“Prepared for questions of this kind”

Alena Buyx is Chair of the German Ethics Council. In November 2020 this panel of experts wrote a position paper on the distribution of the Covid-19 vaccine in Germany together with the Standing Committee on Vaccinations (STIKO) and the German Academy of Sciences Leopoldina. The paper became the foundation for the STIKO recommendations on which the present prioritisation for vaccinations is based.

Professor Buyx, how did the Ethics Council proceed on the subject of prioritisation?

It was a complex process. We examined the relevant constitutional and ethical principles together – in other words, self-determination, damage prevention and welfare – as well as fairness and general legal equality, of course, and in addition to this solidarity and urgency. We applied these principles to the concrete issue and in relation to the available scientific findings. This process led to the general list of priorities.

So STIKO could be said to have done the “fine-tuning”?

Yes, because at that point in time, for example, it was not yet clear which vaccines would be the first to be approved or which people within the healthcare system had the highest risk of infection. STIKO concretised the recommendations against the background of steadily increasing research results. This evaluation is an ongoing process, and new knowledge is constantly being taken into account.

In the paper the Ethics Council also took a stance against compulsory vaccination. Nevertheless, debate continues about whether vaccination should be made the prerequisite, for example, for attendance of events or whether care staff should be obliged to have a vaccination. How do you see this from the ethical perspective?

We rule out general compulsory vaccination in our paper for ethical reasons. With regard to compulsory vaccination in individual areas we say this could be conceivable under very specific circumstances. First, more information has to become available about whether vaccinated people are really no longer able to infect others. Second, making vaccination compulsory would only be thinkable in specific contexts – for example, in places where it would be impossible to protect very vulnerable people by any other means. We will probably need a societal debate in the future on whether vaccinated people should be treated differently from others.

Another debate is currently focusing on Germany’s and the EU’s vaccine procurement policy and the progress of the vaccination campaign in Germany. How do you see this debate?

I’m an impatient person. Things are going too slow for me too. It certainly makes sense to raise questions about how the whole process has progressed and what could have been done better. At the moment, however, I consider it more important to look ahead and to analyse where the bottlenecks are. The fact that there would initially not be enough vaccine was clear – now the distribution of available doses has to be optimised. There is certainly potential for improvement on the technical side – for example, when it comes to the allocation of appointments. It is also crucial that we quickly move on to the next prioritised group when not all of those entitled to receive the vaccine have taken it. Things are running a little bumpily here, and we need a little understanding for that: the situation is totally unprecedented and the learning curve is steep.

You say you are impatient: have you already been vaccinated?

No, but I am counting the days and weeks. The timing will simply depend on when it’s my turn. Although I’m a doctor and employed within the healthcare system, I don’t work directly with patients.

A fair global distribution of the vaccine is also an important topic. Has the Ethics Council also examined the issue?

It was not our immediate subject, but we discussed it because it is a question ethicists cannot overlook. You cannot and must not ignore the fact that people worldwide have been affected by this pandemic. That’s why I consider it important for Germany to show solidarity and contribute to international vaccination initiatives like COVAX as well as working with the World Health Organisation. We can do even more here to ensure that the vaccine swiftly gets to poorer regions too. At the same time Germany and the EU should promptly find a mechanism for immediately passing on over-ordered quantities of vaccine to developing countries.

You and your colleagues are in great demand for medical ethical opinions – initially, the focus was on triage, the prioritisation of patients for treatment, now it is on the distribution of vaccines. Has corona become a kind of touchstone for your discipline?

Your observation is correct, but I wouldn’t speak of a touchstone. Perhaps, unlike people in other disciplines, we were already having thoughts about this subject. I actually wrote a book contribution ten years ago about solidarity during a pandemic. At the time I didn’t think I would ever deal with a real pandemic, but as medical ethicists we have long had to examine questions such as the distribution of scarce resources or balancing the rights of individuals against the needs of the general public. Nevertheless, our discipline is continuing to develop during the pandemic: thinking an issue through in theory is one thing, but it’s a completely different matter when a real pandemic is involved, one that is also negotiated in the public political arena.

Theory can now prove that it also applies in practice…

I have always found the accusation that theory doesn’t take practical problems into account unfair. But, of course, it is true: theory is pure. It is much more logical and therefore also simpler than reality. Nevertheless, reality must also take theory seriously; there is an interaction. And this interaction is what we are now experiencing in real time, and that is quite exceptional.

Alena Buyx became Chair of the German Ethics Council in May 2020; she has been a member of the council since 2016. The physician also holds degrees in philosophy and sociology and has conducted research at Harvard University and University College London, among other places. She has been professor of the ethics of medicine and health technologies at the Technical University of Munich (TUM) since 2018.

© www.deutschland.de