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.

But we won’t get to enjoy the luxury of agreement 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 behavioural 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 neighbourhood but 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 an example to mind with ease. I’ll estimate that shark attacks are very frequent. If I’m on my Twitter feed 24/7 reading about the news 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.

1:17 Coronavirus: Early data shows COVID-19 vaccine having impact on hospitalizations, death rates in Canada

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 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-19.

His disagreement was based not on facts, but on values; as he tweeted, it is his opinion that not 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?

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 Q&A after a politician provides an update.

We need clarity on what question we’re looking to answer. To get there, we need more open, transparent discussion of what our priorities are for our vaccination campaign.

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.

—

Brooke Struck is research director at The Decision Lab, a Canadian social enterprise that uses behavioural science research and consulting to improve society. Before joining TDL, Dr. Struck consulted in evidence-based policy and data-driven decisions, advising clients such as the European Commission, the US National Science Foundation, and the Government of Canada.