immunization Archives - Prindle Institute

Lawmakers are getting creative in breaking partisan deadlock over a long-overdue third coronavirus relief bill. After a months-long standoff, Congress remains at an impasse. While Democrats are advocating for a $900 billion starting point that includes state and local government funding, the Republican leadership has indicated they want something around $500 billion with a liability shield to insulate employers from coronavirus-related lawsuits that might be brought by employers over unsafe workplaces.

Part of this negotiation concerns whether to include another round of stimulus checks like those that went out in the spring. Despite popular appeal on both sides of the aisle, those opposed to direct payments stress the cost of such a policy and the need to limit government spending. They also argue that aid efforts should be more narrowly focused on providing relief for those who are most deserving (i.e., the unemployed who are actively seeking work).

In an attempt to appease these critics, former Maryland Representative John Delaney recently suggested providing $1,500 stimulus checks to individuals in exchange for them getting immunized. Its appeal to holdouts is fairly straightforward: rather than a cash giveaway with limited impact and so-so odds of success, this policy is more obviously goal-oriented. It’s a specific answer to a particular problem: only 60% of Americans say they would be willing to get vaccinated, but we need to at least 75% of the population to be immunized to start approaching herd immunity. In order to close that gap, “we have to create […] an incentive for people to really accelerate their thinking about taking the vaccine,” Delaney argues. By making stimulus payments contingent on showing proof of immunization, we can expect a great many more Americans to get a vaccine who might otherwise resist.

So is Delaney’s proposal just good policy or might it be objectionably coercive? Putting money in people’s pockets while stopping the spread of COVID-19 certainly has the potential to create a lot of good. And it does so without getting into sticky conversations about public health and bodily autonomy; we can leave all that anti-vaxx baggage at the door. As Delaney explains,

“If you’re still afraid of the vaccine and don’t want to take it, that’s your right. You won’t participate in this program. But guess what? You’re going to benefit anyhow, because we’ll get the country to herd immunity faster, which benefits you. So I think everyone wins.”

Delaney emphasizes that his plan would not force anyone to get vaccinated, it simply encourages socially responsible behavior by providing financial incentive. And “It’s not like we don’t pull levers to get people vaccinated,” Delaney argues. “We do that now.” There are already similar measures in the U.S. to encourage vaccinations like MMR immunization for children attending public school.

But school vaccinations look a bit different than withholding financial aid in a pandemic in order to effect compliance. For one, there is a distinct difference in exit options. Parents can avoid vaccinating their children by pursuing medical, religious, or philosophical exemptions relatively easily (as Kenneth Boyd has previously discussed here). But Delaney’s proposal doesn’t intend to make similar space. Clearly, one could choose to forgo government assistance, but the situation has the most vulnerable among us over a barrel: barter your beliefs or risk (more) financial insolvency. (And given the mild to moderate side effects from the Pfizer-BioNTech COVID-19 vaccine recently reported in the severely allergic, at least some (albeit few) of those beliefs surely qualify as legitimate.) This policy, then, threatens to severely undermine individual autonomy. With unemployment insurance benefits set to run out and the federal moratorium on eviction expiring, a $1,500 stimulus check might not save the day, but it’s not the sort of thing many could afford to turn down either.

Apart from these worries, though, there is concern that Delaney’s proposal fails to account for the reasons supporting relief in the first place. Political justifications for government’s obligation in this regard come in various flavors, but the two featuring most prominently at the moment involve causation — as lockdown orders have interfered with citizens’ ability to pursue their livelihoods they are due some financial consideration — or economic preservation — to lessen the economic downturn we will all experience (to greater and lesser extents), it behooves us to ensure that bills can be paid, goods can be bought, money moves through the economy and isn’t hid under mattresses, and that the workforce can be maintained and summoned back at a moment’s notice. At bottom, both these accounts rest on an understanding that the government is duty-bound to provide assistance to citizens, vaccinated or not, because our fortunes are inextricably linked. And while these two justifications might not necessitate that all citizens be treated alike, they also can’t justify differential treatment according to immunization status.

In the end, these two projects are simply too far apart. As Howard Gleckman, senior fellow at the Urban-Brookings Tax Policy Center, sums up, “It’s always nice to be able to kill two birds with one stone, but in this case I think the two birds are flying off in different directions.” Those most in need of direct payments are the same people most likely to abstain from vaccination, and those more likely to get vaccinated are the same ones less likely to put that stimulus check back into the economy. We’re trying to solve two collective action problems — herd immunity and economic recovery — by tying them together, but they may be less connected than they might first appear.

But let me not overstate the case. This is not an argument against the use of financial incentives or psychological nudges in general. It isn’t even an argument against incentivizing people to get vaccinated. I’ve merely tried to offer an explanation for why Delaney’s particular proposal can’t be considered a solution to Congress’s current problem. There are reasons regarding fairness, justice, and autonomy that speak against holding direct relief payments contingent upon vaccination and for keeping the issues of economic stimulus and immunization separate.

While every state in America has legislation requiring vaccinations for children, every state also allows exemptions. For instance, every state allows a parent to exempt their child from vaccinations for legitimate medical reasons: some children with compromised immune systems, for example, are not required to be vaccinated, since doing so could be potentially harmful. However, many states also allow for exemptions for two other reasons: religious reasons, and “philosophical reasons.” While religious exemptions are standardly granted if one sincerely declares that vaccinations are contrary to their religious beliefs, what a “philosophical reason” might consist in varies depending on the state. For example, Ohio law states that parents can refuse to have their children immunized for “reasons of conscience”; in Maine a general “opposition to the immunization for philosophical reasons” constitutes sufficient ground for exemption; and in Pennsylvania “[c]hildren need not be immunized if the parent, guardian or emancipated child objects in writing to the immunization…on the basis of a strong moral or ethical conviction similar to a religious belief” (a complete list of states and the wordings of the relevant laws can be found on the National Conference of State Legislatures website).

Of course, not all states grant exemptions on the basis of any reason beyond the medical: California, Mississippi, and West Virginia all deny exemptions on the basis of either religious or philosophical reasons. And there seem to be plenty of good reasons to deny exemption except only in the most dire of circumstances, since vaccinations are proven to be overwhelmingly beneficial both to individuals, as well as to the community at large by contributing toward crucial herd immunity for those who are unable to be vaccinated due to medical reasons.

At the same time, one might be concerned that, in general, the law needs to respect the sincere convictions of an individual as much as possible. This is evidenced by the fact that many states provide religious exemptions, not only for vaccinations, but in many other different areas of the law. Of course, while some of these exemptions may seem reasonable, others have become the target of significant controversy. Perhaps most controversial are so called “right to discriminate” conditions that, for example, have been appealed to in order to justify unequal treatment of members of the LGBT community.

While there is much to say about religious exemptions in general, and religious exemptions to vaccinations in particular, here I want to focus on the philosophical exemptions. What are they, and should they be allowed?

As we saw above, the basis for granting philosophical exemptions to vaccinations seems to simply be one’s sincere opposition (how well-informed this opposition is, however, is not part of any exemption criteria). In practical terms, expressing philosophical opposition typically requires the signing of an affidavit confirming said opposition, although in some cases there is the additional requirement that one discuss vaccinations with one’s doctor beforehand (Washington, for example, includes this requirement). In general, though, it is safe to say that it is not difficult to acquire a philosophical exemption.

Should such exemptions exist? We might think that there is at least one reason why they should: if sincere religious conviction is a sufficient basis for exemption (something that is agreed upon by 47 states) then it seems that sincere moral or philosophical conviction should constitute just as good of a basis for exemption. After all, in both cases we are dealing with sincere beliefs in principles that one deems to be contrary to the use of vaccinations, and so it does not seem that one should have to be religious in order for one’s convictions to be taken seriously.

The problem with allowing such exemptions, of course, is the aforementioned serious repercussions of failing to vaccinate one’s children. Indeed, as reported by the PEW research center, there is a significant correlation between those states that present the most opportunity to be exempted – those states that allow both religious and philosophical grounds for exemption – and those that have seen the greatest number of incidents of the outbreak of measles. Here, then, is one reason why we might think that there should be no such philosophical exemptions (and, perhaps, no exemptions at all): allowing such exemptions results in the significant and widespread harm.

The tension between respecting one’s right to act in a way that coincides with one’s convictions and trying to make sure that people act in ways that have the best consequences for themselves and those around them is well-explored in discussions of ethics. The former kinds of concerns are often spelled out in terms of concerns for personal integrity: it seems that whether an action is in line with one’s goals, projects, and general plan for one’s life should be a relevant factor in deciding what ought to be done (for example, it often seems like we shouldn’t force someone to do something they really don’t want to do for the benefit of others). When taking personal integrity into account, then, we can see why we might want there to be room for philosophical exemptions in the law.

On the other hand, when deciding what to do we also have to take into account will have the best overall consequences for everyone affected. When taking this aspect into consideration, it would then seem to be the case that there almost certainly should be only the bare minimum of possibility for exemptions to vaccinations. While it often seems that respecting personal and integrity and trying to ensure the best overall consequences are both relevant moral factors, it is less clear what to do when these factors conflict. To ensure the best consequences when it comes to vaccinations, for example, would require violating the integrity of some, as they would be forced to do something that they think is wrong. On the other hand, taking individual convictions too seriously can result in significantly worse overall consequences, as what an individual takes to be best for themselves might have negative consequences for those around them.

However, there is certainly a limit on how much we can reasonably respect personal integrity when doing so comes at the cost of the well-being of others. I cannot get away with doing whatever I want just because I sincerely believe that I should be able to, regardless of the consequences. And there are also clearly cases in which I should be expected to make a sacrifice if doing so means that a lot of people will be better off. How we can precisely balance the need to respect integrity and the need to try to ensure the best overall consequences is a problem I won’t attempt to solve here. What we can say, though, is that while allowing philosophical exemptions for vaccinations appears to be an attempt at respecting personal integrity, it is one that has produced significant negative consequences for many people. This is one of those cases, then, in which personal conviction needs to take a backseat to the overall well-being of others, and so philosophical reasons should not count qualify as a relevant factor in determining exemptions for vaccinations.

immunization

This for That: Trading Vaccinations for Stimulus Checks

The Ethics of Philosophical Exemptions