While we’ve heard that pharma’s normal behavior has been suspended in pursuit of a vaccine for COVID-19, we have already seen rumblings of business as usual in the procurement and pricing of remdesivir. Should the first person to be vaccinated for SARS-CoV-2 be the one with the most exclusive credit card, or the most influential government? Should they be among the most vulnerable or the most critical frontline workers?

With these questions in mind, companies should take the following considerations into account for the rationing of a potential coronavirus vaccine.

The first consideration is over who pharma companies should rely on to make decisions about vaccine rationing. If pharma leaders knew the world would only ever get 100 million doses of vaccine, the best response would be to efficiently manage their resources. Eradication would be about management of outbreaks at their source, in which case pharma leaders might decide to delegate that decision to a World Health Organization (WHO)-type body, with a remit to intervene where necessary.

But such a strategy would run into challenges in global and local politics. Already, in the U.S., three groups—the National Academy of Medicine, a nonprofit; the Advisory Committee on Immunization Practices, which works within and advises policy for the Centers for Disease Control and Prevention; and Operation Warp Speed, a government program dedicated to fast-tracking coronavirus vaccine development—have disagreed about how the U.S. should decide who gets a vaccine first. In the face of such confusion, and antagonism to the WHO, the company making those first 100 million doses will face a unique challenge in deciding who to follow.

Second, companies must consider who can safely be given the vaccine. Because of potential risks, the first vaccine’s initial application may be limited with vulnerable populations. We’ve seen before that there are many unknowns about a vaccine even after it is approved for widespread use. Decisions taken in haste can lead to safety issues, which could damage society’s belief in vaccines in general, and the global response to this pandemic specifically. 

The third ethical consideration is how to distribute the vaccine among countries. The decision cannot be based on traditional parameters of willingness or ability to pay. Even if we assume that governments are acting with the best of intentions, allocating doses on a first-come, first-served basis or pricing the vaccine to limit demand will create inequality in how it’s allocated worldwide.

COVAXX, a division of United Biomedical that is developing a COVID-19 vaccine and offers an antibody test, has created an independent prioritization panel to set criteria for any deals done for the first 100 million vaccine doses. (My company, IDEA Pharma, is advising COVAXX.) If companies cannot rely on help from governments or international organizations—as is clearly the case with COVID-19—they must instead establish their own guidelines. 

Such a panel must meet a few requirements. It should have adequate diversity of opinion. The panel should not base its decisions on ethnicity or race—but it also cannot ignore the influence those factors will have on demand. The group should not have a singleminded focus on ethics; that should be balanced with economic, anthropological, virological, epidemiological, public health, and political considerations. 

During the debate over Obamacare in the U.S., we saw the emergence of the term “death panels,” so we know how controversial and uncomfortable discussions over the rationing of care can be. But ration we must. Eventually, the first 100 million doses will lead to 7 billion protected lives. But someone will be patient No. 1.

We should hope that all other manufacturers adopt similar committees. Pharma’s reputation may be saved by the warp-speed development we’re currently seeing, but also perhaps by the slow, intentional reflection of a “life panel.”

Mike Rea is CEO of IDEA Pharma.