It's probably not controversial to put health care workers treating COVID-19 patients at the front of the line for the new coronavirus vaccine, but after they and long-term care residents are immunized, there are many questions about how to prioritize who's next.

How does one prioritize within certain groups? Should the focus be on saving the most lives, or on saving the most aggregate years of life? Should people of color be prioritized because they've had worse health outcomes from the coronavirus? Should people given a placebo in the trials be next?

Those following vaccine news may have started thinking about some of these questions recently, but the principles behind them are ones bioethicists and philosophers of science have considered for much longer.

Vaccination plans are being made at the state level. Connecticut's draft plan has health care personnel, long-term care facility residents, and medical first responders getting the vaccine as soon as it's available. From January to May will be critical workforce, other congregate settings, adults over 65, and high-risk individuals under 65, and then everyone else.

Dr. Benjamin Tolchin, a neurologist and co-chair of the Adult Ethics Committee at Yale New Haven Hospital, said when it comes to allocating resources, a primary guiding principle is saving the most lives with the resources available. But that's not the only ethical principle to consider: Another is equality, considering the pandemic has laid bare many health inequities.

"That might be in conflict with saving the most lives, or it might be compatible with saving the most lives. In the case of the vaccine, it seems very compatible," Tolchin said.

He said that during the pandemic, a lot of ethicists favor trying to save the most lives over the most total years of life. One reason is the uncertainty of forecasting into the future.

Another reason, Tolchin said, is that people of lower socioeconomic status, people of color, and people with disabilities might have lower life expectancy, meaning that allocating resources based on life years saved could end up directing resources to white, wealthy, able-bodied folks.

With therapeutics for those who have contracted COVID-19, "you're seeing a number of prominent politicians and people affiliated with prominent politicians who are, in unclear ways, being bumped to the front of the line for what is a very scarce resource," Tolchin said. He hopes that doesn't happen with the vaccine, saying this is part of the reason why it's "very important to have a very clear, pre-specified protocol."

Beyond questions of allocation, there are also ethical considerations around mandating or just incentivizing people to get the vaccine. Tolchin is concerned about backlash to either.

He said he never could've predicted that mask-wearing and social distancing would become a politically contentious issue, and he's "terrified by the possibility that vaccination could become a similarly contentious issue," where there's a perception that "evil elites" are trying to force or pressure people to take the vaccine.

Audrey Chapman, a professor in the Division of Public Health Law and Bioethics at UConn School of Medicine, thinks there may be an ethical rationale to incentivize taking the vaccine for frontline workers in places where it's not possible to keep a safe distance, such as teachers, but maybe not for other groups.

She believes there's an ethical requirement to prioritize people of color for the vaccine, but she doesn't see that happening due to worries of lawsuits. A criterion she's heard discussed that she doesn't think would lead to as many lawsuits is the degree of disadvantage of particular geographic areas.

Chapman said other disagreements include which groups of frontline workers should go before other frontline workers, and how to treat incarcerated people.

In an email response to written questions, Meg Levvis — professor of nursing at Central Connecticut State University and a bioethics consultant for health care institutions — explained the utilitarian and non-utilitarian concerns driving decisions on vaccine distribution.

"We do not (and should not) apply some sort of quantitative, social worth calculus to the problem," she wrote. For example, Levvis said it would be discriminatory to ignore the high level of risk among nursing home residents, incarcerated people or others in congregate settings "on the basis of biases or unfounded stereotypes concerning their supposed social worth."

Levvis she would give priority to health care workers and then to "essential" workers who are at high risk of transmitting the virus and provide an important service, meaning first responders, law enforcement, and teachers.

She noted that health care workers are essential to everyone's survival and are at high risk of contracting the disease, but they should also be prioritized based on "respect for their dignity and humanity."

"We have to remember they are not merely cogs in a machine but human beings working under dehumanizing conditions in which they are assailed on the street by virus-deniers while enduring the day-to-day trauma of caring for dying patients," Levvis wrote.

"These questions are just so extraordinarily difficult"

As professors of philosophy at Connecticut College, Lindsay Crawford and Derek Turner approach ethical considerations from a philosophical rather than a practical perspective, posing a lot of questions but not taking a side.

"These questions are just so extraordinarily difficult," said Crawford, who is teaching bioethics in the spring. She also noted, "Philosophers tend to be reluctant in giving hard and fast answers; we like to just think about what people might give as an answer."

Turner, whose specializations include philosophy of science and who taught bioethics in the past, said in a separate conversation, "We don't have well worked out, uncontroversial theory that tells us how to balance things like this. There are theories that people study in intro to philosophy classes, utilitarianism and so on, and there are people who work on these questions, but it's just really, really hard."

Crawford noted that when thinking about allocating ventilators, if needed, the primary benefit goes to the recipient alone, but vaccine distribution also involves considering whose lives would be saved by preventing viral spread.

Another question is how to prioritize vaccine order within a particular group. Crawford said the thought behind a lottery system within a group is that nobody's life is more important, but she said this fails to recognize disparities within the group.

She said another question is whether people given a placebo in vaccine trials should be prioritized "on the grounds that they undertook a significant risk, for the benefit of others," even though they may not necessarily be the ones most likely to reduce viral spread if vaccinated.

Turner raised the same issue, asking whether they should get vaccinated now or if studies should continue so we can learn more.

Pointing to communities of color, Turner also questioned, "Should we prioritize communities who've experienced injustice in the past? Should they be towards the front of the line?"

But for as much discussion as there is about this concept, Turner noted there's also a high level of mistrust of the medical establishment in some communities of color, understandable given the history. This means some people who ethicists and philosophers think should be prioritized may be less likely to want to get the vaccine.

Among 12,648 U.S. adults Pew Research surveyed from Nov. 18 to 29, 42% of Black Americans said they would definitely or probably get the vaccine if it were available today, compared to  61% of White adults, 63% of Hispanic people, and 83% of Asian-Americans.

e.moser@theday.com