Bioethics Essay Contest Winner: Vaccine Trials in Prisons? An Unethical Response to High Prison Infection Rates

The reasons for the heightened infection and mortality rates are multifactorial, but includes the high population density in prisons, high admission and discharge rate from such facilities, disproportionately high rates of chronic diseases, often inadequate medical supervision, poor sanitation, and the inability for facilities to adequately isolate infected prisoners.^1-3 The impacts of the high infection and death rates among this population is understandably difficult to quantify and will surely have lasting impacts on the many communities who suffer from higher than average incarceration rates as a results of systematic racism, the effects of low socioeconomic status, and other upstream determinants. However, quantifications of these impacts are beginning to be published. One such study by Reinhart et al., published in November 2020, has investigated the immediate effects of the high prisoner infection rate on infection trends in the surrounding populations by analyzing Cook County Jail discharges and infection nodes by zip codes in the Chicago area. They found that jail-community cycling was a significant predictor of COVID-19 cases and was able to account for 55% of the variance between zip codes.⁴ It is no surprise therefore, that high infection rates of any disease among incarcerated people, especially those diseases with similar transmission patterns as COVID-19, are a problem that needs to be addressed early on to prevent large scale spread.

Conducting research on the imprisoned population has been restricted following major policy shifts in the 1970’s, which specifically barred incarcerated people from participating in vaccine research trials. In light of the current pandemic, Wang et al. published an article in JAMA in September of 2020 re-examining this particular exclusion. They argued that this population should be allowed to volunteer to participate in phase 3 vaccine trials because they are so disproportionately impacted by COVID-19 and its repercussions. If proper informed consent can be obtained without coercion, they suggest that it may even be unethical to not allow these people to participate and potentially benefit from these trials.¹

While this standpoint in theory may increase the autonomy of the incarcerated population in America, others question how practical it is to assume sufficient informed consent can be obtained without coercion in an environment that is so often under-resourced. These questions include whether or not sufficient medical personnel can be provided to these facilities to provide sufficient informed consent, monitor symptoms, and provide treatments when side effects do occur, as well as whether or not coercion can really be eliminated in a prison environment at all, and many others.⁵

Outside of these practical concerns however, it is not clear that allowing participation in vaccine trials is truly ethical. While this population is disproportionately affected by COVID-19 and could therefore have theoretically benefitted from a vaccine under investigation, this population is at increased risk for COVID-19 largely because of the environment that they have been forced into and have no autonomy over. Therefore, inviting participation in a study that may protect them from a disease that the very design and resources of their environment is causing them to get at higher rates, instead of changing that environment, does not truly improve autonomy, only the appearance of it. Further, allowing participation is not a neutral act in itself; when the general population is benefitting from the poor environment prisoners live in, we are incentivized to allow the continuation of that environment and inhibit future prison reform. When the public is benefitting from the poor sanitation, tight quarters, and inadequate medical attention these people are already facing, we are less likely to see those things change in the future.

Overall, while some members of the medical community see the current COVID-19 pandemic as an event that may have warranted an exception to the policies in place protecting incarcerated people from potential abuse caused by participation in some branches of medical research, doing so may not have been practical given the often under-resourced status of most prisons, and further, may have had negative impacts on the future of prison reform. It is essential that in future events of similar significance, we maintain the high ethical standards in place to protect underprivileged populations who are at risk for abuse in research studies.

by Evalina Bond

Works Cited

1. Wang EA, Zenilman J, Brinkley-Rubinstein L. Ethical Considerations for COVID-19 Vaccine Trials in Correctional Facilities. Jama. Sep 15 2020;324(11):1031-1032. doi:10.1001/jama.2020.15589
2. Saloner B, Parish K, Ward JA, DiLaura G, Dolovich S. COVID-19 Cases and Deaths in Federal and State Prisons. Jama. Aug 11 2020;324(6):602-603. doi:10.1001/jama.2020.12528
3. Strassle C, Jardas E, Ochoa J, et al. Covid-19 Vaccine Trials and Incarcerated People – The Ethics of Inclusion. N Engl J Med. Nov 12 2020;383(20):1897-1899. doi:10.1056/NEJMp2025955
4. Reinhart E, Chen DL. Incarceration And Its Disseminations: COVID-19 Pandemic Lessons From Chicago’s Cook County Jail. Health Aff (Millwood). 08 2020;39(8):1412-1418. doi:10.1377/hlthaff.2020.00652
5. Reiter K. Does a Public Health Crisis Justify More Research with Incarcerated People? Hastings Cent Rep. Mar 2021;51(2):10-16. doi:10.1002/hast.1235

As a fourth-year medical student at the University of Wisconsin School of Medicine and Public Health (SMPH), Evalina Bond, MD ’21, received the 2021 Dr. Norman Fost Award for the Best Medical Student Bioethics Essay. The contest — sponsored by the SMPH and its Department of Medical History and Bioethics — asked students to choose a topic related to the COVID-19 pandemic’s impact on the ethics of conducting vaccine trial research on the American prison population.