Internists Support Framework for the Ethical Allocation of COVID-19 and Other Vaccines During Pandemic

Philadelphia, PA (Nov. 24, 2020) – In a new policy statement, the American College of Physicians (ACP) recommends a framework for the ethical and phased allocation of vaccines to the U.S. population to slow down and prevent the spread of COVID-19, recognizing that vaccine supplies will be limited and may have varying levels of effectiveness in different populations. In Ethical Allocation of Vaccines During Pandemics Including COVID-19, ACP supports many of the conclusions of a report from the National Academies of Sciences, Engineering and Medicine (NASEM), and says that allocation of vaccines must maximize saving those most likely to become severely ill or die without the vaccine. ACP agrees with NASEM that mitigating health inequities is a moral imperative of an equitable vaccine allocation framework. ACP also supports points made thus far by the Advisory Committee on Immunization Practices (ACIP) that a vaccine implementation strategy should be as simple as possible, maximize efficiency, minimize overly burdensome or restrictive eligibility screening policies, and be flexible yet specific enough to provide guidance.

Specifically, ACP:

  • Supports many of the conclusions of the NASEM report, Framework for Equitable Allocation of COVID-19 Vaccine, proposing a phased allocation of vaccines, agreeing with NASEM that within each phase, all groups have equal priority, and that equity is a crosscutting consideration. ACP recommends that ACIP and the Centers for Disease Control and Prevention (CDC) adopt the following phased allocation of vaccines which includes NASEM recommendations and ACP modifications:

Phase 1a

  •  High-risk health care workers in direct patient care, including trainees and workers in nursing homes, home health care and health care facility services
  • First responders

Phase 1b

  • Persons (all ages) with 2 or more underlying health conditions (as listed by CDC) putting them at significantly higher risk of severe illness or death from COVID-19
  • Older adults and individuals with disabilities of all ages living in congregate settings such as skilled nursing and long-term care facilities, prisons and group homes, and in multi-generational households
  • If availability of vaccine allows for it, individuals age 65 and older not already included

Phase 2

  • K-12 teachers and school staff; child care workers
  • Other critical workers in high-risk settings such as public transit and food supply
  • Persons (all ages) with 1 underlying health condition (as listed by CDC) putting them at moderately higher risk
  • Persons and staff in homeless shelters, group homes, prisons, jails and detention centers not included in Phase 1
  • All individuals age 65 and older not in Phase 1
  • If availability of vaccine allows for it, family caregivers of those age 65 and older

Phase 3

  • Young adults
  • Children
  • Critical workers at increased risk of exposure not included in Phases 1 and 2

Phase 4

  • All other individuals living in the US

Additionally, ACP:

  • States that in allocating treatment resources, maximizing benefit means prioritizing those most likely to survive; but in allocating preventive services, maximizing benefit means prioritizing those most likely to become severely sick or die. Moreover, receiving a vaccine benefits both the individual and the public’s health.

  • Agrees with the NASEM report’s statements on the values of maximum benefit, equal concern, and mitigation of health equities. However, ACP differs on some of the report’s assumptions and rationale, broadening and deepening the set of ethical principles to include respect for autonomy, beneficence, nonmaleficence, and justice.  ACP asserts that the application of our framework’s principles—but not the principles themselves—may change as more scientific evidence becomes available. Earlier this year, ACP released Non-Discrimination in the Stewardship and Allocation of Resources During Health System Catastrophes Including COVID-19, which emphasized the need for fairness and equality and the application of ethical principles in the allocation of treatment resources during the COVID-19 health crisis.

  • Says that promoting equity and non-discrimination is essential, and does not support proposals that discriminate against the elderly, persons with disabilities, or minorities or other groups.  ACP says that allocation of vaccines must maximize saving those most likely to die without the vaccine, not the number of “life-years,” which is inherently biased against the elderly and the disabled. The physician’s duty to care for all prohibits discrimination against classes or categories of patients. The NASEM/ACP approach aligns with the crosscutting consideration of equity, but may require special outreach and engagement efforts to promote trust in the vaccine and its use among vulnerable or marginalized groups.

  • Recommends strategies to reduce virus transmission that will remain necessary until effective vaccines have been widely administered, including maintaining physical distance, wearing face coverings such as surgical or cloth masks in setting where physical distancing is not possible, appropriate mask use, self-isolation, quarantine, frequent hand hygiene, covering cough and sneezes using bent elbow or tissue, refraining from touching the face and frequent disinfection of frequently touched surfaces.

  • “This framework is meant to provide fundamental ethical guidance to assist in the equitable allocation of COVID-19 vaccines,” said Jacqueline W. Fincher, MD, MACP, president, ACP. “Vaccine allocation must be based in ethics. We must be patient-centered and also protect the public health, first ensuring that clinicians, other health care professionals and the health care system can care for patients and do so without exposing them to the virus, and then vaccinating and protecting those individuals most likely to become severely ill or die.”


    About the American College of Physicians

    The American College of Physicians is the largest medical specialty organization in the United States with members in more than 145 countries worldwide. ACP membership includes 163,000 internal medicine physicians (internists), related subspecialists, and medical students. Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. Follow ACP on Twitter, Facebook, and Instagram.

    Contact: Andrew Hachadorian, (215) 351-2514​,