This Note consists of three parts: A. Context, B. On vaccines, C. Guidelines for the Vatican Covid-19 Commission
Covid-19 is exacerbating a triple threat of simultaneous and interconnected health, economic and socio-ecological crises that are disproportionately impacting the poor and vulnerable. As we move towards a just recovery, we must ensure that immediate cures for the crises become stepping-stones to a more just society, with an inclusive and interdependent set of systems. Taking immediate actions to respond to the pandemic, keeping in mind its long-term effects, is essential for a global and regenerative “healing.” If responses are limited solely to the organizational and operational level, without the re-examination of the causes of the current difficulties that can dispose us towards a real conversion, we will never have those societal and planetary transformations that we so urgently need (cf. Fratelli Tutti, 7). The various interventions of the Vatican Covid-19 Commission (“Commission”), established by Pope Francis as a qualified and rapid response to the pandemic, are inspired by this logic, and so is this Note, which deals specifically with the issue of Covid-19 vaccines.
B. On vaccines
Fundamental principles and values
1. On several occasions, Pope Francis has affirmed the need to make the now imminent Covid-19 vaccines available and accessible to all, avoiding “pharmaceutical marginality”: “if there is the possibility of treating a disease with a drug, this should be available to everyone, otherwise an injustice is created”. In his recent Urbi et Orbi Christmas message, the Pope stated that vaccines, if they are “to illuminate and bring hope to all, need to be available to all… especially for the most vulnerable and needy of all regions of the planet”. These principles of justice, solidarity and inclusiveness, must be the basis of any specific and concrete intervention in response to the pandemic. The Pope even talked about it in the Catechesis during the General Audience of 19 August 2020, offering some criteria “for choosing which industries to be helped: those which contribute to the inclusion of the excluded, to the promotion of the least, to the common good and care for creation”. Here we have a broad horizon that evokes the principles of the Church’s Social Doctrine, such as human dignity and the preferential option for the poor, solidarity and subsidiarity, the common good and the care of our common home, justice and the universal destination of goods. This also recalls the values that in the language of public health constitute the shared values in health emergencies: equal respect for people (human dignity and fundamental rights), reduction of suffering (solidarity towards those in need or sick), correctness or fairness (no discrimination, and fair distribution of benefits and burdens).
2. The Pope’s reminder to the pharmaceutical companies highlights that the final moment of vaccine administration is not the only one that must be taken into account to reach its universal and fair destination. Rather, its entire “life cycle” must be considered, from the very beginning. We shall therefore proceed in this text by examining the various stages of the vaccine journey, ranging from production to approval, from administration to distribution, on which the recent Note of the Congregation for the Doctrine of Faith (CDF) also insists. In each of these phases we recognize ethical implications that we must duly take into account so as to analyse the much needed political-economic, organizational and communication decisions. We will conclude with some recommendations for concrete actions, which can mobilize civil institutions and networks, as well as ecclesial agents, in order to contribute to an equitable and universal access to the vaccine.
Research and production
3. The first issue that is often raised around vaccine production concerns the biological materials used for their development. According to the available information, some of the vaccines that are now ready to be approved or applied use cell lines from voluntarily aborted foetuses in more phases of the process, while others use them in specific laboratory tests.
4. This issue has already been addressed by the Instruction Dignitas Personae, from the Congregation for the Doctrine of Faith (8 September 2008). Once we establish that the aim of (public) healthcare cannot justify voluntary abortion in order to obtain cell lines for vaccine production – and thus their distribution and marketing is also morally unlawful in principle – the Instruction states: “within this general picture there exist differing degrees of responsibility. Grave reasons may be morally proportionate to justify the use of such “biological material”. The theme has been addressed in the recent Note from the very same Congregation, with specific reference to Covid-19 vaccines.
5. The Pontifical Academy for Life returned to the matter with two Notes (5 September 2005 and 31 July 2017 respectively). In particular, the second referred to these preparatory techniques by ruling out “a morally relevant cooperation between those who use these vaccines today and the practice of voluntary abortion. Hence, we believe that all clinically recommended vaccinations can be used with a clear conscience and that the use of such vaccines does not signify some sort of cooperation with voluntary abortion. While the commitment to ensuring that every vaccine has no connection in its preparation to any material originating from an abortion, the moral responsibility to vaccinate is reiterated in order to avoid serious health risks for children and the general population.”
6. The various mechanisms of production and action of the vaccine are significant when it comes to the logistics of distribution (especially in relation to the temperature at which they are stored), and their ability to protect against infection or the clinical manifestation of the disease. In the first case, when the vaccine protects against infection, it contributes to “herd” immunity. Conversely, in the latter case, when the infection arrives without clinical manifestations, the vaccine does not reduce the circulation of the virus (hence the need to directly vaccinate those who are most at risk).
7. The issue of production is also linked to that of vaccine patents. The financing of research has followed different paths, in the form of both the investment of resources from States (issued directly to research, or though prior purchase of a certain number of doses), and donations from private entities. It is therefore a matter of specifying how the vaccine can effectively become a “common good,” as already expressed by several political leaders (eg. the President of the European Commission). In fact, since it is not an existing natural resource (such as air or oceans), nor a discovery (such as the genome or other biological structures), but an invention produced by human ingenuity, it is possible to subject it to economic consideration, which allows the recovery of the research costs and risks companies have taken on. Nonetheless, given its function, it is appropriate to consider the vaccine as a good to which everyone should have access, without discrimination, according to the principle of the universal destination of goods highlighted by Pope Francis (cf. no. 1). “We [cannot] allow the virus of radical individualism to get the better of us and make us indifferent to the suffering of other brothers and sisters… letting the law of the marketplace and patents take precedence over the law of love and the health of humanity”.
8. The sole purpose of commercial exploitation is not ethically acceptable in the field of medicine and healthcare. Investments in the medical field should find their deepest meaning in human solidarity. For this to happen, we ought to identify appropriate systems that favour transparency and cooperation, rather than antagonism and competition. It is therefore vital to overcome the logic of “vaccine nationalism”, understood as an attempt by various States to own the vaccine in more rapid timeframes as a form of prestige and advantage, procuring the necessary quantity for its inhabitants. International agreements are needed, and are to be supported, in order to manage patents so as to facilitate universal access to the vaccine and avoid potential commercial disruptions, particularly to keep the price steady in the future.
9. The industrial production of the vaccine could become a collaborative undertaking between states, pharmaceutical companies and other organizations so that the production can be carried out simultaneously in different parts of the world. As it has happened for the research – at least partially – it is desirable that positive synergy also occurs in the production stage. This would allow the enhancement of existing plants in the various areas in which vaccines will be administered, on the basis of the principle of subsidiarity.
Approval, distribution and administration
10. Once the various phases of the experimental studies have been completed, the question arises as to how the product can be approved in the current emergency situation by the regulatory authorities to put it on the market and use it in different countries. Given the diversity of the bodies recognized as competent for such authorization, and the international dynamics of the pandemic, it is necessary to coordinate the procedures necessary to achieve this objective and promote cooperation between regulatory authorities.
11. In the public debate, there are different positions on the criteria of administration and access to the vaccine. Despite the difference, however, we find certain lines of convergence that we intend to support. There is agreement on the priority to be given to professional categories engaged in services of common interest, in particular health personnel. This also includes activities that require contact with the public (such as school and public security), vulnerable groups (such as the elderly, or people with particular pathologies). Of course, such a criterion does not resolve all situations. A grey area remains, for example, when defining the priorities of vaccine implementation within the very same risk group. A more attentive stratification of populations could help resolve these dilemmas (e.g. vaccine in areas with higher density maximizes its benefits). In addition, other relevant aspects besides health (such as the different practicability of restrictive measures) for a fair distribution must be taken into account.
12. This order of administration, at an international level, implies that “the priority must be given to vaccinating … some people in all countries, rather than all people in some countries” (WHO Director). That some countries receive the vaccine late due to prior large-scale purchase by richer states must be avoided. It is a question of agreeing on the specific percentages according to which to concretely proceed. Vaccine distribution requires a number of tools that must be specified and implemented to achieve the agreed objectives in terms of universal accessibility criteria. The CDF recalls the existence of “a moral imperative for the pharmaceutical industry, for governments and international organisations, to guarantee that effective, safe and ethically acceptable vaccines are made available in the poorest countries, in a manner that is not burdensome for them.” In particular, it is necessary to develop a distribution program that takes account of the collaboration needed to deal with logistical-organizational obstacles in areas that are not easily accessible (cooling chains, transport, healthcare workers, the use of new technologies, etc.). The characteristics of the vaccine also affect this aspect (e.g. storage temperature). This confirms the need for an international body with the task, the moral authority, and the operational capacity to coordinate the various stages of the vaccine process. At present, the World Health Organization remains an important reference point – to be strengthened and improved – regarding the emerging problematic issues.
13. On the moral responsibility of undergoing vaccination (also on the basis of what has been said in n. 3), it is necessary to reiterate how this issue also involves the relationship between personal health and public health, showing their close interdependence. In the light of this connection, we consider it important that a responsible decision be taken in this regard, since refusal of the vaccine may also constitute a risk to others. This also applies if, in the absence of an alternative, the motivation is to avoid benefiting from the results of a voluntary abortion. In fact, in these cases, as the Congregation for the Doctrine of Faith states, it can be considered “morally acceptable”, under precise conditions, “to receive Covid-19 vaccines that have used cell lines from aborted fetuses in their research and production process.” This is a matter of material passive cooperation (as opposed to formal cooperation), since it is indirect and remote, particularly given the intention underlying the decision, the contingency with respect to the accused immoral event, and the current circumstances in which we find ourselves. Therefore, the criteria that would make ethically illicit the decision to vaccinate are non binding. For this reason, such refusal could seriously increase the risks for public health. In fact, on the one hand, those categories of people who cannot be vaccinated (e.g. immunosuppressed) and who can thus only rely on other people’s vaccination coverage (and herd immunity) to avoid the risk of infection, would be more exposed. On the other hand, becoming ill leads to an increase in hospitalizations, with subsequent overload for health systems, up to a possible collapse, as has happened in various countries during this pandemic. This hinders access to health care which, once again, affects those who have fewer resources. The Bishops of England and Wales have recently reaffirmed that “individuals should welcome the vaccine not only for the sake of their own health but also out of solidarity with others, especially the most vulnerable”.
C. Guidelines for the Vatican Covid-19 Commission
14. For the sake of clarity on the work of the Commission, some guidelines for its work in relation to the vaccine are given below. The general intention is to obtain a safe and effective vaccine for Covid-19 so that treatment is available to all, with a particular concern for the most vulnerable, respecting equity across the full spectrum of the vaccine development/deployment (research, design, production, funding, distribution, programs and implementation). Transparency and correct communication are essential to foster trust and adherence to the vaccine process. 
15. Objective 1: Ethical-scientific evaluation. Based on the science available, the Commission will be able to contribute to evaluations on vaccine quality, methodology and pricing necessary for equitable distribution to the most vulnerable.
Actions required: Work closely with major organizations who are developing, evaluating, delivering, and administering vaccines with the possibility, when necessary, of informing opinions on public positions on the quality/equity of proposals for distribution and utilization. For this reason, the Commission aims to have access to the most accurate scientific information as well as to make use of various abilities to audit proposed vaccine and treatment strategies, in particular with regard to their impact on the most vulnerable. As the Holy Father indicates, “We cannot allow the various forms of nationalism closed in on themselves to prevent us from living as the truly human family that we are.” We must provide “vaccines for all … [placing] before all others the most vulnerable and needy!”
16. Objective 2. Global cure with “local flavour”. A global cure, with local flavour (locally informed vaccine programs): we aim to develop resources to assist local Churches in preparing for this vaccine initiative and treatment protocols to those in their particular communities.
Actions required: Work closely with the Dioceses and Christian communities worldwide to understand their varied needs and use that information to develop robust positions, recommendations and tools appropriate to various needs. This will start by listening to local Churches and then helping them to advocate for certain structures and supports from the government and other agencies.
17. Objective 3. Partnership and participation. To have a close collaboration with the many organisations that are necessary to contribute to the planning, execution and evaluation of recommendations for global vaccine administration.
Actions required: Work with representatives from major institutions and organizations involved as well as global health organizations, NGOs, and donor organizations to help in developing, evaluating and participating in solutions.
18. Objective 4. Joining forces. Effective collaboration with the working groups of the Commission and other ecclesial groups to propose best possible recommendations to the Church.
Actions required: Work with the other Commission Task Forces using the framework of Laudato si’ and Fratelli Tutti taking into account their recommendations for the final recommendations made by the Commission.
19. Objective 5: Leadership. Deepening the understanding and commitment of the Church in protecting and promoting the God-given dignity of all.
Actions required: Help the universal Church and the world articulate and model the deeper reasons for meeting this challenge as a global human family. The Church could offer to function as a catalyst for addressing this challenge in a manner that reflects an awareness and respect for the dignity of all.
20. Objective 6. The Church at the service of “healing the world”. Leading by example in ways that are clear and contribute significantly, among other things, to achieving the goal of equitable distribution of vaccines and treatments.
Actions required: Creatively use the voices of the Church worldwide to speak, exhort and contribute to assuring that quality vaccines and treatments are available to the global family, especially the vulnerable. The Church has many ways to assist in this such as her health networks, the Bishops’ Conferences, multiple church organisations who do outreach to the poor, religious communities, etc. Consider donations to groups that work to get treatments and vaccines to those most in need.
 Pope Francis, 2020. “Address to the Members of the Banco Farmaceutico Foundation”, September 19, 2020.
 Pope Francis, 2020. “Urbi et Orbi – Christmas 2020”. December 25, 2020
 Cf. Compendium of the Social Doctrine of the Church, nn. 105-208.
 Pope Francis, 2020. To Heal the World. Catechesis on the Pandemic. Introduction.
 Cf. Nuffield Council for Bioethics, 2020. Fair and equitable access to Covid-19 treatments and vaccines. London: NCB, p. 3. London: NCB,p. 3
 CDF, 2020. “Note on the morality of using some anti-Covid-19 vaccines”, December 21, 2020, n.6.
 Cf. Charlotte Lozier Institute, Covid-19 Vaccine Candidates and Abortion-Derived Cell Lines, 3 December 2020, in https://lozierinstitute.org/update-covid-19-vaccine-candidates-and-abortion-derived-cell-lines/
 CDF, 2008. Instruction Dignitas Personae: On Certain Bioethical Questions, n. 35.
 Cf. CDF, 2020. “Note on the morality of using some anti-Covid-19 vaccines”, December 21, 2020. nn.2-3.
 «Allocation guidelines must balance the obligation to assist individuals most likely to benefit against the obligation to secure the greatest aggregate benefit across the population». In: Wu, J.H., John, S.D, and Adashi E.Y., 2020, “Allocating Vaccines in a Pandemic: The Ethical Dimension”, The American Journal of Medicine, November 2020, Volume 133 (11).
 President Von der Leyen has repeatedly expressed that the Covid-19 vaccine needs to be addressed as a public good, since all the efforts to tackle the pandemic can only succeed if we work together for the common good. See for example her later speech https://ec.europa.eu/commission/presscorner/detail/ov/SPEECH_20_2258
 Pope Francis, 2020. “Urbi et Orbi – Christmas 2020”. December 25, 2020.
 Ghebreyesus, Tedros, 2020. “WHO Director-General’s opening remarks at the media briefing on Covid-19”, 4 September 2020.
 Ghebreyesus, Tedros, 18 August 2020.
 CDF, 2020. “Note on the morality of using some anti-Covid-19 vaccines”, December 21, 2020. n.6
 CDF, 2020. “Note on the morality of using some anti-Covid-19 vaccines, December 21, 2020.
 According to the United States Conference of Catholic Bishops (USCCB), “given the urgency of this crisis, the lack of available alternative vaccines, and the fact that the connection between an abortion that occurred decades ago and receiving a vaccine produced today is remote, inoculation with the new Covid-19 vaccines in these circumstances can be morally justified”. USCCB, 2020, “Moral Considerations Regarding the New Covid-19 Vaccines”.
 As highlighted on a note on the website of the Conference of Latin American Bishops (CELAM), if there is no other option but to take available vaccines in order to protect every human life and the health of all, vaccination cannot be considered to be in cooperation with evil (e.g. with abortion), but a rather a direct act of care for life. Cf. CELAM, 2020, “Vacunas con Fetos Abortados”.
 Catholic Bishops’ Conference of England and Wales, Department for Social Justice, 2020. “Covid-19 and Vaccination”.
 “The imbalanced and opaque sequence that characterized the early distribution of the limited supplies of the drug remdesivir should serve as a cautionary tale. The same mistakes must not be repeated. Only transparent and consistently applied allocation procedures will ensure public trust, especially in the case of vaccines. Ensuring that the allocation of vaccines is effective, fair, and justifiable to all is a priority that must not be compromised.” In: Wu, J.H., John, S.D, and Adashi E.Y., 2020, op. cit.
 Pope Francis, 2020. “Urbi et Orbi – Christmas 2020”. December 25, 2020.
 Pope Francis, 2020. Fratelli Tutti. On Fraternity and Social Friendship, n. 143.
 Cf. Pope Francis, 2020. To Heal the World – Catechesis on the pandemic. Vatican: LEV.