Will Utahns wait their turn in line once vaccines open up for those with underlying conditions?

With the state now offering the COVID-19 vaccine to a large group of people with underlying health conditions, Utahns won’t be required to produce a doctor’s note or other proof they are eligible.

Instead, the state is relying on the honor system. It’s an effort to get shots into arms as quickly as possible, but it will almost surely result in abuse as people find there are relatively few obstacles that prevent them from skipping forward in line.

“It is possible for people to lie about whether or not they have one of these underlying health conditions,” Gov. Spencer Cox acknowledged at a news conference on Thursday, where he pleaded with Utahns to play by the rules.

But Tom Hudachko, a spokesman with the Utah Department of Health, said in an email that the department has determined it’s more important to ensure the process is simple and efficient for the approximately 275,000 Utah residents who have qualifying medical conditions than it is to make it overly cumbersome just so “a few others don’t get in line early,” he said.

Requiring paperwork as proof of eligibility would not only “significantly slow the process of getting vaccines into these peoples’ arms,” Hudachko said, but it would also place an “unnecessary burden on health care workers who would be responsible for providing such documentation.”

This shift to more widespread vaccine access comes as Utah’s death toll from the coronavirus approaches 2,000. But the seven-day average for the rate of positive coronavirus tests has been dropping, under both the state’s traditional measure — which still stood above 10% last week — and its new methodology, which hovered around 6% last week. The number of Utahns who are fully vaccinated with two doses topped 225,000 midweek, with that total likely to top 250,000 over the weekend.

What’s happening elsewhere?

As states begin making larger groups of residents eligible for vaccinations, they’ve taken different approaches to the question of whether to require paperwork to vaccinate people in a priority group.

It can be difficult to find information on each state’s rollout, but Washington, New Jersey, Massachusetts and Alabama have so far reported using the honor system.

In Texas, health care providers have been told to look at people’s medical records to determine their status for the shots, when possible. In other circumstances, people can disclose their underlying health conditions and receive the vaccine with no paperwork required, according to the Dallas Morning News.

At vaccination clinics operated by New York state, residents are required to provide proof of eligibility for underlying conditions with a doctor’s letter, medical information that shows evidence of their health condition or a signed certification, according to the state’s coronavirus information website.

While it remains to be seen how well the honor system will be implemented here, Margaret Battin, a professor of philosophy at the University of Utah, said she wondered whether the community influence of The Church of Jesus Christ of Latter-day Saints could affect the success of the policy.

“The teachings of the church ... I think would tend to discourage behavior like cutting in line,” said Battin, who is also an adjunct professor in the U.’s medical ethics and humanities program within the Department of Internal Medicine. “All that ‘do the right’ and ‘choose the right,’ that kind of moral teaching might well play a role in the behavior of many people in this state that might not be so true in a more heterogenous state like New York.”

Hudachko said the decision was made primarily based on feedback from vaccine and health care providers that requiring paperwork would create “significant bottlenecks.” He said he hasn’t been able to make comparisons on which approach is more effective and noted that several states haven’t yet started vaccinating people with underlying health conditions.

Equity issues?

While the honor system poses its own problems, Jim Tabery, an associate professor of philosophy at the U., said he thinks the vaccine rollout as planned is the “ethically appropriate way to go.”

“Obviously when you’re thinking about something like this, your mind naturally goes to kind of the vaccine line jumpers or the freeloaders,” he said. “There might be some of that out there, but the question is: What system are you envisioning creating that would weed them out? And would it in fact be a better system?”

Requiring people to jump through hoops to prove they have an underlying health condition could be “terribly invasive” for people with disabilities he said, and it could also pose equity issues in gaining access to the vaccine. Individuals within hard-hit communities of color, for example, may not have access to a health care provider to obtain proof of their condition or might struggle to get work off to get an appointment.

“If you’re dealing with someone [in that situation] who’s got diabetes and you’re saying, ‘In order to get the vaccine, we also need some sort of confirmation that you have diabetes,’ you’re essentially asking them to kind of go see a health care provider that they don’t have access to,” he said. “And so most likely what you’re doing is guaranteeing someone is not going to get access to a vaccine.”

Up to this point, it’s been “relatively simple” for vaccination providers to determine eligibility in Utah, Hudachko noted.

The first round of inoculations was largely based on employment, and it was easy for health care workers, teachers, first responders and long-term care facility staff to prove they qualified based on pay stubs or badges. And older adults have been able to “easily provide proof of age with a government-issued ID or similar document with their birth date listed,” he said.

Even so, Salt Lake County Health Department spokesman Nicholas Rupp said there have been a few instances where people have tried to “cheat the system” and have been turned away at a vaccination site.

“Fortunately, it isn’t a widespread problem,” he said. “We’ve had more people genuinely misunderstand their eligibility, but even those aren’t widespread.”

The county has not taken a position on the use of an honor system, but Rupp said the health department will follow the directions of the state and governor “and encourage people to be honest so vaccine goes first to those truly at the greatest risk of serious illness.”

Vaccine chasers

In announcing Thursday that the vaccines would be open to people with underlying conditions immediately, rather than the March 1 date previously planned, Cox noted that those who now qualify are at the highest risk for hospitalization and death because of COVID-19.

And he urged Utahns who aren’t eligible not to schedule appointments.

“We have so many more vaccines coming and they’re coming soon but we’re prioritizing these individuals — again based on age and these underlying comorbidities — because they are at the greatest risk of hospitalization or death,” he said. “So if you jump ahead in line, that means there is someone else who won’t get the vaccine as soon as they could have and it’s very possible that they could end up hospitalized, or even worse, dying.”

Those who follow the rules “can sleep well at night by knowing you didn��t cheat the system, that you were willing to give it to those who needed it the most,” he added.

Hudachko noted that every Utahn who is 16 and older who wants one is expected to have the opportunity to receive a vaccination by the end of May. People who are considering gaming the system to get their shot a few weeks early, he said, need to consider that “the person you are skipping ahead of is far more likely than you are to become seriously ill or even die if they were to become infected with COVID-19.”

As the state opens vaccines up to more people, Tabery said the most ethical thing those who aren’t eligible for one yet can do is wait their turn.

There are legitimate questions about fairness within the vaccine rollout, he noted. But if, say, a grocery store employee felt like he or she should have been included in the latest round of inoculations, the way to deal with that is to contact state leaders to voice that concern — not for someone to take matters into their own hands.

The exception to that rule, Tabery said, is a scenario in which there are excess doses that need to be used and will go bad if they aren’t. Both the Pfizer and Moderna vaccines must be stored at freezing temperatures and, once thawed, have to be used within a certain time frame.

“If somebody were to find themselves in a situation where they just so happened to be at the hospital or at the pharmacy and the pharmacist or the nurse says, ‘Hey, we’ve got an extra dose. This is going to go to waste if you don’t use it,’ then it would be it would be wrong not to take that,” he said.

It’s likely many people will make these ethical calculations during this phase of the state’s rollout, but Battin indicated that social stigma and disapproval of people who do cut the line will be the primary defense against that behavior.

Tabery said he anticipates there will be times where people cut the vaccine line and that those instances, when identified, will make the news.

But he’s confident most Utahns will “play by these rules.”

“I do think there’s a kind of underlying communal mentality to the state of Utah, which serves it well in situations like this,” he said. “And so I’m sure there will be line cutters. I’m sorry that they found themselves in a situation where they felt like they had to or could do that. But I think they’re certainly going to be the exception — not the rule.”