**Abstract**

Major public and private laboratories entered into a race to find an effective Covid-19 vaccine. With the arrival of the vaccines, governments have to implement vaccination programs to achieve the necessary immunization levels to prevent further transmission of the disease. In this context, the ethical dilemma of compulsory vaccination *vs*. voluntary vaccination has been raised. Underlying this dilemma lies the problem of the ethical models on which the political decisions of governments in health matters based. The chapter proposes and argues the need to base health policy decisions on an ethical "first person" model, based on personal responsibility, that allows us to move from a normative ethic to an ethic of responsible behavior. This change in the ethical model, together with certain proposals for political action, will help us to restore institutional trust, so that the necessary levels of collective immunity against Covid-19 can be achieved through the voluntary vaccination of the citizens.

**Keywords:** Covid-19, vaccination, ethics of responsibility, prevention, institutional trust

#### **1. Introduction**

While we are still suffering the effects of the Covid-19 pandemic, the major public and private laboratories have entered into a race to find an effective vaccine against Covid-19. A vaccine capable of generating immunity is the only tool that can stop the spread of the virus. As of April 20, 2021, 13 vaccines have been approved and used, and there other 60 vaccine development projects worldwide [1]. The development of these vaccines has posed some serious ethical problems. Some groups were carrying out safety and efficacy tests on animals and humans in parallel, when the normal procedure would be to carry out the tests in animals and, once safety and efficacy have been proven, to carry them out in humans [2, 3]. Other groups had planned to inject the virus directly into healthy volunteers to test the efficacy of the vaccines [4]. In April 2020, the best forecasts spoke of a vaccine by the end of the year, and others by mid-2021 [5]. As we have already said, by mid-April 2021, we have 13 vaccines that are being applied all over the world. The truth is that each country, when the vaccines arrive, will face two successive scenarios: at first, two or three vaccines will arrive which have passed the safety and efficacy clinical trials, but with a limited production that will not allow the vaccination of the entire population; later, when the safety and efficacy of the first vaccines have been verified in the vaccinated population, the production of the most effective and safe vaccines will be increased, and the mass vaccination of the population can be considered [6].

In the first moment, when there is a shortage of available vaccine units, the ethical dilemma that arises is: whom to vaccinate? When there is a shortage of health resources, decisions must be made according to the principle of distributive justice, and the criteria for inclusion (prioritization) of the groups of users who can access vaccination will have to be determined.

In the second stage, when vaccine production has increased, mass vaccination of the population will be considered. In regard to the implementation of mass vaccination, two basic ethical dilemmas arise: the first is that of "free vaccination" *vs.* "paid vaccination"; the second is that of "non-compulsory vaccination" *vs.* "compulsory vaccination". In the case of vaccination against Covid-19, it is clear that the concern will focus on mass immunization, and as a rule, governments will carry out vaccination at no direct cost to citizens, thus eliminating the first dilemma. In this context, the only ethical dilemma that will arise will be compulsory *vs*. non-compulsory vaccination.

In this chapter, we aim to demonstrate that underlying these dilemmas are a series of ethical models on which the political decisions of governments about health matters are based. From there, we propose and argue the need for a "firstperson" ethical model, based on responsibility, which allows us to move from a normative ethics to an ethics of responsible moral behavior, and which, together with certain proposals for political action, will succeed in recovering institutional confidence so that the necessary levels of collective immunity against Covid-19 can be achieved through the mass and voluntary vaccination of citizens.

## **2. Whom to vaccinate?**

In the midst of a veritable forest of vaccine research projects, three are leading the way [7]. Therefore, a first scenario is presented with three or four approved vaccines with relative safety and efficacy, enough to reduce mortality, infections and the need for hospitalization. Thereafter, it will be necessary to initiate worldwide production of them in unprecedented quantities. Some centers expect to produce 100 million vaccines per year, while the alliance between various international organizations is talking about achieving 2 billion doses per year. Despite all these efforts to expand production, it is certain that, initially, there will not be enough vaccine for everyone, and governments will have to decide whom to vaccinate as a priority.

Given the lack of availability of health resources, in this case vaccines, *the principle of equal access* to them cannot be applied. The *principle of equity* then appears. Equity is *distributive justice* understood not as the equal distribution of resources, but as justice in relation to needs, especially in the distribution of risks and benefits in society. Following this principle, at least two groups appear in the risk/benefit ratio, and should be the target of the first group of available vaccines: health professionals and users of the health system over 70 years of age.

During the first wave of the Covid-19 pandemic, we have seen in different countries that a large number of health workers has been infected. The infection of such workers has had important consequences for the management of hospitals and the care of patients [8]. Those over 70 years of age have the highest mortality rate from Covid-19 [9]. During the first wave, in some European countries, 66% of deaths officially attributed to COVID were in this population group. The specific case of nursing homes [10] was particularly dramatic, as stated by the WHO [11]. In this sense, the elderly over 70 years of age and those living in nursing homes, as well as their caregivers, should be included in the priority group from the first moment of vaccination.
