is a senior facility, long-term care facility, school, or similar place where unvaccinated yet qualified recipients may reside. Are there residents who inquired about the vaccine or are known to staff to be qualified perhaps based on age?  If the surplus can't be used for residents, then the manager should scan the organization to determine whether there is a staff member in greater need. Remember the Marine motto: officers eat last.   

Ethical Leadership Matters

The local government profession operates from a foundational set of values dedicated to serving the best interests of all. That includes a commitment to integrity, fairness, and equity in all aspects of service delivery, even in the most dire of emergencies, so that we can merit the trust of those we serve.

In responding to an incident where employees may have inappropriately secured vaccinations outside of the protocols, Doug Thornley, city manager for Reno, Nevada, reminded his staff that “we are guardians of the public trust, and we must protect that trust. We cannot use our positions to take vaccines that, at this stage of the game, are reserved for people most at risk.”