Why It’s So Hard to Choose Who Gets the COVID-19 Vaccinations First

As Canada prepares to ramp up its vaccine rollout, one question looms: Who should be first in line to get the jab? This much is uncontroversial: The elderly living in care homes and front-line healthcare workers should be the first in Canada to get vaccinated. Throughout the pandemic, we’ve heard a lot about the increased risk these groups face, the strain that the medical system would face if many of them were to get infected, and the psychological toll that the pandemic has taken on them. 

There are two reasons why this early consensus has come so easily. The first is that there isn’t any serious doubt about whether these statements are true. The second is that there isn’t any serious disagreement about whether these constitute good reasons for vaccine prioritization. And because these reasons point towards prioritizing the same people, we get to enjoy the luxury of agreement.

But that won’t last forever. We haven’t been faced yet with having to figure out exactly what we mean when we say some group or other “should be prioritized” for vaccination. “Should” can mean a lot of different things. And that makes it hard to answer the question.

As behavioral scientists have been showing for decades, we react quite predictably when faced with a hard or ambiguous question. Instead of answering it, our mind will reach for another question to answer instead, one that’s in the same neighborhood but is much easier for us to answer. This is called “question substitution,” and it’s subconscious.

For example, I don’t know how frequently shark attacks occur. If you ask me, I’ll probably answer a different question: How easily I can bring to mind an example of a shark attack. So, if there’s been a shark attack recently that’s all over the news, I’ll bring this example to mind with ease. I’ll estimate that shark attacks are very frequent. If I’m on my Twitter feed 24/7 reading the latest news about the case, I’ll rate attacks as even more frequent than somebody who just glances at the newspaper casually here and there. This whole process happens subconsciously.

Coming back to vaccine prioritization, figuring out who “should” be prioritized for vaccination is very difficult. Naturally, we’ll reach for other, similar questions we feel more confident about. Some of us will think of whoever is most exposed to the virus. Some of us will think of those who face the most serious outcomes, or whose infection creates the largest challenges for the healthcare system. And some of us think about moral worthiness.

The first signs of disagreement are already visible. Question substitution can help us to understand these disagreements. For instance, Erin O’Toole, the leader of Canada’s federal Conservative Party, criticized the Liberal government for listing some federal inmates among prioritized vaccine recipients. This was not because he disagreed with Justin Trudeau’s assertion that prisoners have a heightened risk of contracting or falling severely ill with COVID. His disagreement was based not on facts, but on values: As he tweeted, it is his opinion that “[n]ot one criminal should be vaccinated ahead of any vulnerable Canadian or frontline health worker.” He’s arguing that a different metric should be applied: moral worth (which, in his view, inmates do not seem to have).

In other words, O’Toole wasn’t saying that Trudeau was wrong about who faces higher exposure risk and vulnerability. He’s saying that Trudeau is answering the wrong question. In this instance, the question substitution is obvious.

Perhaps this kind of analysis could also help us to make headway in discussions about whether racialized Canadians should be offered priority in the vaccine campaign. Some people are critical of prioritization based on race. Is that because they don’t believe that racialized Canadians face higher exposure risks and vulnerability? Or are these critics arguing that exposure and vulnerability are not the relevant questions to be addressing?

Similarly, through the pandemic, we have talked at length about those members of society who have braved great challenges to help us all keep trucking along. They include front-line healthcare workers, long-term care workers, teachers, and early childhood educators. While “the rest of us” have had our normal routines torn to shreds, they have battled on in the face of great adversity. We, meanwhile, have stayed home and had our groceries delivered.

But who is delivering those groceries? Did they just magically appear at our door? Did they collect and bag themselves, coming off self-stocking shelves? Of course not. Somebody had to keep producing, preparing, and packaging the food. It had to be delivered to distribution centres and stores. Shelves had to be stocked. Orders had to be received. Food had to be plucked from the shelves, bagged, queued up for delivery. A driver had to pick it up and bring it to your front door.

Most of this labor is invisible. It matters which stories we tell (and which ones we don’t). This has an impact on what jobs we understand to be “essential,” which workers are viewed as heroic, and, ultimately, who we believe needs to get a spot towards the front of the line. And vaccine prioritization has elements of both practicality as well as justice to consider.

It will be difficult to reach the same solution if we can’t even agree on what question we’re trying to answer. We need to have an open, transparent conversation clarifying precisely what our goals are; we need to ask probing questions. “Are you saying you’re not sure the evidence shows that inoculating teachers (for example) would decrease community transmission? Or are you saying that community transmission is less important than, say, healthcare burden?”

Those are not the kinds of questions we hear in Parliament. They aren’t the kinds of questions that emerge when our politicians telegraph barbs at each other through the media. They aren’t even the kinds of questions that many media representatives ask during the Q&A after a politician provides an update.

We need clarity on what question we’re looking to answer. Currently, there doesn’t seem to be much progress on that front. As a result, question substitution will continue mostly unchecked. We’ll talk right past each other without realizing we’re talking about different things. And social cohesion around vaccination (and the wider pandemic response) will continue to be a point of friction—at a time when we all need to stick together.