Policy and Practice

North Carolina has taken a number of policy actions to help slow the spread of COVID-19. These actions have included executive orders from the Governor, as well as suggestions and guidance from the Department of Health and Human Services.

U.S. State Data and Policy Actions to Address Coronavirus

The Kaiser Family Foundation has summarized state-level data on social distancing actions, health policy actions, relevant guidance, and other metrics.

Data for all states is available on the Kaiser Family Foundation website.

NC Executive Orders and Guidance

The table below summarizes Governor Roy Cooper’s Executive Orders regarding the COVID-19 pandemic.

Full information and the most current guidance are available on North Carolina’s COVID-19 website.

Executive Order 181


  • Modified stay-at-home order from 10 p.m. to 5 a.m.
  • Requires nighttime closure between 10 p.m. to 5 a.m. for certain businesses and activities
  • Prohibits the sale and service of alcohol for onsite consumption from 9 p.m. to 7 a.m.

Executive Order 180


  • Requires face coverings in all public indoor settings
  • Retail business locations with more than 15,000 sq. ft interior space must have a worker at each public entrance to enforce face covering requirements

Executive Order 176


  • Extends the Phase 3 order (Executive Order 169)
  • Reduces indoor gathering limits to 10 people

Executive Order 169


  • Prohibitions and restrictions revised that move the state into Phase 3 measures

Executive order 153


  • Restaurants, breweries, wineries, distilleries, and other establishments that serve alcohol for onsite consumption are required to cease alcohol sales and service each day from 11 p.m. to 7 a.m.
  • Health care
  • Child care
  • Education
  •  Businesses
  • Individuals, families, and communities
  • Housing and sheltering
  • Human services
  • Law enforcement
  • Veterinarians and animal services

Vaccination Plan

North Carolina has created a phased vaccination plan to ensure that COVID-19 vaccines will be distributed first to those most at risk, reaching others as supplies become available. The state’s vaccination plan is available on the NCDHHS website.

Ethical Vaccine Distribution Framework

The ethical principles chosen to guide the process used to allocate vaccine reflect the need for a protocol which provides strong ethical justifications for priority, results from significant collaboration with community stakeholders and under-represented groups, follows evidence-based scientific principles, reflects a just and fair process, and is transparent and open for revision as circumstances dictate. The team, using a rural Eastern North Carolina lens, reviewed the protocols initially listed by the National Academy of Medicine (NAM) and the Advisory Committee on Immunization Practices (ACIP) and developed a comprehensive articulation of ethical principles foundational to proposed distribution plans. This review generated a two-component ethical substantive and procedural framework that aligns ethical principles and the inclusion of an overarching principle of accountability. Below is the template demonstrating this work and links to ethical distribution plans for North Carolina and publicized by the ACIP and the NAM. 

Ransom & Lee Ethical Goals and Principles for Vaccine Distribution Plans*

What are the rules for distribution?
(Substantive rules)

How are the rules implemented?
(Procedural rules)

Goals Principle Goals Principle
Achieving the greatest good for the greatest number of people by prioritizing the order of distribution based on ethical principles Utilitarianism  Establishing a system that consistently provides equitable access without undue burden on vulnerable populations and mitigates health inequities  Justice
Choosing a system which recognizes our obligation to be prudent and equitable stewards of the medical resources with which we are entrusted  Rationing (Stewardship) Adopting fair and appropriate distribution norms which provide structure for social cooperation. This provides a way to ensure fairness by providing health care access to vulnerable populations. Moreover, this allows for a more ethical and transparent approach to meeting the health care needs of vulnerable populations Distributive Justice
Adopting fair and appropriate allocation norms which provide structure for social cooperation. This provides a way to ensure fairness by providing health care access to vulnerable populations. Moreover, this allows for a more ethical and transparent approach to meeting the health care needs of vulnerable populations Distributive Justice

Ensuring that the distribution of the vaccine reflects those carefully chosen ethical principles based on sound evidence 

Categories of Accountability: 

1) Community Accountability – Committing to intentional involvement with vulnerable populations to improve the quality of care provided to everyone, managing the gap between the health and well-being of vulnerable and non-vulnerable populations, and providing supportive outlets for health and community development, thereby mitigating health care inequities 

2) Public Accountability – Engaging the involvement of stakeholders and active participants in making health care decisions regarding health care resources through consideration, empowerment, and impartiality

Providing a clear and understandable set of priorities for vaccine distribution and the manner in which those priorities will be implemented  Transparency Establishing a distribution system that is accountable and transparent by tracking vaccine distribution, explaining allocation decisions, and treating people consistently, thereby ensuring and preserving the greatest good Transparency
Including stakeholders, community members, and underrepresented minorities in the process of developing protocols for vaccine distribution Transparency (procedural) Engaging stakeholders, community members, and underrepresented minorities in the process of developing the methods and manner of distribution  Transparency (procedural)
Adopting a method of allocation that acknowledges historical issues of trust in the health care system, cultural belief systems, and seeks to create a system that promotes and enhances trust and well-being that the order of vaccination follows ethical principles Trust Adopting a method of distribution that acknowledges historical issues of trust in the health care system, cultural belief systems, and seeks to create a system that promotes and enhances trust and well-being Trust
Establishing protocols for distribution that respect the autonomy of patients by providing an alternative method for addressing risks  Autonomy Creating a system that equitably and effectively distributes scarce vaccine resources through a process which is fair, based upon priorities developed in a transparent manner Rationing
Adopting a system of distribution which recognizes the need for centralized direction of the distribution of vaccine resources, but which uses ethical principles to ensure the appropriate use of state power to achieve public health ends Precautionary Principle  Establishing a system that provides sufficient accurate information to allow patients to make informed decision to consent to or refuse the vaccine Autonomy
Allocating and distributing the vaccine based upon sound, evidence-based science and with a healthy respect for the comorbidities and other health factors impacting potential recipients Beneficence and/or Non-maleficence    

*Copyrighted, December 2020

Application of Principles to the Ethical Allocation and Distribution of COVID-19 Vaccine

Immediately after announcements regarding the development of a vaccine for COVID-19 were made public, many began to wonder about its efficacy and ethics. These concerns centered on both the research regarding the vaccine(s) and how it (they) would be distributed. All have agreed that the criteria for distribution should incorporate ethical guidance, and that distribution should be both equitable and based on sound evidence. 

The novelty of COVID-19 is coupled with the need to properly address the healthcare inequities in the United States. This overwhelming burden presents a moral challenge whose resolution requires the ability to handle activities surrounding professional competence, ethical conduct, health promotion, and population benefit – accountability. The concept of accountability is not new, and over the years, it has been influenced by both political and social movements. Applying equity to the distribution process will have to be done in tandem with acknowledging the disparities in the American healthcare system, as well as how the hierarchical system of front-line workers includes some of our most vulnerable populations. This requires the application of concepts that consider both the limits of healthcare facilities and the increasing health care needs of the population.

In considering the ethical principles which must inform theallocation of the COVID-19 vaccine, the research team recognized and acknowledged that no one set of ethical principles provided the “right” governing justification for prioritizing one group over another. Rather, the purpose of establishing ethical guidelines for the allocation of scarce resources is to ensure that, whatever ethical principle(s) guide allocation, those principles are communicated clearly, applied objectively, and explained to the general public in a way that creates confidence in the allocation choices made.  To that end, the research team accepted the allocation rules adopted by the North Carolina Department of Human Resources, the ACIP guidance, and the framework established by the National Academy of Medicine.

Although these frameworks differ in subtle ways, the ethical principles motivating the choices simply reflect different opinions about the relative risks faced by each at-risk group, and therefore, the most effective way to achieve the ethical and medical outcomes? goals? of the allocation.

With regard to the ethical rules which should govern the distribution of vaccine, the early rollout of the vaccine already reveals societal hesitation to immunize against the disease. In order for the chosen allocation methods to be effective, the distribution process must be informed by the ethical principles of justice, transparency, and accountability mentioned above and tempered by a healthy respect for the right of individuals to exercise their right to autonomy in choosing not to be vaccinated. In order for these principles to be met, the distribution process must:

  • Adequately and clearly explain why:
    • the vaccine is being allocated in the manner chosen
    • the vaccine is efficacious and safe to address the underlying risk
    • the vaccine is considered safe by medical authorities, including sufficient information concerning the clinical trial process, the expedited trials period, and the representation of all necessary groups in the trials process
    • the vaccine’s benefits outweigh both its burdens and the relative risk of choosing not to be vaccinated
  • Clearly reflect a distribution process which:
    • is designed to follow the allocation priorities accurately and objectively
    • is designed to fairly and equitably resolve disputes about the order of allocation, particularly when (1) priority group members refuse the vaccine, or (2) members of the same level of priority are denied vaccine due to scarcity
    • is implemented in a way which can be tracked, quantified, and viewed by the general public to ensure reliability and transparency
    • instills confidence in vulnerable groups of all kinds that the vaccine distribution process is not tainted by prejudice, favoritism, or past discrimination
    • is implemented by healthcare agencies, companies, government agencies, and nonprofits in which the public is likely to have a high degree of trust

Although these may not be considered “rules” per se, they are principles which will determine the degree to which the general public adheres to the recommended vaccination process and commits to it at a level sufficient to effectively meet the public health crisis that the COVID-19 virus presents. In the absence of both a substantive set of rules for allocation and a set of procedural rules to ensure public confidence, the benefits of the COVID-19 vaccine will not be realized.