Questions of ethics are posed most squarely when the rules are vague or imprecise and the dilemma is evident. Confusion about applicable rules fosters cheating and encourages rationalizations. Ethicists say that, if the public is to co¬operate, accept difficult decisions and act ethically, the rules must be transparent and open in explaining what ethical choices have been built into plans.

In Canada recently, vaccinations for the H1N1 flu were being given according to a priority list based on vulnerability to complications from H1N1.

Publication of the rules was sporadic, uneven and unorganized. There were many media articles with conflicting advice. The risks presented by the flu were inconsistently presented.

The list of those to receive vaccinations in priority included pregnant women, those under 65 with conditions such as asthma, children aged six months to five years, some health workers and those living with infants under six months or with people with compromised immunity as for them, receiving the vaccine could be a matter of life and death.

For some time supplies of flu vaccine remained distressingly limited. Many people behaved ethically and well. But soon queue-jumping started. Well-connected hospital insiders went to the front of the line for H1N1 immunization, ahead even of vulnerable children. Hockey teams were vaccinated. A doctor tried to rationalize the vaccination of a hockey team because the team “…might be carriers who were exposed to a wide number of people in a variety of places.”

Queue-jumping by sports teams led to the firing of a health official. A newspaper was supportive in a editorial arguing that team members play in venues where thousands of people gather, and  “are in, close sweaty contact with the players of other teams.” Some queue jumpers in a high-risk group, such as seniors or people with chronic conditions brought children to the line, bringing an added level of complexity to the ethical issues.

In the public’s mind, these rationalizations did not receive warm acceptance. Safety first slowly came to be widely recognized as the principle to be observed and more people began to wait their turns.

Queuing is a national culture varying from country to country. So is cutting into a line. You can learn a lot about standing in line and waiting your turn from lineups for ski lifts in where people are not accustomed to joining or forming a queue. Skiers will move directly to their goal without paying much attention to others who are already present.

In North America, skiers are channeled toward lifts through series of fenced lanes that make corral and loading chutes in a Chicago slaughterhouse look simple. In Europe you are faced with a narrowing free-for-all. Like salmon in a stream you get bunched up more and more tightly as you approach the lift. Creative ways of elbowing ahead are a winning strategy. There are really no rules other, possibly, than don’t stand on anyone’s skis. No one supervises the quiet riot.

In some cultures people respect queues as people in queues will object if they feel disrespected. In countries where there is an instilled sense of “fair play” and more reserve about talking to strangers (as in the United Kingdom), often people will remain silently frustrated at what they have witnessed.

Wikipedia observes, “In former Communist countries, where waiting in long queues was a near-daily sport, rules are very clear and well observed. In Russia, for example, it is acceptable for a person to leave the queue to use the bathroom (or similar brief diversion) and then return to their original place without having to ask permission. It is also common for a person to be allowed to jump to the front of the queue in special cases, like the need to purchase a ticket for an imminently departing train. This can also be seen in Cuba and in Spain where an arriving patron asks “¿Quién es el último?” (Who is last?) and is then behind that person in the queue, which is not always a physical line.”

A flow chart for those in need of a clear definition.

I’m not sure there is any new lesson to be learned here. A shortage of vaccines has brought many face to face with an ethical dilemma. We have looked in a mirror. There has been considerable misbehavior as people not at risk take advantage and force themselves into priority.

There has been much good behavior as well, and perhaps even more significantly, much public discussion about the issues. It may be that we have learned something from all of this. The next time a health crisis occurs the problem may be administered better and the rest of us will behave with more consistent responsibility.

The conduct of the doctors and other medical personnel was at times disappointing. You did not hear that Doctors were refusing to give a vaccine to someone not in a high risk group. Perhaps they should have shown more leadership. A senior medical health officer sounded positively silly when he said in public and in the media that they had “left voice mail at the office of a doctor who had given transactions to persons not at risk”.

And finally, again from Wikipedia, the numbers.“ According to one study, a person cutting in line has a 54% chance that others in the line will object. With two people cutting in line, there is a 91.3% chance that someone will object. The proportion of people objecting from behind the cutter is 73.3%, with the person directly behind the point of intrusion objecting most frequently.” How do they know?