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A vaccine honor code will work

The moral compass of most people — even powerful people accustomed to certain advantages — will point in the right direction.

A pharmacist administers a dose of the Pfizer-BioNTech COVID-19 vaccine at a nursing home in Brooklyn, on Jan. 5.Eric Lee/Bloomberg

The COVID-19 vaccines are here, but supplies are scarce and the rollout is painfully slow. In these conditions, the vaccines need to be distributed fairly and effectively, prioritizing groups based on age, medical condition, residence in group settings, or occupation. But the fairness and speed of the system depend in part on how vaccinators verify a person’s membership in these groups. Once the vaccines are distributed to the initial priority group of health care workers, will someone seeking the vaccine be asked to provide identification? Proof of employment as a high-risk front-line worker? Proof of certain medical conditions?

Such bureaucratic requirements will deter many people who critically need to be reached: those without identification, those who are hesitant about vaccination, undocumented immigrants, people with undiagnosed conditions, people with no relationship to a health system, and others on the margins in a variety of ways. Erecting a paperwork barrier will impede the rollout both operationally and ethically.

A simpler approach based on trust and empathy is called self-attestation, essentially an honor code for vaccine distribution. Vaccinators simply ask people seeking the vaccine to attest that they fall into a priority group. If they attest, they’re vaccinated. New York state just began using a simple self-attestation form for vaccine seekers. This approach minimizes the barriers to access, increases the efficiency of the entire system, and leads to less virus in circulation and a faster end to the pandemic.


This approach has worked well in other public health efforts. In the 2009 flu vaccine rollout, for example, a homeless population successfully self-attested to not having Guillain-Barré syndrome or allergies to eggs. Currently, potential blood donors must self-attest to illnesses, medications, and recent travel or tattoos. Self-attestation is also endorsed for potential over-the-counter access to hormonal contraception, in part because women know their own contraindications. And in the age of COVID-19, self-attestation is being used at businesses, schools, and universities for routine screening for symptoms such as fever.


But there is an obvious loophole. People may not tell the truth about themselves, and the early, restricted supply of vaccines might go to the wrong people, undercutting the careful prioritization of the groups in line. This will no doubt happen, but it will probably not erase the equity built into the line. Only a portion of vaccine supplies will be available to the public for self-attested access. The rest will be delivered through specific channels, such as on-site delivery to long-term care facilities or targeted outreach to homeless populations.

Further, the moral compass of most people — even powerful people accustomed to certain advantages — will point in the right direction. The ordering of the vaccine line naturally elicits empathy: The people early in line are grandparents, those struggling with medical conditions, and essential workers who risk infection every day in order to keep the country functioning. Talk about it with your neighbors, friends, and children: Most of us can see that this priority order is right.

In the short term, the nation will be constrained by how quickly the vaccines can be manufactured and distributed. The United States is averaging about 2,700 deaths daily to COVID-19, and a new strain has emerged that is probably more contagious. The nation needs a delivery system that protects Americans as rapidly and equitably as possible, and self-attestation is a familiar and efficient system.


On balance, it’s better to vaccinate a few line-cutters than to erect a barrier to the most vulnerable among us. We wait our turn for a vaccine not because we are forced to, but because ethics, empathy, and epidemiology compel us to.

Kate Miller is senior scientist at Ariadne Labs and research scientist at the Harvard T.H. Chan School of Public Health. She does not yet qualify for vaccination. Dr. Rebecca Weintraub is an assistant professor at Harvard Medical School, on the faculty at Ariadne Labs, and associate physician at Brigham and Women’s Hospital. A vaccinator, she has received her first dose of the COVID-19 vaccine. Dr. Atul Gawande is founder and chair of Ariadne Labs, a surgeon at Brigham and Women’s Hospital, and professor at Harvard T.H. Chan School of Public Health and Harvard Medical School. He is a member of the Biden-Harris Transition COVID-19 Advisory Board. He enrolled in a COVID-19 vaccine trial last summer and recently learned he received the vaccine.