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Covid-19 vaccine boosters continue to stir controversy as most of the world seeks a first dose, not to mention the intense debate over the scientific evidence for their need and timing. Meanwhile, individuals are also grappling with ethical questions. We asked STAT readers if they had qualms about getting an extra dose before others had their first, and whether they thought their individual decisions mattered. A snapshot of the more than 400 survey responses to boosters now versus the rest of the world first:

  • “Better in my arm than in the trash.”
  • “I do not want to jump the line.”
  • “If I don’t take it, it’s not like it’ll be shipped to India.”
  • “Do both!”

Late last month, when we invited readers to tell us their thoughts on getting another dose beyond one Johnson & Johnson shot or two doses of Moderna or Pfizer’s mRNA vaccine, U.S. health officials had just recommended extra doses of Covid vaccine following their review of evidence that vaccine protection is waning (a Food and Drug Administration advisory panel meets next week on Pfizer’s booster).

At the same juncture, global health leaders, notably the World Health Organization’s Mike Ryan, opposed offering boosters before first doses have reached more people around the world. Ryan struck a chord with this comparison: “We’re planning to hand out extra life jackets to people who already have life jackets, while we’re leaving other people to drown without a single life jacket.”

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In the several weeks since, like so much during the pandemic, the ground has begun to shift. Acting FDA Commissioner Janet Woodcock and Rochelle Walensky, director of the Centers for Disease Control and Prevention, advised the White House last week to go slow on boosters — except for people with weakened immunity — and WHO Director-General Tedros Adhanom Ghebreyesus this week implored richer nations to halt boosters until the end of the year so lower-income countries could get their shots. For example, only a little more than 3% of people in Africa are fully vaccinated.

While many readers have concerns about the ethics of people in wealthy nations receiving boosters amid global vaccine supply inequities, even more think the shot they might score doesn’t take away one from another person half a world away might get. A few have doubts about rolling up their sleeves again, given the currently limited science behind boosters.

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Polio is still a vivid memory for some readers, who endorse the booster strategy as one familiar to them from years past.

People who work in health care are eager to get more protection, especially those who are also hoping to shield their children or other vulnerable loved ones from possible infection.

  • “I’d like to not die while taking care of patients.”
  • “I’m an R.N. and I not only believe science, I follow the evidence. I have no desire to play Russian Roulette with my life (or the lives of others). Fed up to the eyeballs with the folks who have no good reason to decline vaccines.”
  • “I’m currently a resident physician at Texas Children’s in Houston working ER shifts. I live with a breast cancer survivor and with a toddler. I think a booster would diminish my likelihood of having even mild disease and make me less transmissible if I got it. … I would gladly take a booster to decrease the likelihood of having disease, even though I would support a policy stance of not offering boosters until more of the world was vaccinated.”

Others picked up Ryan’s life jacket analogy.

  • “This is not a moral issue with me — simply a biological one. The life jacket analogy didn’t ‘float’ for me. … Closing the door to our own citizens in some altruistic attempt to be ‘loved’ by the rest of the world doesn’t work for me.”
  • “Instead of the analogy of giving people a second life jacket, a better analogy is that we are shooting ourselves in the foot — forcing the non-vaccinated world to continue evolving ever-more-dangerous variants that can come back to haunt us.”
  • “Offering booster shoots is like putting a patch on a life jacket that is rapidly deflating.”

In sum, the responses were too nuanced to tally as yeas and nays for boosters, befitting a less than black-and-white question. Roughly speaking, more than one-quarter had qualms of any kind and nearly three-fifths had zero qualms, leaving one-twelfth somewhere in between.

More than a few readers invoked the airline safety message to don your oxygen mask first so you can help others, as in diminishing the spread of the coronavirus and future variants. “We need our own house more or less in order so that we have the energy and money to help those who are less fortunate,” one reader said.

Nancy Berlinger, a bioethicist and research scholar at The Hastings Center in New York, listed three reasons for feeling morally uncertain about getting a booster: evidence, global justice, and equity.

“Does it matter if the evidence shows that a fully vaccinated, healthy, middle-aged person needs a booster to remain fully vaccinated? Sure, that would matter to me and it would matter to the community that I’m part of,” Berlinger told STAT in an interview. “But first, show me the data, focus on vaccine justice for poor nations, and vaccinate my 87-year-old mother before me. Those are the things that ethically matter.”

She’s also concerned about public health messaging in the U.S. that pushes boosters for all ahead of data, while in her view, strategies here need to focus on unvaccinated populations. And then there’s the rest of the world.

“We must commit our vast resources to helping poor nations protect their citizens from preventable illness and death. That’s the ‘pan’ part of ‘pandemic.’ This is a moral and ethical imperative,” Berlinger said. “I know people have said I can’t take my booster and mail it to somebody in the developing world, but we can keep articulating this as an issue.”

Turning to Singapore, which is beginning to roll out boosters for some groups, Owen Schaefer, a biomedical ethicist at the Yong Loo Lin School of Medicine at the National University of Singapore, told STAT in an interview that as a matter of public policy, large-scale booster campaigns are unethical at this time given the scarcity of vaccine supply around the world, leading to thousands of easily preventable deaths. Last fall, he and co-authors of a commentary in Science outlined an ethical framework for allocating scarce vaccines based on what they called fair priority.

“However, what is right or wrong for an individual to do is different from what is right or wrong for a country to do,” he said. “If you refuse a booster vaccine, that dose is very unlikely to be sent abroad instead. So, it is not unethical to accept a booster shot when offered.”

For people who are concerned about the global implications of booster campaigns, Schaefer recommended they consider taking political action. “If it becomes evident that people see booster campaigns as excessive and unjust, public policy may shift to better address global vaccine inequity.”

Craig Klugman, a bioethicist at DePaul University, does not plan to get a booster shot, he said in response to STAT’s survey. “As a professor of bioethics, I agree with the WHO that giving boosters when so much of the world has not had any violates justice with the exception of those at-risk.”

Some readers who are immunocompromised — from an organ transplant, cancer, or another condition — differ on what they’ll do.

  • “I am a 65-year-old woman with a number of comorbidities, so a booster would be reassuring. But I would be willing to wait if it means more people can get vaccines, especially in poor countries.”
  • “For me with no antibodies and the Delta variant running riot, l don’t feel I had a choice.”

The conflicted and the nonconflicted readers explained why.

  • “I’m extremely conflicted about it seeing the lines of people waiting for doses in Africa and Asia. I want these people to be protected, and selfishly, unvaccinated people grouped together anywhere in the world is a threat to me because this is how variants are created and spread.”
  • “It’s not as if the booster I decline in Louisiana will be sent to someone else who needs it more. But by taking it, I participate in something that I think is ethically wrong but that my refusal to participate also wouldn’t do anything to remedy.”
  • “I think it matters a lot more that people in countries that can’t afford much vaccine are given it by countries, above all ours and the U.K., whose wealth has in fact been extracted from them, now and/or in the past.”
  • “I think vaccines should be widely available before thinking about extra doses. On the other hand, in Uruguay we got Sinovac vaccine, that doesn’t have great response, so I understand the need for boosters.”

Other readers think it’s a false trade-off to pose the question as rich versus low-income countries. Instead, they point to people who choose not to get vaccinated.

  • “We are in the position we are in now NOT because of people who have received full vaccine doses. We are in this position because of the large number of Americans who won’t get vaccinated at all. If they had all done so by July, we may have been able to keep the Delta variant from gaining such a foothold in the U.S. and could collectively turn to help lower resourced countries.”
  • “I think it is disgusting that the US (and other wealthy countries) has not done more to get doses to poorer countries, even while we sit on a surplus of vaccines that some members of our own population refuse to get.”

One reader suggests we can have it both ways: “First, it’s my government’s responsibility to protect its citizens first, the rest of the world second. Second, it’s a false choice. We can do both, we just have to be willing to spend the money and engage the resources.”

One last question: What should our next survey ask? Let me know at [email protected].

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