From Ethical to Political Borders: An Analysis of Vaccine Nationalist Policy in A Global Public Health Crisis

At the height of the COVID-19 pandemic, many of us were scrambling to be vaccinated to protect ourselves from the notoriously destructive outbreak—but as we received our preventative treatments, did we truly consider that our ability to receive vaccines was not a global norm, but a privilege shaped by greater policy decisions? Vaccine nationalism, although a seemingly obscure philosophy, is much more prevalent in our world than the majority realizes. This policy of restricting vaccine allocation undeniably shaped distributive decision-making during COVID-19; yet its moral complexities inspire us to question blind assumptions: Is it ethical to prioritize national welfare over international equity when distributing necessary treatment? Who makes these decisions? At what point does self-preservation endanger the wellbeing of a larger community?

Table of Contents

• Introduction

• Global and National Organizations

  1. Public Health-Oriented Organizations

  2. Organizational Responsibilities

• Case Studies

  1. COVID-19: India’s Export Restrictions

  2. COVID-19: The European Union and AstraZeneca

• Government-Company Relationship

• Motivation

  1. Political Motivation

  2. Economic Motivation

  3. Medical Motivation

• Deontology

  1. Pro-Vaccine Nationalism

  2. Anti-Vaccine Nationalism

• Consequentialism

  1. Pro-Vaccine Nationalism

  2. Anti-Vaccine Nationalism

     1. Immunization and Access

     2. Global Consequences

     3. Political Impacts

• Vaccine Hesitancy

• Conclusion

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Introduction

A commonly recognized aspect of human behavior is how it is often motivated by inherent self-interest. Yet this self-interest is not restricted to an individual being; in fact, the term nationalism defines how this egoism is magnified to describe a country’s spirit of self-interest, which has guided policy throughout history to simultaneously drive unification and division. However, in global public health crises, a new facet of nationalism is often expressed: one that informs medical ethics, rebuilds nations, and reshapes political relationships. Emerging primarily during crises in the 20th and 21st centuries, especially the COVID-19 pandemic, “vaccine nationalism” is common policy for governments or governing bodies attempting to purchase and distribute vaccines. However, vaccine nationalism raises an essential ethical concern: how should governing bodies balance internal national restoration (1) with an obligation to international wellbeing during widespread health crises? While historically both individuals and nations have often acted on the aforementioned motivation of self-interest, pragmatic self-interest raises an interesting question of ethical duty: in such an interconnected modern world, does an obligation to make sure global societal wellbeing is prioritized exist?

(1)  For context, restoration, here, is defined as matching or exceeding the norms for economic, medical, political, and social function prior to the disruption of such a health crisis.

Vaccine nationalism refers to policies through which governing bodies secure and obtain access to vaccines for their own populations, often with little regard for international impact.

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To this end, a governing body might pursue a bilateral deal—which, in this context, refers to a two-sided agreement between a pharmaceutical company and the region’s governing body—with a particular vaccine manufacturer to supply requirements ahead of international needs. Vaccine nationalism may also manifest as laws limiting technology transfer, trade supply, or vaccine exportation to other countries. This paper will address the implications and ethics of vaccine nationalism during a public health crisis to assess distribution protocol for scarce resources in high demand, by reflecting on the past crisis of COVID-19 and determining new approaches. Using deontological and consequentialist frameworks, along with the principles of justice and beneficence, to inform my position, I will analyze government contracts with domestic vaccine producers, or pharmaceutical companies. I will offer my opinion on the ethical supportability of allowing a country to prioritize its own national welfare over international equity (2) by preemptively purchasing, or restricting the distribution, of life-saving vaccines. Ultimately, I will address the following ethical question: is it ethically permissible for governments to prioritize national welfare over international equity when allocating life-saving medical resources?

(2) Here, “equity” can be distinguished from “equality” in that “equity” supports the distribution of vaccines based on differing levels of medical need and vulnerability, rather than strict “equality” in allocation, which would imply identical or similar distribution regardless of circumstance and geopolitical disparities.

A recent example of a public health crisis was the COVID-19 global pandemic, in which various nations pursued vaccine nationalist policies in an attempt to purge the disease from their specific region under a governing body that controls medical policy. While vaccine nationalism has historically been  relatively common in public health crises, as will be demonstrated through the examples this paper will provide, other approaches to regulating distribution also have been used. For instance, some countries in Europe supported vaccine multilateralism—or, synonymously, vaccine internationalism—during COVID-19, advocating for collective and coordinated international action for the equitable development, manufacturing, and distribution of vaccines. Multilateralism treats vaccines as global public goods and aims for a cooperative and collaborative approach to allocation (Singh et al.). 

However, even in an increasingly interconnected world, it is difficult to balance resources and ensure that distribution is equitable, since factors such as manufacturing, hesitancy, and healthcare complexity often distort the clarity of vaccine allocation protocol. While internationalism was also the widespread goal of various global initiatives, which will be explained later in this paper, it is arguably unfeasible because of its policy of priority distribution to high risk and susceptible populations, regardless of national income-based immunization gaps, as well as the effort and cost of vaccine trade across borders.

Vaccine nationalism represents an incredibly significant ethical dilemma, or situation of complex moral decision-making, during a public health crisis. While we must evaluate its ethicality, we may not deny its effectiveness or frequency in health policy during global crises. Ultimately, my research and ethical analysis have brought me to conclude that vaccine nationalism is not ethical, through these frameworks and principles that emphasize its evident moral complications. However, this paper will present an analysis that dissects both opinions on vaccine nationalist policies in global public health crises that has previously been rare in research of the field’s history, to demonstrate the various perspectives that support and contradict these policies and contextualize the actions of governing bodies who implement them.

Global and National Organizations

Public Health-Oriented Organizations

To understand the ethical complexities of vaccine nationalist policy, it is primarily essential to examine the current international and intra-national systems that shape overall health infrastructure. Firstly, an essential part of allocation of vaccines in a global health crisis are the  global organizations that oversee distribution. Often, these regulatory and international bodies aim to coordinate distributive efforts between countries by supporting widespread distribution, guiding supply chains, and establishing clear allocative priorities. These priorities are typically informed by epidemiological data, which measure where a disease is more severe or a population is more vulnerable.

Still, the distribution of vaccines to various countries or regions does not necessarily ensure that all individuals in need will be able to access them. Dosage delivery alone cannot control access to vaccination; instead, it is influenced by local healthcare infrastructure, public awareness, and willingness to be vaccinated. Ultimately, vaccine distribution systems often include global and national organizations that operate to control allocation, while immunization outcomes still depend on structural factors beyond the jurisdiction of such organizations.

For instance, the World Health Organization (WHO) is one of the primary international governing bodies that regulates overall distribution, manufacturing, production, and other aspects pertaining to vaccine distribution. WHO is one of the bodies that emphasizes the potential for vaccine internationalism, due to its ostensible lack of bias towards a certain country or region, as an international organization. For instance, “[in] 2021, during the COVID-19 pandemic, WHO set the target for 70% global vaccination coverage by mid-2022” (“Vaccine equity”) to prioritize prevalent, equitable distribution of vaccines. 

In addition to formally constituted bodies like the WHO, international associations can be formed on an ad hoc basis to regulate emergency research, manufacturing, and distribution of vaccines during a public health crisis. One of the most relevant examples of these international collaborations is COVAX, or the global initiative called COVID-19 Vaccines Global Access. COVAX, co-led by Gavi, the Coalition for Epidemic Preparedness Innovations (CEPI), WHO, and the United Nations International Children’s Emergency Fund (UNICEF) — all of which create an amalgamation of charities, vaccine alliances, and pandemic preparedness initiatives — aimed to ensure fair, equitable access to a COVID-19 vaccine worldwide. Likewise, the International Vaccine Institute (IVI) facilitates international organization for vaccine research, development, and distribution from its headquarters in South Korea.

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However, healthcare involves a coalescence of national government agencies who engage with health policy to ensure the wellbeing of those within the region. These national or regional regulatory bodies often prioritize the wellbeing of the specific population that falls within their scope over international health, as the latter arguably lies outside of their jurisdiction. For instance, the United States of America utilizes a variety of national health agencies to regulate different means of medical treatment, including vaccines. To illustrate, the federal Food and Drug Administration (FDA) plays a role in typical healthcare regulation, while the federal Centers for Disease Control and Prevention (CDC) deals with healthcare providers, treatment, and emergency medical distribution in the midst of a public health crisis like a global pandemic (“Memorandum”). Conversely, in Europe, the European Medicines Agency (EMA) is a “decentralized agency of the European Union [(EU)]… responsible for the scientific evaluation, supervision, and safety monitoring of medicines” (“European Medicines Agency”).

Organizational Responsibilities

These governing bodies have similar responsibilities within their respective spheres of influence: overseeing the distribution of vaccines, especially during critical times of a public health crisis. By using a data-driven process and rigorous monitoring to determine allocation, they model distribution based on population data, risk factors, and vaccine availability within their countries. This system is also aided by existing immunization supply chain and logistics systems. With more national immunization programs monitoring and investing in these systems to rejuvenate and improve technology, immunization recommendations and the systems that dictate in what order of priority a vaccine should be distributed have become more organized and widespread, working towards eliminating knowledge gaps. Vaccine delivery is a complex system and, despite the level of interconnectedness of the modern world, concern surrounds the prevalence of distribution.

Public information is a key part of this process, in ensuring that global populations understand the hierarchical order of distribution and vaccination systems. WHO prioritized this during COVID-19, offering a series of virtual webinars to detail the organization’s plan for regulatory development of a vaccine. Delivered by a WHO professional, these webinars enabled WHO to solidify public trust in the organization by increasing transparency; for instance, the first webinar was called the “National Deployment and Vaccination Plan: preparation, submission, and review process” (Gurung), underscoring the vitality of maintaining transparency with those likely to receive the vaccines. WHO also maintains their responsibility to aid countries in developing and refining national policy, although policy is ultimately left to the autonomous decision of that nation itself.

Another essential role of health governing bodies is declaring a health crisis. Guided by the International Health Regulations (IHR), these bodies ensure that all 196 countries compliant with global health security regulations must “report events of international public health importance… [and] address hundreds of diseases, health threats, and conditions” (“International Health Regulations”). WHO Member States are required to report potential outbreaks within 24 hours to ensure maximally effective mitigation. Then, following the report and investigation of detection, spread, and other relevant issues, an IHR Emergency Committee will convene to determine if it is necessary to call a Public Health Emergency of International Concern (PHEIC), or a formal declaration of a health crisis that requires an internationally-coordinated response. Since 2007, six events have been declared a PHEIC: “the 2009 H1N1 influenza pandemic, Ebola ([during the] West African outbreak 2013-2015, [and another PHEIC due to the] outbreak in Democratic Republic of Congo 2018-2020), poliomyelitis…, Zika… and COVID-19” (Wilder-Smith et al.).

Ultimately, however, global healthcare is decentralized. While the WHO may dictate influential protocols for significant global health threats and regulatory practices, each individual country often actively engages with  domestic organizations. For instance, the FDA has much greater oversight of day-to-day healthcare systems in the USA as a government agency. Contrastingly, the WHO is a specialized agency of the United Nations, which, despite having international influence, has no enforcement power of its regulations in the USA or other member countries. Notably, the jurisdictional boundaries that result from political borders often contribute to ethical issues surrounding vaccine nationalism, reintroducing the question of how national restoration and prioritization is balanced with an obligation to global prosperity and health. 

Therefore, global health organizations have played significant roles in the distribution of care during public health crises. Although their responsibilities vary based on the sphere of influence of these bodies, whether nationally or internationally formed, all work towards improving the health of populations by coordinating a response to inform and immunize the public.

Case Studies

In order to contextualize the realities of vaccine nationalism, we must recognize significant examples of the ideology in practice. Palpable during COVID-19, vaccine nationalism facilitated national and regional restoration, demonstrating the unique obligations that a governing body firstly owes to its residents and citizens—obligations that are extremely prevalent in nations with a social contract, where citizens relinquish certain rights in return for government protection in the event that their remaining rights or general societal order are threatened.

COVID-19: India’s Export Restrictions

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For instance, India, considered a pharmaceutical powerhouse and a then-key member of the COVAX initiative, imposed a number of export restrictions and prohibitions on medical technologies and materials during the pandemic. An export restriction or prohibition is government-imposed policy or regulations that limit or prohibit the transfer of these specific services and goods to foreign entities. While India, at the beginning of the COVID-19 crisis, had exported over 60 million doses of the AstraZeneca vaccine to 76 countries as part of the COVAX initiative, manufactured at the Serum Institute of India (SII), its export restrictions limited this ability at the height of the pandemic’s destruction. In 2021, India saw a devastating surge in domestic COVID-19 cases, reaching, for instance, 414,188 cases in one day in May, with more than 21 million overall confirmed cases and 234,083 deaths nationally (Ferguson). For example, India placed restrictions on: “13 active pharmaceutical ingredients (APIs) and their formulations... [and] hydroxychloroquine (HCQ) and its formulations" (“Trade barriers”). While India focused its efforts on providing resources to Indian citizens, it then limited available resources for vulnerable populations in countries with less accessibility to vaccines during a global pandemic, issuing an “India First” policy that limited the resources that could be distributed through COVAX during an essential time of international crisis. 

There are ethical ramifications involved in a decision like this. While India closed off export trade for high-demand, necessary resources, they continued to import resources that they needed, emphasizing the juxtaposition between personal and external interests. However, they also benefitted Indian citizens by helping them to eliminate major threats of COVID-19 faster than they likely would have been able to without the restrictions, imploring us to ask: To what extent should and can a country sustain international obligations during a domestic emergency? According to a Health Policy report, “The Indian export ban hit hardest on Africa which was [supposed] to receive hundreds of millions of doses of AstraZeneca vaccines, produced by the [SII], through… COVAX” (Kirshnan). Once some of these restrictions were lifted, notably on manufactured vaccine doses, in late 2021, 600 million doses of the vaccine were predicted to be exported globally. While these doses were initially planned to arrive in developed regions according to COVAX’s distribution plan, such as Europe and the United States, where cases were also at a global high, health officials in India, such as South-Asia head of Doctors Without Borders Leena Menghaney, determined that “the vaccines have to go where [supply is] needed most…. When India starts sharing vaccines with developing nations, the variants can be controlled” (Kirshnan). This call for more equitable distribution clarifies India’s priorities after attempting to mitigate the surge the nation experienced in cases of COVID-19: to limit destructive spread of the virus internationally, prevent the emergence of new variants, and reduce cases in struggling developing nations.

Although the restrictions imposed in this case study were eventually lifted, timing is essential during a public health crisis as globally destructive as the COVID-19 pandemic. In illustration, considering only the factor of a country’s population size and its subsequent time taken to vaccinate, vaccinating a domestic population to reach a certain level of immunity might take X time and Y resource in India, which is a large country, and might take A time and B resource in a much smaller country.  The time and resources it takes to implement vaccine nationalism and achieve the goal in India could see substantial devastation occur in one or more other countries, which need less time and resources to immunize a population but may be unable to access either (“COVAX Facility”).

COVID-19: The European Union and AstraZeneca

Another palpable example of vaccine nationalism emphasizes its presence within a multinational governing body, such as the EU. For context, the EU can qualify as a governing body in charge of regional healthcare because of its jurisdiction over medical policy for all member states. The European Commission is a branch of the EU that dictates and governs medical distribution policy for all the member nations of the organization.

Through a European Commission contract with the European-based pharmaceutical company AstraZeneca, the EU ensured that its Member States would receive priority distribution of vaccines before they were offered internationally. This included the immediate purchase of 300 million doses of the vaccine, and an additional 100 million on a population-based rate. When asked to comment on the Commission’s priorities for public health, Ursula von der Leyen, President of the European Commission, said, “The Commission is working non-stop to provide EU citizens with a safe and effective vaccine against COVID-19 as quickly as possible” (“Coronavirus: the Commission signs first contract”). This decision was also part of the EU’s 2020 European Vaccines Strategy to combat the COVID-19 pandemic, prioritizing member states’ interest compared to other initiatives like the COVAX for equitable access to testing, treatments, and vaccines.

For clarification, within this paper, I recognize that the EU is logistically and legally a multinational alliance of independent sovereign states with jurisdiction over collective policy, which may negate the use of the term “vaccine nationalism” and denote it as a form of “limited vaccine internationalism” because this distribution technically transcends national borders and encompasses a variety of nations with differing forms of healthcare systems (3). However, for the purposes of this paper, I will be analogizing the approach undertaken by the EU with other examples of vaccine nationalist policy that have been enacted historically, due to the similarities present between the EU, a governing body, restricting vaccine priority to a certain region through an agreement with a vaccine manufacturer and typical vaccine nationalism, demonstrated by nations like India. Therefore, the term vaccine nationalism will be used to refer to this type of vaccine policy, because the EU clearly resembles the restriction of preventative treatment that we see with vaccine nationalism. However, this paper stipulates that this classification does not entirely undermine the independent sovereignty of the nations involved. 

(3) This difference between the healthcare systems of EU Member States creates a contradiction between the theoretical and principle-based jurisdiction the EU should have over each Member State’s distribution protocol, and the realistic challenges that these variances create.

This restrictive distribution policy describes regional or national “[priority] in global vaccine distribution” (Qi 2025). While for reasonable purposes, to mitigate the disease that causes a public health crisis, it belies the previously mentioned ideology of vaccine internationalism. Therefore, vaccine nationalism is often classified as a “‘my country [or region] first’ allocation policy,” which is occasionally characterized as “selfish [as it leads] to an unequal global vaccine allocation” (Qi 2024). In this sense, concurrent attention to multiple countries’ needs during a global public health crisis is considered a necessary part of vaccine internationalism. However, it can comparatively be viewed as limited altruism, in the sense that it acts in the interest within a large community instead of across all humankind. This idea of vaccine restriction is evident in the given case studies. Firstly, the EU is an example of a region or international body controlling vaccine distribution within a certain region, rather than to a specific nation. However, this would still parallel vaccine nationalism because of how it involves a political or governmental body deciding to sign an agreement with a pharmaceutical company, in this case, AstraZeneca, to restrict access to a vaccine to the specific region.

Furthermore, the relationship between the EU and vaccine nationalism may be seemingly paradoxical because of the systemic philosophy of universal healthcare that is so prevalent among member nations. Nevertheless, a country that believes in universal healthcare for its own citizens would not necessarily believe in vaccine internationalism. Instead, this form of socialized medicine further explains the governing body’s clear priority of its people, with a prime concern being the assurance of their citizens’ wellbeing. Moreover, India’s export restrictions also correspond with the idea of vaccine hoarding. By not distributing the resources and vaccination materials needed to create a treatment similar to the one they distributed internally, they seem unwilling to share research and vaccines, demonstrating a characteristic that seems reminiscent of what humanity defines as hoarding.

Ergo, both India’s export restrictions and the EU’s AstraZeneca limitation policy demonstrate clear, real-world examples of vaccine nationalist policy. These manifestations appeared during our most recent public health crisis of COVID-19, emphasizing the prevalence of these policies as an ethical dilemma. 

Government-Company Relationship

Moreover, a fundamental consideration in the issue of vaccine nationalism is the relationship between a governing body and the company they sign a bilateral agreement with, and the hypothetical situations that could further complicate distribution protocol. When companies sign these agreements with governments who want to guarantee their countries sufficient vaccine supply, there might be conflicts of interest, such as disagreements between a company and a government about distributive protocol.

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Historically, there are few absolutes in vaccine distribution, which varies so greatly based on the health contexts and circumstances of the time; still, the governing body often maintains jurisdictional precedence if disagreements arise between manufacturer and customer. Contracts typically specify performance terms, however, which includes how said disagreements should be resolved. Generally, given the power and influence of the local government on a company’s ability to successfully continue their business functions, these companies seldom retain final decision-making ability—as specified contractually—in the event of a disagreement between these parties. This dynamic ultimately reinforces vaccine nationalism, since governments are better positioned to prioritize domestic access to vaccines when their authority outweighs that of pharmaceutical companies.

Another essential feature of this paper is that vaccine nationalism exists on a spectrum. Firstly, the core principle between the variations of how this policy manifests is intrinsic: the prioritization of a region or nation’s own population through agreements or regulations that restrict the allocation of vaccines. To clarify, this paper will classify vaccine nationalism as a policy that limits the exportation or international distribution of vaccines for any period of time, ensuring priority even if supply is later more widely allocated. However, elements of these policies are also contingent and subject to variation. For instance, the means of restriction can vary, from the implementation of a bilateral agreement with the pharmaceutical company to a government-controlled restriction through export regulations.

Arguably, vaccine nationalism also creates a spectrum of severity in reference to these policies. On the lesser end of such a scale is mild vaccine nationalism, to the extent of vaccinating healthcare workers and other high- and moderate-risk domestic populations.

Mild vaccine nationalism, which may take different amounts of time and effort depending on the demographics that are prioritized, is labelled as so within this paper primarily because of its distinctions of priority level, based on vulnerability and susceptibility. Next, on the higher end of this inexhaustive list is hoarding vaccine doses considerably beyond national or regional restoration, without opening access to other areas. This spectrum also complicates a stance on the ethicality of vaccine nationalism. Because this spectrum is so nuanced, extreme vaccine nationalism, moderate vaccine nationalism, and other forms all operate on different levels, meaning that the subsequent determination of ethicality may be affected. 

Ultimately, contractual obligations and legal precedents have laid a foundation to clarify the relationship between a governing body and a pharmaceutical company that signs a contract to restrict vaccine distribution to a certain nation or region. Additionally, the scale of vaccine nationalism, with its varying degrees, has been clarified to match the nuanced policies of distribution we see reflected in real-world settings.

Motivation

A country’s motivation for employing vaccine nationalist policies during a public health crisis is also something to consider. With the global elements of restoration, which I will elaborate on later in this paper, that affect all nations, it brings us to ask: why would India restrict materials for all other nations? Why does the EU only want to distribute to its Member States?

Political Motivation

One common motive relates to a nation’s political situation. Representative of the traditional definition of nationalism, nations often are motivated to have leverage against another country or demonstrate their superiority in comparison to the global landscape. This can appear in both a beneficial and negative way. For example, once India lifted its export restrictions, it prioritized distributing vaccines to neighboring countries in Southeast Asia, strengthening geopolitical alliances with nations along its borders.

Conversely, this ideological or technological superiority can spark more tension within foreign relations. For instance, the USA and China have historically engaged in “broader… conflict… as the two digital powers are fighting for technological supremacy” (Bradford). While some manifestations of superiority can be prosocial and constructive, it may be exhibited through tense conflict for mastery in medical technology. 

Economic Motivation

Moreover, economic considerations naturally influence governmental decision-making. Driven to improve their national economic situation from pandemic-related deficits, countries may believe that restoration is only possible by restricting vaccines to their own nation. For example, China exemplifies a leading economy that has profited from national vaccine manufacturing and distribution. The company Sinopharm, based in China, had an increase in revenue of roughly 14.2%, significantly greater than previous years, from just 2020 to 2021 because of domestic vaccine production to meet demands of the Chinese government’s strategy of state priority (“Listed Companies”). Also, vaccine nationalism offers the chance for the restoration of economic normalcy, by prioritizing efficient internal distribution. If vaccination is enforced because this resource is distributed throughout a nation, employees are often able to return to work and conduct business as normal without worrying about the significant chance of infection. This reduces the uproarious economic chaos that ensues from risk of infection and serious illness within such a public health crisis.

Medical Motivation

Arguably most significant, though, is the medical motivation that incentivizes nationalist governments to distribute vaccines nationally before allowing domestically-located

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pharmaceutical companies to distribute them on a more widespread scale. During a time of high demand, like a global pandemic, vaccines may be scarce, and a governing body’s primary obligation regarding medicine is to prioritize the health of its own people. Based on this, although medical reasons may motivate internationalists to pursue global distribution policy, nationalist governments work to fulfill this obligation, justifying why they consider their reasons to be medical. Furthermore, it is important to consider that nations often are attempting to create herd immunity. Herd immunity describes a medical phenomenon in which, if there is a sufficient number of people in a certain area or region who have been immunized against a particular disease or infection, said disease or infection is less likely to spread easily. In order to be effective, herd immunity requires a very high rate of vaccination, often ranging from 83-94% of the population. Were countries able to advance the rate of vaccination significantly, which restricting vaccines to their own nation demonstratively does, they would be able to work towards creating herd immunity, if residents of the country agree to be immunized. Domestic priority in vaccination also allows a return to a semblance of normalcy. With less fear and stigma surrounding close human contact, people can assume their regular jobs once more, including those of medical providers. Caretakers in nursing homes, hospice workers, doctors, nurses, and other medical professionals are among those who can now aid the continued safety and treatment of the rest of the national population without worrying as much about their personal or familial safety.

Thus, economic, political, and medical motivation are all factors that incentivize governing bodies to pursue vaccine nationalist policies, attempting to improve public health through national priority during a public health crisis.

Deontology

Among the many ethical concepts applicable to vaccine nationalism is the framework of deontology, which evaluates the ethicality of an action based on the obligations and duties that a stakeholder has to themself and others. Under deontological principles, an action is ethically permissible if it fulfills the duties involved, regardless of the outcomes.

Pro-Vaccine Nationalism

Deontology can argue for the support of vaccine nationalism in various ways. For instance, it asserts that a national health governing body, such as the USA’s FDA or CDC has the obligation to its own people to prioritize the importance of that country's state of public health. This duty exists because the government of the USA legally creates health agencies like these; therefore, the primary mandate of these organizations is to protect public health within the USA. In this instance, deontology can be used to justify that specific governing body’s responsibility to diminishing the impacts of disease in the nation which they primarily control over all else. 

In this context, the deontological framework also embodies beneficence. Understandably, most national governments prioritize the maintenance of their citizens’ wellbeing over international interests, in accordance with the social contract that many countries may instate formally or informally. Furthermore, within countries that develop vaccines, governments often contribute heavily to research, with public funding, regulatory systems, and important investments. For instance, a branch of the USA’s Department of Health and Human Services Office agreed to provide $1 billion for the development of the J&J vaccine.

This then led to a “subsequent agreement” permitting the USA’s government to “purchase an additional 200 million doses” of the vaccine, after the “vaccine… [was] provided at a global not-for-profit basis for emergency pandemic use” (“Johnson & Johnson Announces Agreement with U.S.”). This emphasizes the aforementioned scale that vaccine nationalism rests on. While this could be considered internationalism, the subsequent agreement ensures some form of vaccine nationalism, by giving the USA, the nation where the vaccine was manufactured, priority access to additional vaccine doses. Ultimately, this represents that the governing body may therefore obtain a right to priority access that the pharmaceutical company must uphold by entering into a vaccine nationalist agreement, because said nation works to improve the manufacturing, research, and development of vaccines.

This also plays on the reality of vaccine nationalism: that “[p]olitically it will be difficult, if not impossible, to convince countries’ populations that they need to wait until health care workers in low‐income countries have been immunized. In an ideal world, rich countries, through government or private investments, would mobilize enough funds to cover an equitable worldwide rollout of an effective vaccine, in which all regions of the world that are most severely affected or predicted to be most affected are prioritized for distribution, but previous attempts to establish such coordination have not been successful. Therefore, the realistic alternative is for each country to do what it perceives as being in its best interest, which means acting in such a way that it can maximize the benefits for its own population” (Lie et al.). Such a decision inherently presses a country to determine where its priorities lie; and a government’s distributive decision can have life-saving implications during a public health crisis. 

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Arguably the most significant duty held by a stakeholder that supports vaccine nationalism is a general governing body’s obligation to protect the welfare of its people primarily. This obligation reflects the idea of a social contract, explained earlier in this paper; however, this specifically applookinglies to a government’s obligation to protect public wellbeing through healthcare and health policy. Typically, this duty applies to populations under the governing body’s jurisdiction, as it is common for political authority to be derived from these citizens. Such citizens entrust governments with safeguarding public health, especially amidst the growing dangers of a crisis, which creates a duty for governments to prioritize protecting their own populations during emergencies. Especially in democracies, governments exist specifically to ensure the welfare of their citizens. In a voting democratic government, the governing body is accountable to its national population. Potentially risking more widespread national immunization in order to simultaneously prioritize—on a similar level—the vaccination of non-citizens could deny this obligation, as they are undermining the reason for which said democratic system has been created. In this sense, vaccine nationalism reflects the basic political responsibilities that a government holds to its people. Additionally, some may argue that governments, who are responsible for the systems they directly govern, cannot effectively manage foreign and global healthcare systems. Since they can deal with national health infrastructure, hospital management, and domestic responses to emergency crises, governments can be said to have a stronger responsibility to the people already under their institutional control, rather than attempting to extend this jurisdiction to foreign healthcare, which is also a potentially implausible idealization of government capabilities to manage a crisis. Since global emergencies are immensely more complex than smaller-scale outbreaks, healthcare internationalism could be an irrational ask of governments that often struggle to adequately manage other crises. In this sense, deontology dictates that a nation’s most effective means of fulfilling its moral and political obligations is fulfilling its duties to uphold the welfare of the citizens under its control, rather than navigating complex international health infrastructure with vaccine internationalism.

Anti-Vaccine Nationalism

Deontological principles, however, also contradict the ethicality of vaccine nationalist policies. Most notably, the responsibilities of professionals with influence in health policy could be said to contradict the restriction of vaccines and vaccine-related materials to a single nation. In systemic restrictions against vaccine access and distribution based on a person’s nationality, healthcare providers are violating one of their most fundamental medical policies. The Declaration of Geneva is “one of the World Medical Association’s (WMA) oldest policies” (“Declaration of Geneva”), universally adopted in 1948. Since then, editions have been revised and re-edited to comply with growing technological innovation and manage recent issues, but have maintained status as a guideline that dictates the ethics of a healthcare professional’s practice. One section of the 2006 edition of the Declaration claims that, “I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient” (“WMA Declaration of Geneva”). Arguably, the most applicable part of this obligation is a healthcare professional’s promise not to let “nationality” interfere with the relationship between their “duty and… patient,” which is an obligation that public health systems may share. 

Most notably, medical oaths such as the Declaration of Geneva are essential and fundamental codes of ethics that inform not only individual practice, but the broader institutions that dictate how care is delivered. Studies analyzing the contents of these oaths bolster this position, emphasizing that “the modern… Physician’s Pledge [or Declaration of Geneva is] relevant, not only to physicians but also to all of our healthcare colleagues working on the frontlines of this pandemic… [and] that these documents, together with the long tradition of medical ethics, provide a concrete and current basis through which we can navigate the many ethical and moral dilemmas that we may already have faced or will face in the future” (Packianathan et al.). Particularly during public health emergencies when access to life-saving resources depends on policy decisions about distribution, local health infrastructure, which governments play a crucial role in establishing, often dictates which populations physicians can serve. Thus, their commitment to refraining from discriminating against patients within this healthcare system encourages them to follow the Declaration. In this same vein, the principles articulated in the Declaration of Geneva hold significance that transcends immediate care; they articulate the importance of nondiscrimination in medicine and the equal moral worth of each patient, informing broader discussions about global health ethics. Since these principles shape many global health norms, it is reasonable to deduce that, in parallel, healthcare policy-making governing bodies should employ similar nondiscriminatory institutional structures that impact access to care (4).

(4)  I also recognize that the Declaration of Geneva’s status as a voluntary oath stands to mean that it cannot be enforced, especially by governing bodies who have no practical obligation to directly uphold it. In this sense, the Declaration of Geneva’s jurisdiction is limited. However, this paper addresses it in terms of the similar tensions between doctors’ individual practices and global health systems that are informed by smaller-scale healthcare protocol.

Additionally, deontology outlines the obligations associated with political ethics in vaccine nationalism, particularly when considering the responsibilities of the officials governing body. Government officials may purport that their sole obligation is to protect the wellbeing of their inhabitants within their national jurisdiction; nevertheless, this does not eradicate the moral obligations that may transcend antecedent political frameworks, encouraging them to preserve their duties within relations to their international counterparts. Still, I remain cognizant of the moral imperative that governments are institutions and not human persons, meaning that they have no direct moral obligations, and that the only relevant parties with moral responsibilities are the humans that operate them and are the subjects of said ethical obligations as people in positions of power. However, the previous deontological assertion relies on the moral obligations of the individuals that hold governmental positions, as the precedent of the social contract enforces their duty to uphold national wellbeing and safety.

In a dynamic of distribution based on epidemiological demographics, a system detailed earlier in this paper, international collaborations are prioritized. Members of governing bodies between nations have the moral—and, occasionally, political, based on the status of the international relation—duty to support one another by promoting global public health cooperation. In the same vein, each nation is expected to promote global restoration how they can. This “ability” to contribute to global restoration is often assessed by international collaborations that facilitate distribution, such as COVAX in the following example: During COVID-19, more affluent countries would pay directly into COVAX, who paid global pharmaceutical companies for vaccine supply. COVAX would then use the money from these nations to purchase and distribute more supply, which also went to nations incapable of paying COVAX for the vaccines. These nations with a lesser ability to pay for vaccines, as determined by COVAX’s socioeconomic thresholds, would receive discounted or free—without pricing—vaccine supply. In this sense, nations helped COVAX to continue distributing vaccines to other countries that would have struggled to acquire them independently. These duties vary based on preestablished alliances, geopolitical and trade relationships, and other means of interconnection between nations. For instance, as a nation allied closely with Europe, the USA may have greater obligations to distribute vaccination resources to these European nations than it does to an Asian or African country. Still, if the USA provided vaccine supply to its close European allies, many of which are more able to fend for themselves than some African and Asian countries, can a policy of prioritizing the USA and these European nations before others still be ethically defensible? Questions such as these reflect on the issue of ethicality within international relations.

Ultimately, duties of a nation to its international counterparts may vary, based on law, treaty, policy, practice, tradition, or other considerations. Still, we must consider that an ethically defensible stance may be one that enables a nation to pursue international distribution, protecting its moral obligation to aid other countries rather than acting solely in self-interest. Additionally, wealthy nations are not just neutral observers or bystanders within these systems of dependence, but participants in economic development that causes inequality. The global structures that benefit rich countries mean that they control pharmaceutical patents, biotechnology investments, and global trade systems, all of which are relevant to establishing a vaccine nationalist agreement with companies that can access such resources. 

Additionally, we can reflect on the reasons for the creation of these systems, which are often embedded in historical injustice. For instance, colonial systems where Western powers dominated local practices in regions like Africa, Asia, and Oceania—where we see fewer vaccine nationalist policies—instated mercantilist systems that forced native populations to rely on these imperialists for regular economic function. Thus, these imperialist powers could assert significant control over technology developments and trade, ensuring that disparate ability to access necessary resources would continue past a region’s attainment of independence. Based on present inequities that are sustained from historically oppressive practices, affluent nations therefore have a moral obligation to rectify this systemic injustice caused by the structures that have been built to exacerbate economic inequality internationally, because of advantages in resources and subsequent access. This argument also remains fundamentally deontological because the duty to rectify such harm relies not on the potential outcomes, pertaining to economics and supply chain logistics, but on their role in systems that generate these evident inequities.

Therefore, the framework of deontology ethically assesses the duties of a stakeholder pertaining to a decision or action that they must fulfill in the context of vaccine nationalism. Here, deontology is employed to contrast international and national obligations, informed by medical oaths, sociopolitical structures, and other factors that can sway distribution.

Consequentialism

Vaccine nationalism can be observed through a consequentialist framework. The purpose of a consequentialist framework is to assess the ethicality of an action or decision based on its potential outcomes or repercussions. According to this theory, an action is considered ethical if it leads to what are considered the most favorable consequences, which, in this case, would promote the most effective immunization of populations.

Pro-Vaccine Nationalism

A specific version of consequentialism is utilitarianism, which is an ethical framework that values a decision that would produce the greatest outcome for the greatest number of people, which would be the outcome that maximizes happiness and wellbeing while minimizing suffering. In this sense, utilitarian consequentialism measures ethical value on maximizing net utility, which refers to an outcome that brings the most pleasure, satisfaction, or improves wellbeing while simultaneously causing minimal pain and suffering.

Primarily, vaccine nationalism offers the opportunity for quicker economic restoration within a nation, allowing more people to return to their daily lifestyle in the workforce and enabling the normal continuation of economic activity. This also connects to the bioethical principle of beneficence. Since governments and domestic pharmaceutical companies are prioritizing people of a certain nation, they are considerably “doing good” for said citizens. However, beneficence is not synonymous with utilitarianism; even if vaccine nationalist policy implementation could benefit a national population, this does not provide the greatest good for the greatest number of people, which would support distribution on an international level. 

Notably, the idea of utilitarianism is also relevant in democratic nations that employ government styles where popular sovereignty allows citizens to elect representatives to have a figure capable of expressing many of their political views and needs. Firstly, “[f]ellow citizens share “associative ties,” common governmental, civic, and other institutions, and a sense of shared identity” (Emanuel et al.), which also perpetuates national unity. Since vaccine nationalism emphasizes the government’s prioritization of its own people, it can restore and renew public trust in its politicians in a way, which would contribute to the greater good for a large amount of the population under the government’s jurisdiction.

Similarly, this idea can be summarized in that “the legitimate authority of representative government officials inheres in their representing and promoting the interests of their citizens” (Emanuel et al.). While public trust in politicians is an outcome of instating vaccine nationalist policies, it simultaneously improves national health standards. According to a study that researched the implication of trust in politicians, “individuals with a higher level of political trust will be more likely to exhibit vaccination intentions” (Lim et al.), or an intent to be vaccinated. This also corresponds to the potential for herd immunity nationally, in which the greater percentage of individuals vaccinated lowers the overall chances of an infection spreading through a community.

Logistically, it is important to consider that feasibility is an essential component of these nationalism-based allocative policies. Global distribution models, like vaccine internationalism, often assume perfect and simplistic cooperation. However, in reality, states often act independently, heeding precedents set by previous geopolitical rivalries and actions. Additionally, considering the potential costs and inefficiency involved in purportedly idealistic international transportation of supply, vaccine nationalism may be the most realistic and ethical policy available amidst a non-ideal domestic climate, because of a geopolitical system of various distant and independently sovereign nations. 

Moreover, through a consequentialist lens, a facet of vaccine nationalism that is important to examine is its impact on pharmaceutical companies, if widespread access was supported. For example, COVAX offered discounted or free-of-charge distribution of vaccines to nations that failed to pass a threshold of ability to pay for the supply. Potentially, if distribution like this was more prevalent, pharmaceutical companies may yield less revenue for profit, incentivization, and further innovation. Consequently, this could limit a company’s willingness to continue innovating products, as companies are inherently self-serving in order to maintain relevance in a competitive global economy. It also could set a precedent for restricted distribution for cost protection. Companies, including pharmaceutical ones, have fiduciary and financial responsibilities to their shareholders. Without sufficiently fulfilling these responsibilities, innovation, research, and development could potentially stagnate, supplying an argument against pursuing an internationalist policy, which would potentially prioritize philanthropy or altruism over the company’s fundamental need for profit. 

To elaborate on COVAX circumstances, affluent nations with the means to pay for their supply of the vaccines COVAX bought from pharmaceutical companies would pay directly into COVAX, who would provide them with their required supply. However, third-world countries with less means to pay would be offered supply at a discounted price or at no cost, and would receive access to the vaccine. While this celebrates the global distribution of vaccine internationalism, it relates to how internationalism could limit the revenue that pharmaceutical companies receive, as COVAX and other global allocation initiatives would have less financial materials to pay for the supply with. Consequently, this could deter willingness and capability for pharmaceutical companies to manufacture necessary treatments. An important consideration within this scenario is that COVAX operates by creating a pooled fund of money from the nations it plans to distribute to, before purchasing a specific supply of vaccines compliant with the necessary allocation. This operation, however, may still be impacted by the argument of negotiated pricing. If COVAX enters a contract with a nation requiring them to pay more money for their supply than COVAX plans to pay the pharmaceutical company to acquire the supply, then COVAX may still be able to fulfill the fixed prices of the pharmaceutical company while offering less capable nations lower pricing. Still, negotiated pricing does not play as significant of a role as it might if COVAX bought vaccine supply from manufacturers and then were reimbursed or offered discounted to free pricing for nations.

Anti-Vaccine Nationalism

Still, when both options have the potential to offer benefits, a utilitarian perspective to measure the net utility of a certain decision can aid decision-making. A utilitarian lens would advocate in support of internationalism, as this perspective dictates that the wellbeing of humankind globally matters more than that within a given nation, as long as this immunization is effective and successful, to maximize the net benefit of distribution for the greatest number of people. Subsequently, vaccine nationalism could potentially prompt national benefits, ranging from continued pharmaceutical innovation, to national herd immunity, to political trust, through feasible internal distribution of a necessary resource.

Immunization and Access

In terms of other effects that vaccine nationalist policies can produce, consequentialism asserts that these policies may have adverse outcomes. The following points will outline the outcomes that can result from implementing a vaccine nationalist policy, instead of the previous deontological duties, to examine what the future impacts of vaccine nationalism look like. Firstly, the greatest ramifications arguably impact smaller and low-income nations. Looking at the global balance of pharmaceutical industry, the USA houses 56.1% of the

Image by Krisana Manglani from Google Sheets

world’s 50 largest pharmaceutical powers, Europe hosts 34.3%, and Asia with 9.6%, leaving many regions, without these major companies, with lower vaccine accessibility (Gavali). Although having a pharmaceutical company within national borders cannot guarantee vaccine supply from said company, research demonstrates that countries that house major pharmaceutical firms often secure earlier and more reliable access to vaccines through advance purchase agreements and arrangements regarding domestic supply (Privor-Dumm et al.). Therefore, if continents and nations with significantly greater access to vaccine manufacturing, research, and development restrict their distribution of such materials, they exacerbate the preexisting disadvantages of smaller nations who are unable to establish large manufacturing powers in their own nations.

Moreover, consequentialism recognizes that vaccine nationalist policies have the potential to deepen international wealth and immunization gaps. For instance, in the midst of the COVID-19 pandemic, around mid-2021, Africa’s rate of 3% immunization starkly contrasted Europe’s much higher rate, representing one example of the gaps in equitable immunization that would result from such a significant inequity in access to vaccines. While other factors also contributed to these disparate rates, such as a reluctance to rely on Western medicine, the previous statistics regarding regional distribution of pharmaceutical powerhouses also demonstrate the difference in access to companies between Africa and Europe, which is why vaccine nationalism was more common in the latter and thereby often contributed to the restoration of European nations. By exacerbating these differences in immunization gaps, other nations also become unable to adequately return to normal lifestyle and, subsequently, regular economic activity. With people unable to fully assume their previous roles in the workforce due to fear of the spread of disease and an inability to sufficiently immunize the population, international wealth gaps worsen. 

Ultimately, these countries, without major pharmaceutical industries, will be slower to recover economically, socially, politically, and in many other forms. Considerably, “vaccine nationalism in this case amounts to a double injury: people already unjustly deprived – who are suffering from basic health deficits and extreme poverty – are further deprived due to vaccine nationalism during a crisis on the part of the affluent. The fact of extreme global injustice already implies a moral failure on the part of affluent countries. Their exercise of partiality during a crisis compounds an already serious moral failure” (Beaton et al.). This holds that, by fulfilling their previously outlined international obligations, first-world and affluent nations will be able to prevent the further deprivation of necessary resources that third-world countries without significant pharmaceutical industry and manufacturing facilities struggle to access.

Global Consequences

However, these adverse effects do not only impact smaller, low-income countries; they extend to the first-world countries who implement these policies and restrictions in the first place. By restricting equitable global vaccine distribution, these nations are, in a way, allowing disease to continue to disrupt national economic function. Ultimately, though, this function can adversely impact global supply chains, which first-world countries heavily rely on for trade and economic prosperity. Third-world countries, like those that rely on other nations for the manufacturing of vaccines, are conversely relied upon by first-world countries for raw materials, consumer markets, and other economic functions. These economic ramifications evidently have the potential to impact more affluent countries with access to domestic pharmaceutical innovation, with the ability to sign these bilateral agreements with said companies. 

Interestingly, vaccine nationalism resembles the common moral issue known as the Prisoner’s Dilemma, embodied through political philosophy and real-world public health issues. The Prisoner’s Dilemma describes a circumstance in which multiple individuals acting in their self-interest produce a worse outcome for themselves than if they had cooperated. Thus, vaccine nationalism becomes a paradox where a governing body’s sense of self-interest undermines the benefit attained. While it appears rational when decided from the perspective of a single government, the irrationality of these policies in an international system are reflected by slower global vaccination, a higher risk in virus mutation, and a longer-lasting pandemic. 

To elaborate on this virus mutation risk, viruses mutate naturally. However, with limited vaccination in certain areas, or when a population is partially vaccinated, the virus faces evolutionary pressure to mutate to survive. Therefore, the variants that can evade immunity from vaccines or are not prevented by vaccines are more likely to spread. As the virus continues to replicate, the opportunities for mutation grow. This has also been proven historically. COVID-19 variants like Delta and Omicron, which significantly endangered populations, notably emerged in regions with low vaccination access. By refusing to distribute vaccines globally, governing bodies may actively increase global risk, including the threat posed to the vaccinating countries themselves because of these dangerous variants. 

Political Impacts

Converse to the earlier point about restoring public trust, restricting vaccine allocation to prioritize a certain region can erode faith in politicians. According to a study performed, “In seven experiments (total N = 4,215 adults), we demonstrate that… [n]ationally representative samples across multiple countries with large vaccine surpluses (Australia, Canada, United Kingdom, and United States) trusted redistributive leaders more than nationalistic leaders—even the more nationalistic participants” (Colombatto et al.). This unique perspective implies that political faith by a population can vary, entirely dependent on the context that the policies are implemented. It also imposes a sense of responsibility on the government to appeal to the public’s majority opinion on distribution in this time; yet, the juxtaposition of public faith and wellbeing creates a conflict between maintaining trust by not hoarding vaccine supply or prioritizing national health security to mitigate the threat of crisis.

The general ramifications on the actual topic of vaccine nationalism, separate from its stakeholders, are also a key consideration in this case. It is arguable that allowing state borders to determine vaccine allocation can exacerbate the politicization of medical decision-making. Similar to the responsibilities detailed in the Declaration of Geneva, “political affiliation” and “nationality” are meant to be removed from any medical scenario in which they could influence a patient’s treatment, which is applicable since national healthcare policy-makers’ decisions to restrict or enable equitable distribution of vaccines impacts people internationally, who may or may not be able to receive the vaccine. However, in a global health crisis where allocation can already be significantly political, national partiality and its subsequent bilateral agreements turn nationality from a secondary factor in medical treatment—where this characteristic is used to track disease patterns and other medical purposes—to the decisive factor in access to vaccination. In the same vein, vaccine nationalism embeds moral partiality in health institutions. Since a virus logically does not recognize nationality, two patients suffering from the same affliction arguably have equal moral claims to accessing a treatment. Then, in this sense, nationality could be considered irrelevant, as allowing these political borders to decide treatment access makes them morally arbitrary.

Ultimately, extreme vaccine nationalism and internationalism both signify slippery slopes. It is difficult for a nation to balance and weigh their international and national obligations, and the consequences of the decisions they will make. However, other ethical considerations also influence the ultimate decision countries make regarding the policies they make amidst the chaotic emergency vaccine allocation protocols of a public health crisis. 

Vaccine Hesitancy

Image by pch.vector from magnific.com

An interesting facet of this issue brings in a different ethical consideration, pertaining to the people who would have access to the vaccine if an internationalist approach was employed. The belief of vaccine hesitancy “refers to a delay in the acceptance or blunt refusal of vaccines” (Otu et al.), and is commonly attributed to public distrust, misinformation, or religious and social factors. 

In certain nations, significant portions of populations exhibit vaccine hesitancy, being hesitant to take, administer, or simply believe in the efficacy of vaccines. For instance, Burkina Faso has a vaccine hesitant population of 67%, France has 59%, and Russia has 55% (Barceló et al.). This encourages nations to consider: what obligations do manufacturing powers have to countries where the majority of the population is unlikely to administer vaccines? Are there ethical ramifications from not distributing and sharing the manufactured supply? If a country has a surplus of vaccines, does it become unethical to not share these vaccines internationally, especially to some of these countries, although the majority of the population is unlikely to use them? Or should the manufacturing nation secure their own public health standards by stockpiling their domestically manufactured vaccines while other nations experience far lower immunization rates? Were these vaccines distributed, employing an international allocation approach, vaccination could become more normalized in regions where popular belief often counters their use. This could ultimately benefit the overall wellbeing of such populations,  as scientific study dictates that vaccines are much more effective than remaining unprotected through preventative means from a certain disease, implying that nations without strong vaccine recommendations could potentially be endangering these populations. 

On the other hand, the distribution despite protest against vaccination could signify a paternalistic approach, from a vaccine manufacturing power to a vaccine hesitant country. It could symbolize that the manufacturer is more aware of what is considered “healthy” for the other nation, infringing on the hesitant nation’s autonomy and popular belief. This is also a concern confronted in terms of the difference between the popularized forms of Western medicine and traditional practices. Many studies explain that Western practices, like vaccination, are often imposed on native groups, with the justification of being more medically, scientifically, and technologically advanced. While these methods may be more concretely proven to be effective, this also ignores the historical protocols that dictate medicine within a traditional culture, which is an argument that supports restricting vaccines to regions where more people are likely to administer or accept it, rather than imposing such globalized medicine on cultures that oppose these more contemporary practices. In this sense, the distribution of vaccines can be seen as perpetuating this Western cultural imperialism that manifests itself in the medical field.

Vaccine hesitancy ultimately complicates an ethical analysis of vaccine nationalism, because it raises questions about the paternalistic and superiority concerns associated with allocating scarce doses to populations unlikely to use them. Therefore, the relevance of other issues in distribution create interesting nuances, complicating vaccine allocation in a way that exposes the underlying western paternalism that global distribution often ignores.

Ultimately, the implications of vaccine hesitancy complicate, but do not refute, my position regarding the ethicality of vaccine nationalism. While I believe that this form of nationalism is unethical, which I disclosed at the beginning of this paper, I also believe that vaccine internationalism has its own ethical limitations. Internationalism raises concerns about paternalistic approaches that disrespect cultural tradition and autonomy, provoking policy-makers to consider more nuance when making their decisions to implement more widespread, global distributive approaches. Additionally, we must recognize the medical and scientific implications of expanding allocation protocol, in that numerous lives could be saved by this treatment that measurably improves health outcomes. Therefore, immunizing a willing percentage of the population—since no nation has a 100% rate of refusal to entirely administer vaccines—can still considerably ameliorate the destruction that a disease outbreak brings to a region, motivating support for a more global or internationalist policy.

Conclusion

Ultimately, a time of a global public health issue is a crisis that motivates immediate action. However, it is demonstratively difficult to balance the different obligations and consequences that a vaccine manufacturing nation and pharmaceutical power has to its own people and international counterparts. 

In this paper, I have discussed the ethical implications of vaccine nationalist policies, and employing these in terms of allocation of vaccines during a public health crisis. Through consideration of international cooperation, relevant real-world case studies, the relationship between the government and a company, the ethical frameworks of deontology and consequentialism, and other considerations, such as vaccine hesitancy, this paper has reflected on the guidelines of action a country can take in terms of vaccine allocation.

I have also determined that pure vaccine nationalism is often not ethically justifiable. This is demonstrated by the consequentialist analysis presented in this paper, in which I have highlighted outcomes of selective distribution protocol that would degrade quality of life and wellbeing during public health crises. For instance, the measurable destruction that nations with lesser access to pharmaceutical power would face, the potential evolution of viruses into severe mutations and variants, and economic damages to global commerce signify just some of the ramifications of vaccine nationalist policy implementation during global public health crises. The framework of deontology offers a similar, albeit complex, argument. With nondiscrimination policy so prevalent in individual healthcare practice, vaccine nationalist policy could reinforce consideration of background characteristics in healthcare. A question this brings us to ask is: if physicians are not permitted to consider nationality and ethnicity in distribution of care, why should allocation protocols for a necessary health resource follow a system based solely on nationality and ethnicity? 

Still, I concede that arguments surrounding the ethicality of vaccine nationalism conceivably hold little significance in the perspectives of those creating these policies. A consideration established throughout this paper is that governments are inherently nationalist, in the sense that they have certain responsibilities to citizens that are priorities over other nations; and this feeling is often reciprocated, with citizens believing that their wellbeing should take precedence over that of non-citizens, in terms of health policy that the government is able to control. Ergo, it is likely inevitable that nations will continue to implement similar restrictive policies, if only for the sake of national wellbeing. In some sense, this inevitability may mean that the most realistic future approach could be a hybrid solution that pulls from both sides of the vaccine nationalist spectrum. 

For instance, an effective system could be one that emphasizes the importance of protecting the vulnerable, both nationally and internationally. This inclination could be manifested in governments supporting vulnerable populations throughout the world, but in a system of organized priority that recognizes and allows them to uphold internal obligations to its citizens, as established by phenomena like the earlier mentioned social contract. For instance, governments could potentially buy vaccine supply from domestically-located pharmaceutical companies based on established contractual agreements, for a certain number of people with priority for vulnerable populations (5). However, global systems of pooled funding and allocation would still exist, with the expectation that these governments would contribute to a fund that supports international distribution. Still, this expectation would occur after successful distribution—which is difficult to exactly define—to vulnerable populations on a national scale.

(5)  “Vulnerable populations” is a term that can have various connotations. In this context, the phrase is defined in a similar manner to hhoweberow COVAX and governments globally delineated it. For instance, frontline health workers in social or health care settings were prioritized because of likelihood of exposure; individuals identified as high-risk due to old age may be prioritized because of probable severity were these populations to contract an infection; and those with co-morbidites, or preexisting conditions, that could exacerbate an infection were also higher in the hierarchical system of allocation.

Interestingly, the process of determining “solutions” as a substitute for vaccine nationalism is arguably infeasible. Not only do we lack sufficient examples of global allocation initiatives, looking primarily to COVAX, but we find that even our most emphatic examples of vaccine nationalism are sourced from the COVID-19 pandemic. Based on this limited scope, and our lacking examples as a greater global society, it is difficult to determine what other approaches to distribution may look like. Additionally, these governments maintain their liberty to dictate the nuances of distributive policies, as sovereign nations and governing bodies. Expectations for actions to promote international wellbeing can be obsolete with governments that prioritize their citizens over all else.

Vaccine nationalism does not only grapple with the ethicality of national versus international prioritization; it encourages us to reevaluate our geopolitical relationships and global healthcare system. The inquiries and explorations of this paper have developed my personal curiosity about the real-world application of these policies. While history has dictated the patterns for their success or failure, we must consider if, in the future, widespread distribution truly has the potential to improve global health, even beyond the demonstrably significant advancmenets—what with clear increases in global average life expectancy—that have been made in modern medicine and sanitation. Moreover, interestingly, vaccine nationalism encourages us to consider the root cause of why nations must make this decision to prioritize either national or international interests. Rather than being simply a product of nationalism and independent national resources, this tense conflict could result from a structural failure of the complex web of health agencies that develop policy and govern medical-decision making. Is a nation culpable for being unwilling to distribute vaccines internationally, or is it simply because of such a decentralized global public healthcare system?

As this paper has demonstrated, vaccine nationalism, evidently, is both logistically and ethically complex, imploring us to weigh competing obligations to national populations and the broader international community. While vaccine nationalism is often deemed blatantly unethical, we must also be cognizant of its nuance, in how this distributive policy functions as a mechanism for governments to protect their own citizens during times of emergency and resource scarcity. This essential conversation on duties and consequences regarding the implementation of vaccine nationalism is not only a reflection of current geopolitical systems, but a reminder that policy cannot remain stagnant in an ever-evolving world. As technological advancement progresses, enabling us to increase vaccine production and transportative efficacy inconceivably beyond modern estimates, the health policies our society enacts must adapt simultaneously; and, hopefully, the discussions we facilitate now as a reflection of recent policy will guide us into a future where we may better understand the “ethical and political borders” we confront in the pursuit of public health.

Works Cited

Barceló, Joan, et al. "Vaccine nationalism among the public: A cross-country experimental evidence of own-country bias towards COVID-19 vaccination." Social Science & Medicine, vol. 310, Oct. 2022. Science Direct, https://doi.org/10.1016/j.socscimed.2022.115278. Accessed 13 Apr. 2026.

Beaton, Eilidh et al. "Crisis Nationalism: To What Degree Is National Partiality Justifiable during a Global Pandemic?." Ethical theory and moral practice : an international forum vol. 24,1 (2021): 285-300. doi:10.1007/s10677-021-10160-0

Bradford, Anu. "The Battle for Technological Supremacy: The US–China Tech War." Digital Empires: The Global Battle to Regulate Technology, pp. 183-220. Oxford Academic, https://doi.org/10.1093/oso/9780197649268.003.0006. Accessed 13 Apr. 2026.

Colombatto, Clara et al. "Vaccine Nationalism Counterintuitively Erodes Public Trust in Leaders." Psychological science vol. 34,12 (2023): 1309-1321. doi:10.1177/09567976231204699

"Coronavirus: the Commission signs first contract with AstraZeneca." European Union, 24 Aug. 2020, ec.europa.eu/commission/presscorner/detail/en/ip_20_1524. Accessed 13 Apr. 2026.

"COVAX Facility." Gavi: The Vaccine Alliance, www.gavi.org/covax-facility#:~:text=High%2D%20and%20upper%20middle%2Dincome,for%20the%20Gavi%20COVAX%20AMC. Accessed 13 Apr. 2026.

"Declaration of Geneva: The 'Modern Hippocratic Oath.'" World Medical Association, www.wma.net/what-we-do/medical-ethics/declaration-of-geneva/. Accessed 13 Apr. 2026.

Dewan, Angela. "AstraZeneca's vaccine contract with the UK is based on 'best efforts,' just like its deal with a frustrated EU." CNN World, 18 Feb. 2021, www.cnn.com/2021/02/17/europe/uk-astrazeneca-vaccine-contract-details-intl. Accessed 13 Apr. 2026.

Emanuel, Ezekiel J et al. "An ethical framework for global vaccine allocation." Science (New York, N.Y.) vol. 369,6509 (2020): 1309-1312. doi:10.1126/science.abe2803

European Union. "European Medicines Agency." European Union, www.ema.europa.eu/en/about-us. Accessed 10 Apr. 2026.

Ferguson, Sarah. "South Asia Braces for a Health Crisis Following India's

COVID-19 Surge." UNICEF, 7 May 2021, www.unicefusa.org/stories/

south-asia-braces-health-crisis-following-indias-covid-19-surge. Accessed 27 May 2026.

Gavali, Pranav. "The World's 50 Largest Pharmaceutical Companies." Edited by Dorothy Neufeld. Visual Capitalist, 25 Jan. 2024, www.visualcapitalist.com/cp/worlds-50-largest-pharmaceutical-companies/. Accessed 13 Apr. 2026.

Gurung, Santosh, editor. "COVID-19 Vaccine Introduction: Building Global Capacity (webinar series)." TechNet, www.technet-21.org/en/topics/programme-management/covid-19-vaccine-introduction-building-global-capacity. Accessed 10 Apr. 2026.

"International Health Regulations." Center for Disease Control, edited by Global Health Center, 20 Mar. 2026, www.cdc.gov/global-health/topics-programs/ihr.html. Accessed 13 Apr. 2026.

Italy. Costa v. Enel. Members' Research Service, vol. I. European Parliamentary Research Service, www.europarl.europa.eu/RegData/etudes/BRIE/2024/762361/EPRS_

BRI%282024%29762361_EN.pdf. Accessed 13 Apr. 2026. Unpublished opinion.

Jerving, Sara. "Deal to send COVID-19 vaccines from South Africa to Europe dismantled." Devex Impact House: The Capital Summit, 2 Sept. 2021, www.devex.com/news/deal-to-send-covid-19-vaccines-from-south-africa-to-europe-dismantled-101532?utm_. Accessed 13 Apr. 2026.

"Johnson & Johnson Announces Agreement with U.S. Government for 100 Million Doses of Investigational COVID-19 Vaccine." Johnson&Johnson, 5 Aug. 2020, www.jnj.com/media-cen

ter/press-releases/johnson-johnson-announces-agreement-with-u-s-government-for-100-mill

ion-doses-of-investigational-covid-19-vaccine#:~:text=The%20Biomedical%20Advanced%20

Research%20and,S%20under%20a%20subsequent%20agreement. Accessed 13 Apr. 2026.

Kirshnan, Vidya. "As India Lifts its Vaccine Export Ban – will 600 Million India-made Doses of J&J Vaccine be Shipped to Rich Western Countries?" Health Policy Watch, Independent

Global Health Reporting, 24 Sept. 2021, healthpolicy-watch.news/will-600-million-india-made-doses-of-jj-vaccine-be-exported-to-rich-western-countries/. Accessed 13 Apr. 2026.

Lie, Reidar K., and Franklin G. Miller. "Allocating a COVID-19 Vaccine: Balancing National and International Responsibilities." NIH: National Library of Medicine, 9 Dec. 2020. Pub Med, https://doi.org/10.1111/1468-0009.12494. Accessed 13 Apr. 2026.

Lim, Jaeyoung, and Kuk-Kyoung Moon. "Altruism, Political Trust, and Their Influence on COVID-19 Vaccination Intentions." Health & Social Care in the Community, vol. 2025, no. 1, 3 June 2025. Wiley Online Library, https://doi.org/10.1155/hsc/9931276. Accessed 13 Apr. 2026.

"MOU 225-14-017." FDA Domestic Memoranda of Understanding. U.S. Food & Drug Administration, www.fda.gov/about-fda/domestic-mous/mou-225-14-017. Accessed 27 May 2026.

Obinna, Denise N. "Solidarity across borders: A pragmatic need for global COVID‐19 vaccine equity." NIH: National Institute of Health, 28 Sept. 2021. Pub Med, https://doi.org/10.1002/hpm.3341. Accessed 13 Apr. 2026.

Otu, Akaninyene et al. "Beyond vaccine hesitancy: time for Africa to expand vaccine manufacturing capacity amidst growing COVID-19 vaccine nationalism." The Lancet. Microbe vol. 2,8 (2021): e347-e348. doi:10.1016/S2666-5247(21)00126-9

Packianathan, Satyaseelan, et al. "Reflections on the Hippocratic Oath and Declaration of Geneva in Light of the COVID-19 Pandemic." NIH: National Library of Medicine, 2 July 2020.

Pub Med, https://doi.org/10.14423/SMJ.0000000000001117. Accessed 13 Apr. 2026.

Physicians in the Senate. United States Senate, www.senate.gov/senators/PhysiciansintheSenate.htm. Accessed 13 Apr. 2026.

Privor-Dumm L, Excler J, Gilbert S, Abdool Karim SS, Hotez PJ, Thompson D, et al. Vaccine access, equity and justice: COVID-19 vaccines and vaccination. BMJ Global Health. 2023;8:e011881. https://doi.org/10.1136/bmjgh-2023-011881

Qi, Shao. "The origin of vaccine nationalism." Elsevier, vol. 51, 2 april 2025. Science Direct, https://doi.org/10.1016/j.vaccine.2025.126897.

Qi, Shao. "Vaccine nationalism is not unethical from a political ethics perspective: Learning from the global COVID-19 vaccine distribution failure." NIH: National Library of Medicine.

Pub Med, https://doi.org/10.1016/j.healthpol.2024.104996. Accessed 13 Apr. 2026.

Singh, Bawa, et al. "Global vaccine inequities and multilateralism amid COVID-19: Reconnaissance of Global Health Diplomacy as a panacea?" Pub Med. NIH: National Library of Medicine, https://doi.org/10.34172/hpp.2022.41. Accessed 10 Apr. 2026.

Sinopharm. "Listed Companies." Sinopharm, en.sinopharm.com/2023-12/05/c_18807.htm? Accessed 27 May 2026.

"Trade barriers." Access2Markets, 28 Oct. 2024, trade.ec.europa.eu/access-to-markets/en/barriers/details?barrier_id=16542&sps=false. Accessed 13 Apr. 2026.

Wilder-Smith, Annelies, and Sarah Osman. "Public health emergencies of international concern: a historic overview." NIH: National Library of Medicine. Pub Med, https://doi.org/10.1093/jtm/taaa227. Accessed 13 Apr. 2026.

"WMA Declaration of Geneva." World Medical Association, www.wma.net/wp-content/uploads/2018/07/Decl-of-Geneva-v2006-1.pdf. Accessed 13 Apr. 2026.

World Health Organization. "Vaccine equity." World Health Organization, www.who.int/campaigns/vaccine-equity. Accessed 10 Apr. 2026.