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Why Vaccinating the World Is the Best Thing for Australia

photograph of multiple arrows in target's bullseye

With COVID vaccine boosters ready to be rolled out across Australia, a debate has arisen about the ethics of taking a third vaccine shot when nearly half of the world population has yet to receive their first. Tedros Ghebreyesus, President of the World Health Organization, has invoked the principle of health equity in suggesting that booster shots should be restricted until the world’s poorest have access to a vaccine. Daniel Burkett has argued in this very venue that the ethical choice is to boycott the booster – sending a message that we refuse to partake in ill-gotten gains – although A.G Holdier replies that any such attempt might ultimately prove futile. On the other hand, proponents of the shot highlight evidence of its efficacy in reducing infections and symptoms of COVID, and suggest that our moral obligation to get vaccinated might well extend to taking booster shots. In this case, however, we need not choose between self-interest and morality: for those of us in Australia, the two are aligned.

It might be argued that vaccines should be directed, not to the poorest countries, but to those with the highest case fatality rates (CFRs). Research has shown that COVID-19 is more deadly in countries with increased prevalence of obesity, diabetes, cardiovascular issues, and those with older populations: all apt descriptors for Australia. Such a simplistic take, however, would overlook the quality of medical care already available in Australia and our medical system’s strong (albeit still limited) capacity to deal with significant medical emergencies. Furthermore, this analysis relies on questionable data, with severe undertesting for COVID skewing statistics in poorer countries. And as noted by Burkett, any analysis based on CFR would have to consider not only the initial risk of COVID, but the diminishing returns in vaccine effectiveness. Whereas the first dose of a Pfizer vaccine can reduce the likelihood of developing symptoms by around 50%, a second dose adds around 40% more protection and a third only 10-15% when compared to baseline.

So, it is hard to make the case that we need booster shots more than those in the developing world need a first or second dose. A better argument might be that boosters would provide a net benefit to both health and the economy, and, as we can get them, we should take them. This is a kind of medical lifeboat ethics: we have the capacity to save ourselves, and we shouldn’t squander that chance on the naïve hope of saving others. After all, the responsibility of government is to look out for the interests of its citizens. Politically, vaccine boosters are local, immediate and – perhaps most importantly for the current government in the run up to an election – highly marketable to an understandably worried voter base. And whereas bioethicist Nancy Jecker points out that countries like Tanzania, Chad, and Haiti are hovering at a disastrous 1% vaccination rate, this comparison is neither apt nor helpful. The issue there is not so much with vaccine supply (although this may be a contributing factor) as the potent mix of conflict, corruption and political instability preventing acquisition and effective distribution of vaccines. In Australia, we have boosters available (and more on the way), and we have the capacity to administer them. So why shouldn’t we?

A more enlightening comparison would look not at the least vaccinated nations, but those where COVID has taken a significant toll. Countries like India, Brazil, and South Africa, with stable governments, better record-keeping and active – albeit imperfect – vaccination programs. There, the picture is grim. India’s actual COVID death toll could be well over two million (compared to the official figure of less than 500 thousand), while vaccination lags at just over 50% first dose. In South Africa, official figures suggest less than 100 thousand COVID-related deaths. However, excess mortality since the start of 2020 exceeds 250 thousand, with an estimated 95% of these deaths due to the disease. Just over a quarter of the population have received a vaccine dose, and even fewer have received two. In Brazil, somewhere around 600 thousand people have died from COVID, while less than 60% of the population are fully vaccinated (although a more impressive 75% have received at least one dose). Most disturbingly, each of these countries have seen the emergence of new, dangerous variants, with Beta coming out of South Africa, Gamma originating in Brazil, and the now-dominant Delta strain starting in India before taking over the world. This is before mentioning the fast-encroaching specter of the new, ominously named Omicron.

Here is the crucial point. On this issue, we don’t have to choose between morality and self-interest, as suggested by Nicholas Bugeja at The Interpreter. Instead, this is one of those (increasingly rare) cases where morality and self-interest align. The biggest threat to Australia is not a resurgent Delta variant attacking those whose vaccines have diminished in efficacy. The biggest threats are of new variants, incubated in highly mobile, densely packed, and largely unvaccinated populations. Every time COVID-19 is transmitted – wherever in the world that transmission occurs – there is the chance of a potentially dangerous mutation emerging. The best way to deal with this threat is mass vaccination of the unvaccinated, not marginal gains for the already protected.

Nor must we choose between vaccinating the world and protecting our most vulnerable. We can do both. Booster vaccines should be prioritized for those most at risk – the elderly and those with pre-existing conditions – while an increasing share is sent overseas to boost immunity and reduce the threat of new variants. CSL is already contracted to produce about 30 million more doses of the AstraZeneca vaccine, but the government should reconsider its decision to stop production after the current run. We might not be able to vaccinate the whole world, but we can certainly play our part.

It is important to note that this analysis takes a myopic Australian viewpoint and may not apply to much of the world. Here, despite our slow start, vaccination rates are approaching 80% of the total population (and continue to rise), while case numbers remain low. For Holdier, living in Arkansas where vaccine hesitancy (and rampant misinformation) has kept the vaccination rate below 50%, the personal likelihood of catching COVID skews the moral calculus in favor of boosters and away from admirable, but possibly futile, political posturing. There, the risk of catching a current strain may well outweigh the dangers of a new variant.

But in Australia, as borders reopen, international students are welcomed back, and international travel returns, so too does the threat of a new, more virulent, or more deadly strain hitting our shores (the much-hyped Mu variant might have been kept at bay, but Omicron is already here). Hotel quarantine wasn’t enough to keep Delta out last time, although it was a huge help. This time, we will be without our first and most effective line of defense. If we demand people get vaccinated before coming to Australia – and we should – then the onus is on us to make those vaccinations accessible. It’s in our best interest.

COVID-19 Vaccines and Drug Patent Laws

photograph of covid vaccine ampules

One of the problems that Canada has had with the COVID vaccines is a lack of domestic production. We are told that there are plans to construct a new facility for such purposes, but that this will not occur until long after it is needed. In the meantime, it was reported this week that Biolyse, a small pharmaceutical manufacturer in Ontario, has offered to produce millions of doses of vaccine but can’t because patents prevent them from being able to do so. This is just one example of a much larger moral issue regarding potential patent reform.

About three-quarters of the vaccine supply has been secured by 10 countries that account for 60 percent of global economic growth. However, 130 countries haven’t received any doses and they account for over 2 billion people. Companies like Biolyse have offered to produce vaccines for lower-income nations, but they haven’t been able to secure a license from companies like Johnson & Johnson in order to do it. This has led to a growing call for waivers for intellectual property such as patent protections so that more companies can manufacture vaccines to increase the supply.

The move has been led by South Africa and India who are seeking support from to suspend elements of the WTO Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement concerning intellectual property rights for the direction of the coronavirus pandemic. So far, however, the United States and several other countries have blocked negotiations, and this has led to direct appeals to President Biden as “the full protection of intellectual property and monopolies will only negatively impact efforts to vaccinate the world and be self-defeating.”

While efforts such as the UN supported Vaccines Global Access Facility have helped with distribution of vaccines in lower-income nations, the greatly unequal distribution suggests how limited these efforts have been. Supporters of waiving IP rights in this case argue that we should be able to take advantage of unused production capacity to maximize the supply of vaccines. This is particularly important because current estimates show that many nations will be waiting until 2024 to achieve mass immunization. This situation represents a significant drain on the global economy and complicates our ability to deal with variants. Experience also teaches that drug manufacturers in developing nations can make large amounts of quality drugs inexpensively.

Supporters of a waiver also point out the massive amount of public funding that pharmaceutical companies have received to develop coronavirus vaccines and that much of the groundwork for those vaccines were discoveries that came from federally-funded research. Thus, they argue that the vaccine should be a “people’s vaccine” that is universally available to all at no cost. They also suggest that such a waiver would send a message of commitment to public health as opposed to prioritizing intellectual property rights.

Opponents of the measure, however, argue that waiving patents would dampen scientific innovation by deterring private investment. They argue that a waiver “creates a dangerous precedent of nullifying IP rights” which “destroys the bedrock of what makes medial innovation possible.” The argument makes the case that vaccine development is expensive and, without a guarantee of success, a patent protection guarantee is necessary for innovators to continue to fund their efforts. They also argue that existing regulations are already flexible to allow vaccine drug manufacturers to voluntarily engage in agreements with generic drug manufacturers.

It is important to note that just because regulations are flexible to allow something doesn’t mean that that thing will happen. Nor does one case of a patent waver constitute a “precedent.” Typically, precedents require context, so outside of a pandemic scenario, it’s difficult to see how this might become a problem. Unless, of course, that larger context concerns how to reform our use of patents in the face of other significant moral problems, in which case such a moral conversation might be more helpful.

To consider how a wider discussion of the morality of drug patents might be helpful to the issue of the COVID vaccine, we can look to moral philosophers who have addressed the issue. In 2009, philosopher Thomas Pogge argued that developing nations’ adoption of global uniform intellectual property rights under the TRIPs agreement is morally problematic. He maintained that the loss of freedom to produce, sell, and buy medicines produced by patents imposes a huge loss in terms of disease and premature death that cannot be justified. The typical alternatives of government initiatives and partnerships (such as the UN-backed COVID-19 Vaccines Global Access Facility or COVAX) to deliver medicines to developing nations “are really doing good by improving the situation relative to what it would be under TRIPs unmitigated. Still, these efforts are not nearly sufficient to protect the poor.” Indeed while COVAX has delivered hundreds of thousands of doses, “the disparity between high- and low-income countries remains vast.”

Pogge explains how corporate interests and public health outcomes are misaligned; if pharmaceutical companies help low-income patients benefit from patented medicine, it will undermine its profitability by losing out on customers, both in terms of less revenue but also because the disease will be eliminated more quickly. He suggests several reforms to the patent system including the development of a guaranteed Health Impact Fund (HIF) created by governments where a vaccine developer (for example) would agree to provide production and distribution of their drug at the lowest feasible cost in return for a share equal to its share of the assessed global impact for all HIF-registered products from the HIF reward pools (which would constitute a multi-billion dollar fund) for ten years. Since such a fund rewards those in relation to their impact on global health, drug companies would become more incentivized to focus on treatments and diseases that aren’t simply a priority for the affluent.

This idea makes clear that drug patents are a moral issue one which is connected to other major problems involving excessive litigation and marketing. So perhaps it is a good thing that the waiver is agreed to if a more substantial and target reform can eventually take place. Pogge suggests that patent reform such as his proposed HIF would be a significant step in also addressing global poverty as a whole. So, while discussion of waiving patent protections in the case of COVID is morally important, it may be more morally important to fit this step into a larger conversation that considers the morality of the drug patent system as a whole.

Intuitions and the Duty to Aid

photograph of a cluster of traffic lights sending mixed signals

Many philosophers have considered whether folks who are better off have a moral obligation to help those who are desperately poor through no fault of their own. This issue is especially salient at the moment due to the economic fallout from the coronavirus pandemic and ensuing lockdowns across the globe. The result is that the global poor are hardest hit, and the trend of eradicating poverty over the past few decades is reversing. We are thus left to wonder what, if anything, we owe the global poor.

Here enters the work of perhaps the most famous contemporary philosopher, Peter Singer, who argues that many folks in rich countries — like the USA, Japan, and Germany — have a moral obligation to donate a large amount of their income to the global poor because they can afford to without falling into poverty themselves. He motivates this position by an appeal to a simple thought experiment:

“On your way to work, you pass a small pond. … [You] are surprised to see a child splashing about in the pond […] it is a very young child, just a toddler, who is flailing about, unable to stay upright or walk out of the pond. […] The child is unable to keep his head above the water for more than a few seconds at a time. If you don’t wade in and pull him out, he seems likely to drown. Wading in is easy and safe, but you will ruin the new shoes you bought only a few days ago, and get your suit wet and muddy.”

Singer thinks we have a moral obligation to save the child based on the strong intuition that it just seems like the right thing to do — it wouldn’t cost us much to save the child, but it would benefit the child significantly. We can formulate Singer’s argument like this:

  1. Suffering and death from lack of food, shelter, and medical care is bad.
  2. If it is in your power to prevent something bad from happening, without sacrificing anything nearly as important, it is wrong not to do so.
  3. By donating to aid agencies, you can prevent suffering and death from lack of food, shelter and medical care, without sacrificing anything nearly as important.
  4. Therefore, if you do not donate to aid agencies, you are doing something wrong.

The first step of the argument seems obvious: the pain that comes from failing to have your basic needs met is obviously bad. We wouldn’t go to such lengths to try to prevent these things in our own lives if we thought otherwise. And we will grant, for the sake of argument, Singer’s third step: donating to trustworthy and competent aid agencies allows us to mitigate the harm that comes from people being unable to meet their basic needs.

Our focus here is on the second step of the argument. Do we actually have a moral obligation to the poor; or does it merely seem like that? Should we trust our intuition to save the child? Based on recent experimental evidence from psychology and economics, we should be skeptical of our intuition to save the child. Allow me to make the case.

We have solid experimental evidence from psychology and economics that people care how they look to others. As a species, humans are highly cooperative and social, and depend on help from others to survive — so much so that the ancients believed banishment from society worse than death, as it entailed not only death, but prolonged suffering as well. But relying on cooperation from others makes us susceptible to free-riders: individuals who enjoy the fruits of everyone else’s labor, while contributing less than their fair share. We thus use reputations to distinguish the trustworthy from the untrustworthy; we don’t want to cooperate with someone who might defect, especially in situations with high stakes — e.g., it matters who we choose to have children with. And since we cannot read the minds of others, we must rely on a high-fidelity signal of trustworthiness.

Here we need an example of a high-fidelity signal. The classic example is peacocks: their colorful feathery display is a costly signal to prospective mates that even with amplified risk of predation, he can still thrive — a signal that indicates fitness and is hard to fake. Or consider the ability to lift two-hundred pounds over one’s head as a reliable signal of strength: one cannot lift that much weight without possessing enough strength. Colorful features on a peacock would be a fatal liability if the bird weren’t healthy enough; someone simply wouldn’t be able to lift that much weight if they lacked sufficient strength. If we are to rightly trust others, we need a signal of trustworthiness that would be hard to fake by those who are untrustworthy.

One way to signal trustworthiness and communicate that one is a suitable partner for collaboration is through uncalculating cooperation: helping someone without waiting to consider whether the benefits of helping exceed the costs of doing so. By not calculating the advantages and disadvantages of pitching in, we signal to others that we can be trusted as a potential cooperator: we aren’t participating simply because we’ve determined that it’s in our interests. When we cooperate without doing the cost-benefit analysis, we signal we’re committed to the joint venture not merely because it would benefit us. As the authors of a recent study explain:

“To provide empirical support for this account, we experimentally test the hypothesis that people avoid calculating the costs of cooperation because of reputational concerns. Across two experiments, we demonstrate that when people’s decision-making processes are observable to others, they behave in a less calculating way. This observation suggests that they use uncalculating cooperation to gain reputational benefits.”

We often cooperate with others without calculating the cost. We grant friends’ requests without making inquiries about the time and trouble the request might take; we come to the aid of strangers in distress; we adhere to strict moral and religious precepts that are other-regarding, whatever the costs and benefits. These types of behaviors make sense once we frame them in terms of reputation: we cooperate without calculating because of how it makes us look to others. So it looks like we might have the intuition to save the drowning child because it makes us look good to others — consider the social pressure one would feel refusing to help a drowning child in the presence of onlookers. Just the thought of refusing to help seems unconscionable.

The strong intuition to save the drowning child looks like a product of our evolutionary history as a social, cooperative species and the need to look good to others for the sake of our survival. This should make us doubt that our intuitions in the drowning child case track the moral facts; it looks like we have these intuitions for evolutionary reasons rather than anything having to do with any moral obligations — we may only have such intuitions because they aid in our survive and reproduction, not because there is actually a moral obligation to save the child.

Someone may, of course, reply that we could have a strong intuition to save the drowning child both because it is morally required, as well as for reputational and evolutionary reasons. The trouble here though is that we simply cannot rule out that we have the intuition only because it helps us survive and reproduce. By example: it could be that the lottery ticket you hold in your hand is a winner or a loser; you simply do not know, even though it is highly likely the ticket is a loser given the odds. However, since you cannot rule out that the ticket is a winner — this is a distinct possibility — you don’t know the ticket is a loser. By similar logic: we cannot rule out that our drowning child intuitions are only an evolutionary by-product, so we should doubt we know that we have a moral obligation to save the child — and, of course, by extension, that we have a moral obligation to donate to the poor.