Bioethicists are concerned that a unique type of "black market" will emerge once the country authorizes a vaccine against the novel coronavirus, whereby wealthy and well-connected Americans will essentially "jump the line" to get the vaccine before more at-risk populations, Olivia Goldhill and Nicholas St. Fleur report for STAT News.
How a 'black market' for a coronavirus vaccine could emerge
Goldhill and St. Fleur report that, throughout America's coronavirus epidemic, wealthy and well-connected Americans have managed to get quicker access to coronavirus testing and Covid-19 treatments than many others—even though they may have lower risks of contracting the virus or developing a severe case of Covid-19 than less advantaged populations.
According to Goldhill and St. Fleur, experts expect that trend will continue once the United States has an authorized coronavirus vaccine, with wealthy and well-connected Americans attempting to essentially "jump the line" when it comes to getting priority access to the inoculation via a unique type of black market.
"There absolutely will be a black market," Arthur Caplan, a bioethicist at New York University, said. "Anything that's seen as lifesaving, life-preserving, and that's in short supply creates black markets."
1. Gaming the definition of "essential worker"
According to Goldhill and St. Fleur, essential workers likely will be among the first groups of Americans to qualify for receiving a coronavirus vaccine, but who is considered an "essential worker" is not always clear and can vary by state. As a result, one way some Americans could try to game the system when it comes to getting priority access to a coronavirus vaccine is by claiming that they're an essential worker, even if their jobs don't necessarily place them at increased risk of contracting the new coronavirus, Goldhill and St. Fleur report.
For example, workers in the financial services industry are considered essential workers under guidance issued by the Cybersecurity and Infrastructure Security Agency and under executive orders issued by governors in a number of states. But exactly which jobs in the financial services industry qualify for essential worker status can vary.
Bill Lang, a former White House physician who runs WorldClinic, a high-end concierge medical practice, told Goldhill and St. Fleur, "It was left a little bit nebulous but basically covered people who oil the movement of money, so exchanges, trading floors, trading operations, and people who keep money moving at the retail [banking] level." He noted, "They're defined very broadly in New York and Illinois, because that's where so many of our financial services industries are based."
In a statement, the Colorado Department of Health said that giving essential workers priority for a coronavirus vaccine is intended to provide access to those who perform a critical function in society and can't easily socially distance, but the department added that it's hard to write rules that are airtight.
"Given the thousands of different job descriptions in the state, it is impossible to come up with a complete list for every occupation for a specific vaccine phase," the department said. "Vaccine providers will need to use their best judgment about which patients may qualify for vaccination during this phase."
2. Exaggerating health risks
People at high risk of developing a severe case of Covid-19 also are likely to be among the first groups of Americans who qualify for receiving a coronavirus vaccine, Goldhill and St. Fleur report, and that, too, could create an opportunity for some to game the prioritization system.
For instance, it's possible that some doctors could exaggerate their patients' medical conditions to classify them as high-risk and provide them early access to a vaccine, Jonathan Cushing, head of major projects of the health initiative at Transparency International, told Goldhill and St. Fleur.
In addition, Lang said he doesn't think immunization sites will require documentation of health risks. Instead, sites likely will simply ask patients if they have a condition that places them at high risk, leaving room for patients to falsely claim they have such a condition. Alternatively, immunization sites could require certification of a patient's risks from a physician, leaving "[a] lot … to a doctor's judgment," Lang said.
3. Nefarious activity
Vaccines also could be stolen, Goldhill and St. Fleur report, though that may be difficult given that vaccine shipments will be tracked by GPS.
Still, Alison Bateman-House, a bioethicist at the New York University Grossman School of Medicine, said, "I have a lot of respect for the creativity of criminals. … If someone can see a way to make good money off of driving a pallet of vaccines off in a forklift, I'm sure somebody will figure out how to do it."
It's also possible that vaccine administrators could be bribed into providing early access to a vaccine, especially since local immunization sites typically aren't scrutinized as much as vaccine shipments, Hani Mahmassani, director of the Northwestern University Transportation Center, said. "Once this product is in the hands of the entities that are responsible for vaccination, and that's going to be your, sort of, your local entities, really, anything could happen," Mahmassani added.
4. Using their advantages
But ethicists said Americans don't necessarily have to partake in unscrupulous behavior to get early access to a coronavirus vaccine, because the U.S. health care system generally provides the wealthy and well-connected with preferential treatment.
"When we talk about the concept of individuals being able to get to the front of the line, that's not difficult, because our system is designed to advantage those people with means like that," Glenn Ellis, a visiting scholar at the National Center for Bioethics in Research and Health Care at Tuskegee University and a narrative bioethics fellow at Harvard Medical School, said. "They don't have to really do anything sinister. All they have to do is access the system that they are a part of."
For example, large companies could leverage their connections with health insurers to get access to vaccines, experts said.
"Some of the richest investment firms have their own mini health systems, so they can run vaccines through those doctors that give the physicals and maintain the health of the executives in the company," Caplan explained.
How to prevent line-cutting for a coronavirus vaccine
While vigilantly watching for nefarious activity regarding a coronavirus vaccine is helpful, it comes with its own risks, Lang said. "If you add too many inefficiencies of checking and double-checking everyone, then you put so much bureaucracy into the program, you slow things down," he added.
The potential for public shame if wealthy or well-connected people are caught attempting to get early access to a coronavirus vaccine could work as a deterrent, Bateman-House said.
"I can promise you, no CEO wants to be on the front page of the newspaper for giving preferential access to his college roommate," she said. "I think a few public naming and shamings would probably tamp down some activity."
Along those same lines, Caplan said preferential treatment given to politicians such as President Trump, former New Jersey Gov. Chris Christie (R), and U.S. Secretary of Housing and Urban Development Ben Carson after they contracted the novel coronavirus set a dangerous precedent, suggesting to the public, "[w]ell, that's the way it is." When a vaccine is released, those who try to leverage their wealth or connections should be condemned, Caplan said. "Everybody has to condemn them: the media, your neighbor, your boss, everybody" (Goldhill/St. Fleur, STAT News, 12/3).