Actual best practice is likely a compromise between the two extremes of nationalism and cosmopolitanism. Pure cosmopolitanism ignores the morally salient features of nationhood, while pure nationalism ignores the moral interests of those outside a country’s own borders. Democratic nationalism also obscures the further question of what citizens should demand of their governments vis-à-vis meeting the needs of the international community. A position of ‘moderate’ nationalism (or perhaps ‘moderate’ cosmopolitanism) would allow countries (or citizens to demand of their governments) to prioritise the interests of their own people to some degree, while also requiring them to provide meaningful support to the global population.⁷

Models of balancing

Even accepting moderate nationalism, the question remains of what exactly is the appropriate balance. In practice, a number of models have been proposed and carried out. We survey four, and discuss the ethical balance underpinning each.

Cash support

While the US, under the new Biden administration, has pledged to fund COVAX to the tune of billions of dollars, it has also stated that it will not send any actual vaccines abroad until the US is fully vaccinated.⁸ This is an important distinction, because while funding goes some way towards securing vaccines in the future, wealthy countries have secured priority access to current production through advance market commitments. In other words, this approach keeps a country’s own people at the ‘front of the queue’ while offering a degree of financial assistance for other countries.

In present context, this approach leans heavily in favour of national priority, because the world faces an absolute scarcity of vaccines; one country securing a given supply of vaccine means another country will not receive that supply. Much of the current global production has already been secured through advance market commitments. While cash assistance to COVAX now will help contain the pandemic in the future, it still comes too late to reverse the worst near-term effects of vaccine nationalism.

Concurrent distribution

French President Emmanuel Macron has proposed countries to reserve 3-5% of their purchased vaccine supply to redistribute to countries most in need.⁹ This allocation of vaccines, rather than cash, is more sensitive to the current scarcity of vaccines and so more cosmopolitan than the US’ current policy.

Still, this proposal would allocate only a small fraction of vaccines to meet global need, leaning still heavily towards national priority—just not as much as with only offering cash support. By design, richer countries would keep 20 times as many vaccines for themselves as compared with that made available to others. Other countries might supplement that donated supply with their own bilateral deals, but many low and middle income countries will still have to wait months if not years to reach the same level of coverage as wealthier countries.

Vulnerable only

Risks of COVID-19 are not distributed evenly within a population. The elderly and individuals with certain co-morbidities are at particular risk of getting sick and dying of COVID-19, while healthcare workers are at especial risk of exposure. One proposal is to draw a line: a country can strictly prioritise vaccinating its own population until such a time as healthcare workers, the elderly and vulnerable are vaccinated. At that point, a country should be able to open up safely while donating their vaccine supply to international efforts to ensure such vulnerable populations around the world are protected.¹⁰

This framework somewhat more evenly balances cosmopolitan demands with obligations to prioritise one’s own people. It is in this way analogous to a form of rescue ethics that would permit an individual to save the lives of their family members before those of (perhaps more) strangers, but once their family is saved, obligate them to save the strangers before tending to the injuries of their family. However, it focuses primarily on demographic measures rather than actual outcomes, potentially excusing some countries from donating abroad when their need is very limited, while requiring others to donate abroad when many are still dying locally of COVID-19.

Eliminating excess mortality

An alternative is for countries to focus first on eliminating excess mortality through vaccines. Excess mortality refers to the unusually high number of deaths experienced as a result of the pandemic. This will include deaths directly from COVID-19, as well as indirect deaths caused by, for example, lack of access to essential services due to lockdown disruptions. In this model, countries can vaccinate their populations until such a time when they have brought down excess mortality to a tolerable and non-emergency level, perhaps the level experienced during a somewhat bad year of a seasonal flu outbreak.¹¹

This model balances cosmopolitanism with nationalism by identifying a point at which the interests of other countries in receiving vaccine can reasonably trump that of domestic need. Eliminating excess mortality will come at different points for different countries, and so is more sensitive to local contextual factors than a purely demographic-based approach like the preceding one. It also appeals more directly to what matters most during a pandemic: saving lives, whether directly or indirectly threatened by the virus. It will, however, be challenging to operationalise real-time metrics of excess mortality, and requires more willingness than is currently evident on the part of countries to trade off the interests of their own people compared with the much more pressing needs of those abroad.

Weighing up

There is not space here to offer a proper defense of these options over the other. Each espouses a somewhat different balance between national priority and global need, and so which is preferable will depend on how heavily a country weighs competing interests. Notably, even the more nationalistic approaches like Macron’s 3-5% proposal are substantially greater than the normal aid distribution. By comparison, France in 2019 spent 0.44% of its Gross National Income on foreign development aid.¹² In addition, recent polling suggests that even in countries like the US—often perceived as highly nationalistic—there is widespread support for prioritising global over domestic need.¹³

This exceptional level of international support might be reflective of the more pragmatic concern that it is in countries’ national interests to ensure the pandemic is controlled globally. Yet this does not mean that vaccine cosmopolitanism and nationalism collapse into each other—shared interests in global pandemic control will only go so far in justifying support for of international distribution of vaccines. Ethical concerns like those espoused in this article should generally push countries and their citizens to be more generous than they otherwise would be to ensure globally equitable access to COVID-19 vaccines.

However, ultimately, democratic governments are responsible to the people who elect them. Whatever policy they believe is best to pursue, they must persuade their citizens in a democracy that that policy is the one which should be adopted. This requires not propaganda, but sound argument and evidence. In short, we require ethics first to identify the best or most justifiable policy and practical ethics to rationally persuade the people that this is the policy they should support.