Since COVID-19 vaccination began in the United States at the end of 2020 with healthcare workers and other high-risk professionals and medically vulnerable individuals, we have been hearing about “vaccine guilt.” Even though vaccination eligibility continues to expand, vaccine guilt isn’t yet going away. And there might be good reasons that the right kind of vaccine guilt should become more widespread.

The concept of vaccine guilt captures the feelings of some who have access to vaccination – whether or not they accept their dose(s) –in response to the opportunity to become vaccinated before others, especially others they perceive to be better-served by vaccination. Notably, vaccine guilt is distinct from survivor’s guilt, which one might experience when recognizing that many friends, family, colleagues, and strangers did not make it through the pandemic to have the opportunity to receive a vaccine.

Some expressions of vaccine guilt are voiced by healthcare workers who wish their elderly family member could be vaccinated in their place. Others who are vaccination eligible due to professional, medical, or age-based criteria worry that they are being prioritized before more vulnerable groups. Occasionally, individuals haven’t fallen into eligibility criteria but have been lucky enough to be at the right place at the right time – say, at a healthcare facility administering vaccines that had an extra dose to use before expiring – and experience guilt following their good fortune in “jumping the line.”

Vaccine guilt isn’t necessarily a bad thing. As Faith Fletcher, a senior advisor at the Hastings Center pointed out, “what is rooted in vaccination guilt is concern for others.” Feeling vaccine guilt shows that one cares about others. It also means one has access to a COVID-19 vaccine, which (no matter the vaccine one receives among the three authorized for emergency use in the United States) is a safe and effective, though still scarce, resource.

Yet, embedded into vaccine guilt are at least two concerning features. One is what vaccine guilt says about how, as a society, we understand vaccine allocation criteria. The feeling that others are more “worthy” of being vaccinated indicates that we mistakenly assume vaccines are distributed based on individual or social value. The second concern is that vaccine guilt suggests we believe vaccines should be distributed as rewards, based on value, or according to social worth. Feeling guilty because I received a vaccine I don’t think I “deserved” means that not only do I think desert is a rationale for vaccine eligibility, but also that I think it is the right criterion for distribution.

Vaccine allocation criteria are not intended nor designed to track onto personal or social worth. Indeed, some categories of workers are prioritized because their jobs unavoidably increase their exposure to SARS-COV-2, the virus causing COVID-19. Vaccinating healthcare workers is not a “thank you” for their service, but a response to the fact that their work exposes them to more SARS-COV-2. Additionally, healthcare work must continue, especially during a pandemic necessitating acute medical treatment.

Similarly, prioritizing older adults is not motivated by reverence for those who have lived longer, but by COVID-19 infections disproportionately leading to severe outcomes, including death, in older individuals. While age-based rationales for triage scoring and ventilator allocation in the face of shortages due to COVID-19 hospitalizations have at times weighed the value of older and younger lives, the reasons vaccines are prioritized for older adults relate to the risks COVID-19 poses to them.

It is also possible that “vaccine guilt” primarily reflects the reasonable assessment that vaccine allocation criteria inaccurately identify those most at risk of infection and disease, while, according to a risk-based assessment, other individuals and groups ought to be prioritized.

Vaccine guilt could also reflect awareness that socially vulnerable individuals and groups have less access to a vaccine appointment, even if eligible. Indeed, in the United States vaccine eligibility is rapidly expanding to soon include all persons age 16 and up (reflecting the age cut off for which some vaccines are currently authorized for emergency use) by May 1, 2021. Some states have already adopted these criteria. Now we are hearing reports that the US might end up with more doses of vaccines than eligible people willing to accept them. Yet, like many other aspects of healthcare that is not uniformly available across the US, there are vaccine deserts effectively cut off from access. This is to say nothing of the discrepancy between vaccine access in wealthy and less wealthy countries around the world, although COVID-19 is a global pandemic.

Some might experience guilt over being able to navigate the appointment system to receive a vaccine, while others are equally eligible for vaccination but encounter structural barriers rendering vaccines unequally accessible. Or one might feel guilt over the sheer luck of living in a city, or an economically powerful nation, with greater vaccination access instead of in a rural settings or lower income country with less.

This leads me to wonder, what work is guilt doing in vaccine guilt?

At first glance, accounts of vaccine guilt read like personal, psychological, or emotional guilt. However, if we view vaccine guilt in reference to moral emotions, what philosopher PF Strawson called “reactive attitudes,” then guilt serves a moral function.

According to Strawson “reactive attitudes” include anger, resentment, contempt, indignation, forgiveness, and gratitude. They reveal our assessment of another’s quality of will toward us, and they inform how we hold others (and ourselves) responsible through practices of praise, blame, and moral guilt.

For example, if I encounter someone not wearing a mask in a grocery store, I feel anger, or perhaps indignation. I assess the non-mask-wearer as lacking regard for my health and that of others by not taking appropriate COVID precautions. But if I learned that they could not wear a mask for personal health reasons, my anger and indignation would no longer be appropriate. I could not hold them reasonably blameworthy.

This is not to suggest that we necessarily can – or should – know all excusing or exempting conditions that would modify our attributions of blame (or praise), especially when these conditions are personal health facts. But it is to recognize that reactive attitudes participate in and reflect our assessments of moral accountability.

There has been no shortage of examples of holding others personally blameworthy over their choices during the pandemic: judging those who travel, eat inside restaurants, keep their children from or send them to in-person school, and so on. Friends hold other friends blameworthy for gaming a vaccine system to get vaccinated before they are technically eligible, while the public holds medical institutions blameworthy for their broad interpretation of vaccine allocation criteria. In each of these examples, though, part of why it is even possible to hold people blameworthy for these actions is the inconsistency of rules and regulations guiding norms regarding travel, school, indoor activities, and vaccination implementation protocols. Judging friends for gaming a vaccination system reveals not only our disappointment about our friends’ value systems, but also about a vaccination system so susceptible to misuse.

Read along these lines, moral vaccine guilt doesn’t reinforce misunderstood criteria about social value or personal worth to receive a vaccine. Instead, moral guilt reflects indignation with the reality that vulnerable individuals and groups have received insufficient moral consideration in the establishment of vaccine allocation plans that are so susceptible to inequity and manipulation.

As a moral assessment, experiencing guilt (or placing vaccine blame) underscores our responsibility to respond to the injustice that others are wrongly excluded from allocation criteria, that the criteria themselves are so difficult in some cases to track and enforce, and that the structural failures of vaccine rollout (in the US, but also on a global scale) have left many who should be eligible for vaccination with a lack access to doses, while others can maneuver a system to gain access.

Even with vaccines seemingly available and many more people technically eligible, at least in the US, feeling vaccine guilt might be the right reaction to have when one realizes that one got a vaccine because one is privileged, savvy, or lucky, within systems that putatively aimed to be fair, but come up seriously short of achieving fairness.

Many bioethicists and medical leaders have encouraged people to accept vaccination as soon as it is offered to them. This message rightly appeases the emotional guilt that one is getting something one doesn’t deserve or is not yet due; arguably, we are all due vaccination for our own health and that of our community. Some have even suggested it is morally permissible to get “creative” when interpreting one’s vaccine eligibility.

But the moral guilt we feel upon being vaccinated is one we have good reason to sit with, rather than ease. It points to our awareness that, for reasons often not specific to us as individuals, some of us have vaccine access that others simply do not. It also reveals our implication in systems we recognize as unfair. As beneficiaries of flawed or poorly executed public health systems, our moral guilt illustrates our moral responsibility as participants in a collective that permits injustice to continue.

Fletcher suggests that those sincerely concerned about “vulnerable populations…. can practice solidarity by contacting local and state legislators and health directors to advocate for more vaccination programs and sites, especially in underserved communities.” Some have formed networks to provide transport to help people attend their vaccination appointments. Perhaps, then, we should convert our vaccine guilt into vaccine indignation, as well as activism and action.