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Fair Shares and COVID-19 Booster Shots

photograph of COVID vaccination in outdoor tent

Arguments abound regarding the moral importance of receiving the COVID-19 vaccine. Beyond the obvious health benefits for the vaccinated individual, herd immunity remains the most effective way to stop the spread of the virus, limit the development of more deadly variants, and – most  importantly – save lives. In fact, it may very well be the case that these reasons go so far as to provide us with a moral duty to get vaccinated so as not to treat others unfairly and, therefore, immorally. Given all of this, it would seem then that the morality of receiving a third ‘booster’ dose of the vaccine is simple. Unfortunately, ethics is rarely that straight-forward.

Currently, 7.54 billion doses of the COVID-19 vaccine have been administered globally, with 52.2% of the world’s population having now received at least one dose. In the U.S., close to 60% of the population have been fortunate enough to receive two doses of the vaccine, with the CDC now recommending a third dose for certain vulnerable portions of the population. Colorado, California, New Mexico, New York, and Arkansas have gone further than this by approving booster doses for all residents over the age of 18.

Yet, at the same time, only 4.6% of people in low-income countries have received their first dose of the vaccine, with this number dropping to less than one percent in countries such as Chad and Haiti. The reasons for this are many, but one of the largest contributing factors has been affluent countries pre-ordering more doses than they require to fully vaccinate their population. The U.S., for example, has pre-ordered twice as many vaccines as they need, the U.K. has purchased four times as many, and Canada has secured a whopping five times as many doses as would be required to provide a double dose of the vaccine to every one of their residents. These orders are still being filled, and – until they are – many poorer nations are left to wait to receive even their first dose of the vaccine. As a result, the World Health Organization has called on countries to issue a moratorium on providing COVID-19 booster shots until every country is able to vaccinate at least 10% of its population.

Essentially, this matter boils down to the unjust distribution of limited resources – with some countries taking far more than their ‘fair share’ of the vaccine, and leaving others without nearly enough. This has become a fairly common moral issue lately – underpinning problems surrounding everything from toilet paper, to gasoline, to carbon emissions.

There are many reasons why it’s wrong to take more than your fair share of a limited resource. On top of these more general concerns with just allocations, there are ethical issues specific to the case of vaccines. For one, we might claim that we have strong moral reasons to maximize the good. While an initial vaccine dose will grant around 90% immunity to the recipient, using that same dose as a booster will instead grant only a 10% increase in protection. Put simply, a single COVID-19 vaccine dose will do far more good given to an unvaccinated individual than to someone who has already received two previous doses. There are pragmatic concerns too. Unvaccinated populations provide opportunities for the virus to mutate into more virulent strains – strains that undercut vaccination efforts everywhere else in the world.

So let’s suppose that there’s a good case to be made for the fact that countries have done something wrong by taking far more than their fair share of the COVID-19 vaccine, and that the vaccine stock used by affluent nations to provide third booster shots is what we might call an “ill-gotten gain.” What does this mean for us, as individuals? Do we have a moral obligation to refrain from receiving a booster shot until more people – especially those in poorer nations – have managed to at least receive their first dose?

If we think that our resources should go where they’ll do the most good, then the answer may very well be “yes.” This approach is precisely the same as a very famous argument for our moral obligation to donate money to the poor. While buying that Starbucks Double Chocolaty Chip Crème Frappuccino might bring me a modicum of joy, donating that same amount of money could do far more for someone living in absolute destitution. In the same way, while an additional COVID-19 vaccine – used as a booster – will bring me a small benefit, it could do far more for someone else if used as an initial vaccine.

Of course, this argument assumes that by refusing a booster shot, my vaccine dose will instead be sent where it’s more needed. But it turns out it’s notoriously difficult to donate unused COVID vaccines, with some U.S. states already throwing away tens of thousands of unused doses. Suppose, then, that these booster shots are bought-and-paid-for, and that refusing these boosters will not see them go to those who are more in need. What, then, are our obligations regarding these ill-gotten gains?

A thought experiment may help in this situation. Suppose that we were currently suffering through a severe water shortage, and that the government sent out a limited supply of water tankers to alleviate people’s suffering. Your town’s tanker arrives, and everyone receives a reasonable allowance of water. In a shockingly unscrupulous turn of events, however, your town’s local officials hijack and claim the tanker destined for the next town over, parking it on the main street and telling residents to come and help themselves. Whatever water isn’t taken, they claim, will merely be dumped. What should you do? You don’t agree with how this water was obtained, but you also know that if you don’t use it, it’ll only go to waste anyway. You already have enough water to survive, but your plants are looking a little brown and your car could really use a good wash. It seems that, in a circumstance like this, you have every reason to make use of this ill-gotten gain. We have an obligation to maximize the good, and since the harm (depriving others of this vital resource) has already been done, some good might as well come of it, no?

Perhaps. But it is in cases like this that it becomes important to distinguish between maximizing the good in a particular case, and maximizing the good over the long run. While I may have everything to gain from enjoying this stolen water, I don’t stand to benefit from a society in which one town steals vital resources from another. And the same may be true of vaccine booster shots. A global society in which affluent nations overbuy and hoard life-saving resources is one that, in the long-run, will create more harm than good – particularly where this kind of behavior only serves to prolong and worsen a crisis (like the pandemic) for the entire global population. By refraining from taking the COVID-19 booster – at least until those in poorer nations have had the opportunity to receive their initial vaccine – we send a clear message to our governments that we will not partake in ill-gotten gains.

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Individual Rights, Collective Interests, and Vaccine Mandates

Despite popular support, Biden’s recent policy – requiring vaccinations for all government employees and mandatory testing for businesses with more than 100 employees – is attracting the attention of a small but vocal minority. These voices question the very notion of public health and challenge the basis for the state to supersede individuals’ fundamental claim to bodily autonomy. Given these objections, how are we to justify the policy to those who remain opposed? How are we to adjudicate between the claims of individual liberty and the demands of collective interest?

Are vaccine mandates legal? The relevant precedent concerns a 7-2 Supreme Court ruling in Jacobson v Massachusetts which determined that the local government could enforce mandatory vaccinations to fight a smallpox outbreak. In the decision, Justice Harlan argued that

in every well ordered society charged with the duty of conserving the safety of its members, the rights of the individual in respect of his liberty may at times, under the pressure of great dangers, be subjected to such restraint, to be enforced by reasonable regulations, as the safety of the general public may demand.

In fact, tyranny could just as easily come from government failing to take action and allowing individual freedom to trump collective interests. “Real liberty for all,” Harlan wrote, “could not exist under the operation of a principle which recognizes the right of each individual person to use his own [liberty], whether in respect of his person or his property, regardless of the injury that may be done to others.” In a state of nature where everyone is free to pursue his or her own interest to the furthest extent, there can be no security, no rights, and no peace.

But even if such measures have legal history on their side, can these current vaccination mandates be morally justified? As with all things these days, it depends on who you ask. Red state governors have been quick to seize on these policies as obvious government overreach. Big brother is determined to interfere with average Americans’ daily lives and tell them what they can and can’t do with their bodies. These critics claim that the directives go far beyond what is reasonably required for ensuring public safety. These invasive measures are part of a crude, ham-fisted, one-size-fits-all approach to a fairly isolated problem. Big government is making a foot-long incision to get at the issue when a couple of tiny, strategic punctures might do.

So what makes these emergency orders “unreasonable”? Despite over 725,000 deaths from COVID-19 in the U.S. alone, we’re still squabbling over whether workers are in “grave danger.” Folks like Governor Ron DeSantis claim that the choice of whether to get vaccinated “is about your health and whether you want that protection or not. It really doesn’t impact me or anyone else.” And these sentiments resonate with a not insignificant swath of the population that bristle at being told what to do and who pride themselves on being “more worried about herd instinct than herd immunity.” The trouble, as they see it, is that all the bleeding hearts fail to recognize the basic fact that “life is always a risk.” 38,000 Americans die every year in car crashes, but no one is lining up in favor of a ban on driving. “We live with these risks,” these voices contend, “not because we’re indifferent to suffering but because we understand that the costs of zero drowning or zero electrocution would be far too great. The same is true of zero Covid.” In the end, the right balance between personal liberty and public safety is always to be found in letting the people decide for themselves.

But part of our disagreement stems from misunderstanding the science. Contrary to DeSantis’s claims, vaccination is not a private choice without practical consequences for anyone else. The vaccine does not make one invulnerable to infection and having a large unvaccinated population creates a breeding ground for variants. That’s why the unvaccinated represent the greatest threat to pandemic recovery. Leaving it up to individuals won’t do; we can’t simply agree to go our own ways.

As others have noted, the current conversation resembles the standoff over smoking bans in the not-so-distant past. We’re arguing over the answer to a large and complicated question: at what point does one’s private choices about their health encroach on the rights of others to be free from having risks imposed on them by their neighbors’ behavior?

Given the deep disagreement about the predicament we’re in, finding a trustworthy authority has become paramount. One body which might seem especially well-positioned to rule on the matter is the ACLU – the American Civil Liberties Union which is devoted to protecting people’s basics rights enshrined in the Constitution.

Instead of undermining individuals’ civil liberties, ACLU officials David Cole and Daniel Mach argue that vaccination mandates “actually further civil liberties. They protect the most vulnerable among us, including people with disabilities and fragile immune systems, children too young to be vaccinated and communities of color hit hard by the disease.” Echoing Harlan’s sentiments, the ACLU reminds us that liberties and duties are two sides of the same coin; a right’s very existence imposes corresponding obligations. Making a space for others to exercise their basic freedoms means recognizing the limits of one’s individual liberty: the freedom to swing my fist ends where your nose begins. While much attention has been paid to the coercive leverage in demanding vaccination as a condition of continued employment, we fail to appreciate the situation of those who must daily weigh the risk of exposing their immunocompromised family members against the necessity of putting a roof over their heads. While the number of folks faced with this second scenario may be smaller, surely we can appreciate that the injustice in these two situations is not equivalent.

We have a tendency to speak of rights as guaranteeing individuals’ absolute freedom of choice in pursuing whatever might make them happy — rights without obligations and without bounds. We speak in reverence of individual autonomy as the fundamental basis for human dignity. When I am impeded from doing what I want to do, or (worse) made to do something which I would otherwise not, I have been disrespected and harmed. We equate being free with being unconstrained.

But this kind of autonomy fits poorly within our philosophical traditions. Hobbes encouraged us to lay down our sword in order to enjoy the benefits of neighbors who are more than obstacles to our private interests. Kant argued that only by acting from duty can one be truly free. Showing sufficient respect for others means more than simply making space for their unimpeded desiring, willing, and choosing. No one can claim absolute license to pursue their private ambitions, come what may.

Where does this leave us? We find ourselves once again at the intersection of a number of related issues. We’re bad at conceptualizing disease; we’re addicted to the anecdotal, allergic to authority, and eternally unsure of who to trust. Matthew Silk has investigated the media’s troubles in relaying vaccination information; Martina Orlandi and Ted Bitner have explored our failure to change people’s hearts and minds; Marshall Bierson has pointed out how conflicting federal, state, and local legislation is complicating the picture; and Daniel Burkett has explained why we’re upset by others’ free-riding.

So, how should we respond? Megan Fritts recently raised the question of whether doctors are justified in refusing to admit unvaccinated patients to their overbooked and especially vulnerable waiting rooms. Much like we might penalize alcoholics on a donor list for liver transplants, there is at least one line of thought that suggests that those choosing to expose themselves to greater risk should be asked to bear the cost of that choice rather than forcing others to live with the consequences of that decision. Given the scarcity of medical resources and need for emergency assistance, some form of triage is inevitable. And the mantra of personal responsibility has always proven an efficient tool for separating the “undeserving” from the rest of us.

But this solution is too neat; it neglects to investigate who exactly the unvaccinated are. Over the weekend, The New York Times attempted to put a face to this broad label. The obstinate “Don’t Tread on Me!” die-hard doesn’t always track reality. From young mothers to the various outcasts of the healthcare system, there are at least some not-so-unreasonable anxieties expressed by the “vaccine-willing.” And there are, no doubt, a number of the unvaccinated who deserve our compassion and should inspire us to show a modicum of humility. Unfortunately, those folks with a legitimate medical complication or sincerely-held religious conviction constitute a collective that is not anything as large as it purports to be. You know who you are.

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Can We Heckle Unvaccinated Athletes?

photograph of Bryson DeChambeau at event with crowd in background

A lot of the pleasure I take in watching sports comes not only from seeing the teams and people I like succeed, but also from seeing those I dislike fail. For instance, I will gladly watch the Blue Jays players hit an impressive string of dingers, but will equally enjoy seeing Ben Roethlisberger get sacked. Being a sports fan means feeling both pride and schadenfreude, and it comes with the territory of being a professional athlete that some people are going to love you, and some just aren’t.

While there are a lot of reasons one might have for disliking an athlete, the pandemic has brought about a new one: being unvaccinated. There have been a number of professional athletes who have come out as having not yet been vaccinated, for whatever reason. In particular, Bryson DeChambeau, an American professional golfer, stirred up controversy recently when he was unable to participate in the 2021 Olympics due to testing positive for COVID-19, and then did not get vaccinated when he returned. He raised the ire of many golf fans even more when he said that he did not regret failing to get vaccinated, stating that he thought that since he was “young and healthy” that he didn’t need it, and that he was waiting for the vaccine to become “really mainstream.”

The result was a serious increase in heckling during his most recent tour, which resulted in an altercation with a fan during which DeChambeau sought the assistance of the police (despite the incident only involving name-calling). Some reporting on the issue have referred to the incident and others like it as “bullying.”

Others, however, have taken the opposite stance. For instance, sports commentator Drew Magary has called for increased booing of unvaccinated athletes, and singles out additional players like NFL stars Sam Darnold, Adam Thielen, and MLB star Jason Heyward, among others. “Has coddling them worked?” asks Magary. “No. And do you know why? Because these athletes SUCK. They don’t want more information. They have it. Everyone does.”

So, what’s the right thing to do in this situation? As we saw above, certainly some amount of heckling of your least favorite athlete is okay: while I would never openly insult someone on the street, the context of being a fan is such that if I got the chance to attend a Pittsburgh Steelers game I would without hesitation tell Ben Roethlisberger that he’s the worst and not feel bad about it in the least. Clearly there is a limit to sports fandom: you can’t throw stuff or kick your least favorite player as they walk past you, and it would probably be too much to shout a string of obscenities in the vicinity of young and impressionable fans. So where’s the line? And has it moved at all when it comes to heckling on the basis of being unvaccinated?

On the one hand, there is a concern that heckling players for failing to be vaccinated goes too far, in that it attacks someone’s personal convictions. For instance, ESPN notes how some of DeChambeau’s fellow golfers have been sympathetic, feeling that it’s unfair for fans to heckle someone based off a personal choice. It does seem that it might be violating some norm of sports fandom to attack someone’s personal beliefs: yelling at someone that they’re washed up is within the realm of sports, but maybe it shouldn’t extend outside of that realm. If the heckling is not only personal but also incessant, then we can see how someone might interpret it as a kind of bullying.

On the other hand, one might think that unvaccinated professional athletes deserve some degree of derision, not only because they are putting their teammates and opponents – with whom, in the case of NFL players, they are very much in close personal contact – at risk, but also because as professional athletes they are, to some extent, role models, and thus face additional obligations to set a good example for their fans. They also do not seem to have any kind of excuse: on the assumption that they do not have legitimate medical reason not to get vaccinated, they have access to information about the safety of the vaccine, as well as ready access to the vaccine itself. Perhaps, then, heckling could help encourage them to change their mind.

But wait, isn’t it just mean to heckle someone excessively, regardless of the reason? If it makes someone feel bad, isn’t that sufficient reason not to do it?

Maybe not. For instance, consider Magary’s justification for increasing heckling:

“So boo them. Call them names. Get personal from the bleachers. Hold up a giant copy of your vaccination card to taunt them with. Let them understand that there are earned consequences for being so negligent. For endangering everyone around you and then having the naked gall to act like it’s some sacred private decision you just made.”

While Magary thus conceives of additional heckling as a kind of deserved punishment, perhaps we could think about it in a slightly different way: heckling unvaccinated athletes is not a mere expression of disliking someone because they play for a rival team, but as a kind of protest. As we saw above, there do seem to be legitimate reasons to be displeased with both the unvaccinated athletes themselves as well as the professional leagues that allow them to continue to play – i.e., that they are endangering their teammates and setting a bad example. Given that there’s more at stake than just the outcome of a golf tournament (or a football or baseball game) it may very well be warranted to make your opposition to them known.

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Are Vaccines Passports Ethical?

photograph of COVID immunization card

The pandemic has been this recurring episode of things seeming like they may get back to normal only to find that new developments means that things could last longer. It was easy to think that once vaccinations against COVID-19 were available, people would get vaccinated and the pandemic would be over. As one Canadian scientist notes, “Everyone needs this damned virus to go away…but it’s not done with us yet,” while an American virus expert notes “we thought we saw the light at the end of the tunnel—but apparently the tunnel is longer.” Against the backdrop of this frustration and desire to return to normalcy (and to get as many vaccinated as possible), the matter of vaccine passports have become a significant ethical issue as Israel and Europe move ahead with their adoption. Some U.S. states and six Canadian provinces have (or are) adopting a passport system as well. But why does the prospect of a vaccine passport present such an ethical challenge?

The principle behind a vaccine passport system is that it allows businesses and governments to quickly and easily determine who is vaccinated in order to facilitate travel. In many of the jurisdictions which have adopted them, a passport might be required to enter restaurants and bars, nightclubs, sports and fitness facilities, casinos, concerts, music halls, and more. The goal behind the passports is to help minimize transmission while also encouraging people to get vaccinated. However, their efficacy will depend both on the details but also on which goal is taken to be more important.

For starters, some such as Chloe Kent argue that while passports are an ethical means to help facilitate international travel, they are unethical for use domestically. She points out that vaccinations as a requirement to enter a country isn’t new for international travelers and that in many nations which are behind in vaccine rollouts, an international vaccine passport system could help both the country and the tourists. However, she is concerned about the potential inequalities that could result from a domestic passport system. Thus, it is important to note the potential ethical distinctions between different forms of passports.

According to Rebecca Brown et al. from the journal The Lancet, “Immunity passports could be implemented on the basis of either a laboratory test of immune response or an immunizing event, which would identify individuals less likely to get disease or transmit virus when exposed to SARS-CoV-2.” But, according to the authors, the important immunological issues for such passports are the degree of immunity induced and the duration of the immunity: “A neglected issue in discussions of immunity passports is that of individual protection versus community protection. Perhaps the most important consideration for immunity passports is whether an individual can transmit the infection to others.”

They note that studies of previous seasonable coronaviruses suggest that vaccination may protect against severe disease but with a relatively unchanged potential for transmission. This fact, “provides the greatest challenge to the assurance that individuals who carry immunity passports would have a reduced risk to others.”

However, the picture about transmissibility of the virus by the fully vaccinated is complicated. Studies have shown a reduced viral load in those who are fully vaccinated for certain strains; unfortunately, the delta variant is different. Data on the variant has revealed that those with a breakthrough infection carry similar viral loads to those who are unvaccinated. However, it also suggests that these levels diminish much faster in a vaccinated person than a non-vaccinated person. There is also a long-term concern about how long vaccine immunity lasts (and thus whether booster shots may become necessary) and this could make a passport system largely pointless over time.

So, if a passport is designed to prevent spread, it is unclear how well it will achieve that goal. The delta variant complicates the picture, but for other variants a passport system may prevent spread. But overall, the efficacy of a passport system for preventing spread of COVID-19 is not fully clear. However, preventing non-vaccinated people from entering certain public spaces may still protect them as well. The data has consistently shown that unvaccinated people face the biggest risk and take up the bulk of spaces in ICU beds.

On the other hand, Eloise McLennan argues that the growing frustration with not being able to visit loved ones or to interact in public means that a vaccine passport system could incentivize people to get vaccinated. This may be a better alternative to get people vaccinated rather than to mandate vaccines which carries even greater ethical and legal concerns. If more people become vaccinated because of a passport system, then it could create additional economic benefits as pandemic restrictions can be lifted.

On the other hand, critics of vaccine passport systems argue that, in addition to concerns about their potential efficacy, passports segregate society in ways that are ethically harmful. Natalie Kofler and Françoise Baylis argue that, historically speaking, such vaccine passport systems have aggravated inequalities and permitted systemic racism. Indeed, the capacity for creating inequality is one of the major ethical concerns of such a proposal. According to Scientific American, “An ethical immunity passport system should exacerbate inequality. Access to the vaccine is very unequal in different regions and even within the same region.” There are also members of racialized, indigenous, and disadvantaged communities who may be mistrustful of medical and government institutions. As a result, a passport system would encourage division and potentially make things worse for those who are worse off.

International development expert Robert Huish argues that exclusion can marginalize people to disengage from public health efforts to protect the broader community, noting, “If you feel that the system isn’t working for you, public health isn’t speaking on your behalf, they’re coming up with orders that don’t apply, or that make you feel uncomfortable, you’re more likely to withdraw from engagement.” And Brown et al. point out that inequality in healthcare is not new. Yet, this reason is rarely interpreted as a reason to remove health-care treatments or to refuse to introduce new ones. While they believe more effort is needed to secure equitable health outcomes, this is not a reason to reject an immunity passport.

Another major concern about a passport system is that they violate civil and privacy rights. UNESCO’s ethics commission calls for any passport system to not allow the nonvaccinated to be discriminated against by limiting their movements. On the other hand, some argue that the actual loss of privacy involved to confirm vaccination status is inconsequential. And while there may be reason to worry about the segregation of society into the vaccinated and unvaccinated, it is also important to note from an ethical standpoint that this division is already an established fact. While many cannot get vaccinated, many more could. In effect, such people put additional burdens on healthcare systems and economic activity. So, while there is a reason to be ethically worried about the rights of the unvaccinated, the unvaccinated themselves should consider their ethical responsibilities. Sahakian et al. argue, for example, using Peter Singer’s principle of the duty of easy rescue that the extremely low risk of side effects of the vaccine compared to the benefits it creates means that, “vaccination passports are a minimal cost for returning to daily life…they are a small sacrifice for the greater good.”

This point is even more relevant in regions which have a public healthcare system. The cost of a vaccine is a fraction of the cost of an ICU bed, so those who can get vaccinated but don’t incur great additional cost to the public. So, ultimately the question about the ethical justification of a vaccine passport system involves a trade-off between certain potential benefits and costs which may be largely unknowable for now. If the system is unable to prevent spread, it may be able to increase uptake in vaccination rates. But the question is whether these upsides are worth the potential for social division and a violation of rights.

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COVID Vaccines and Primary Care

photograph of elderly man masked in waiting room

Dr. Jason Valentine, a general practitioner in Alabama, has decided to no longer treat unvaccinated patients. Starting October 1st, that is. At the beginning of August, Valentine’s clinic made the announcement, clarifying that his personal rule applied to both current patients and new patients. So long as you are unvaccinated, Dr. Valentine will not be seeing you. When asked why he was choosing not to treat unvaccinated patients, Valentine said “COVID is a miserable way to die and I can’t watch them die like that.” In Alabama, the state with the highest number of new COVID cases per day, such a sentiment is understandable. But is it ethical?

As most people know, doctors are bound by a creed called the Hippocratic Oath. The name of this oath comes from the historical figure of Hippocrates, a fifth century Greek physician, to whom the oath is traditionally attributed (although he was likely not the original author). The Hippocratic oath is the earliest-known source of many central idea of medical ethics that we still hold to today: e.g., the patient’s right to privacy, the obligation of the physician to not discriminate between the poor and the rich, and, most famously, the pledge to do no harm.

Doctors today continue to take a version of the Hippocratic Oath, though the oath has undergone major alterations in the past 2500 years. Still, the pledge to “do no [intentional] harm” remains. Major debates have been carried out historically over what exactly falls under the pledge to “do no harm” — that is, under what conditions are doctors guilty of breaking their oaths? More specifically, is Dr. Valentine breaking the Hippocratic Oath by refusing to see unvaccinated patients?

One argument for thinking that Valentine is breaking his oath is that refusing to see unvaccinated patients constitutes an illegitimate act of medical discrimination. Medical doctors have, historically, been stoically determined to ignore unpalatable particulars about the individuals they were treating. For example, during the Civil War, doctors in both the Union and the Confederate armies treated soldiers injured on the battlefield, regardless of their allegiance (excluding, sadly, Black soldiers on either side). During the second World War, British surgeons operated on Nazi prisoners of war, in many cases saving their lives. Under the Geneva convention, doctors are bound to treat soldiers from their army and enemy soldiers impartially — enemy soldiers are not to receive worse treatment or a lower medical priority because of their military allegiance. Surely, then, if the Geneva convention would forbid a doctor to refuse to see patients who were Nazis, it would prevent doctors from refusing to treat patients who had not received a vaccination for a dangerous and highly-contagious disease?

But there is legal precedent that complicates this verdict, as well. Specifically, doctors are allowed to, and do frequently, refuse to see children who have not received their recommended childhood vaccines and do not have a medical reason barring them from receiving vaccines. Reasons for these policies often include considerations of the extreme vulnerability of other patients that the voluntarily-unvaccinated may encounter in the office, including young children who are immunocompromised and babies who have not yet received all of their vaccines. Another consideration is that many childhood vaccines prevent infection from nearly eradicated diseases like the measles. When children are not vaccinated against these illnesses, breakthrough cases stand a higher chance of spreading, thereby resurrecting an almost defeated enemy.

For these reasons, one may be inclined to praise the doctor’s choice. Surely, if people are barred from seeing their general practitioner, this might motivate the unvaccinated to receive the vaccination, and undo some of the damage done by rampant misinformation regarding vaccine safety and efficacy. However, consider a (hypothetical) doctor who refused to treat patients who drank too much alcohol, or refused to exercise. In these cases, doctors would surely be seen as refusing to do their primary job: assuring the health of their patients to the best of their (possibly limited) abilities. Some philosophers, like Cass Sunstein, refer to actions and laws like these as “paternalism”: acts of mild coercion for the sake of protecting the coerced, are sometimes seen as acceptable — seatbelt laws and cigarette taxes are commonly-accepted paternalistic laws aimed at mildly coercing safer behavior. But when the coercion becomes harmful, or potentially harmful, these measures are generally seen as morally impermissible. For example, holding someone at gunpoint until they throw away all of their cigarettes may be incredibly effective, and maybe even good for the smoker in the long-run, but is surely morally wrong if anything is. The difference between paternalistic measures and harmful coercion is usually understood as a difference in potential harm and a difference in the degree of autonomy the coerced maintains. When laws increase the tax in cigarettes, smokers may be mildly financially harmed, but this generally will not amount to anything financially destructive. Generally, they retain the choice between either taking on a small additional financial burden or giving up smoking. In the gun-to-the-head case, the smoker no longer (meaningfully) retains a free choice. She must give up smoking or face her own death. Anything less than compliance, in this case, results in the most extreme kind of harm.

Clearly there will be many instances of coercive measures that fall somewhere between these two extremes. This raises a tough question for Dr. Valentine: does refusing to treat voluntarily unvaccinated patients constitute a case of permissible paternalism, or impermissible harmful coercion? One reason for thinking that such a decision may not result in real harm is the abundance of options of doctors that most people have access to. Surely needing to switch primary care doctors is merely an inconvenience, and not a significant harm. However, there are factors complicating this. Many people have insurance plans that severely limit what doctors they can see. Additionally, if Valentine is allowed to refuse unvaccinated patients, there is nothing stopping all of the doctors in his area from taking on the same rule. Someone may be effectively denied all medical care, then, if all local doctors decide to take up a similar rule. An inability to access a primary care doctor seems like a more severe harm than the instances of mild coercion in the cases of paternalistic cigarette tax laws.

There is no easy ethical analysis to give to Dr. Valentine’s decision. While we can surely sympathize with the protocol, and hope it leads to increased vaccination rates, we do not want large swaths of the general public living without a primary care doctor. Like many other aspects of COVID-19, ethicists here have their work cut out for them mapping brand new territory.

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Aesop and the Unvaccinated: On Messaging and Rationality

cartoon image of scorpion on frogs back

Aesop shared a fable once about a scorpion and a frog. The scorpion asked a frog to ferry him across a pond. The frog was reluctant because he feared the scorpion’s sting. But the scorpion appealed to the frog’s intellect and pointed out that if he did sting the frog, the scorpion would surely drown as well. So, the frog agreed to the request. But, as expected, about halfway across the pond, the frog felt an awful pain and before they both died, asked the scorpion why. The scorpion replied that he really couldn’t help it saying, “it’s in my nature to sting.”

Why did the frog make that irrational decision, even though he knew better? Fables typically have a moral for us to learn, and this one is no different; make rational decisions. Unfortunately, we make irrational decisions all of the time, even if, in the animal kingdom, we are known as the rational ones.

As of this writing, about 50% of the U.S. population is vaccinated. Since it is estimated that between 70% and 90 % of the population will need to be vaccinated against the COVID-19 virus to reach herd immunity, we have a long way to go. But the vaccination rate overall has slowed significantly. We watched the vaccination rate begin to plateau in late June and early July, at about the same time that the more deadly Delta variant began to ravage the unvaccinated. Now, with new cases rising each day across the country, one wonders why anyone would put off getting the vaccine.

Explanations for this phenomenon abound; some believe that vaccine hesitancy is to blame. Early on in the rollout of the three major vaccines available in the U.S., many were “hesitant” because they wanted more information about the vaccines. Were the vaccines safe? If so, like most medications, they probably were not safe for everyone, so for whom were the vaccines not safe? Where would people go to get the vaccines? What costs would be involved? These are rational questions the population was asking; they may have been gathering facts to make rational decisions. Or were they?

Humans aren’t really known for our ability to be consistent when it comes to making rational decisions. Some of those same people get flu shots every fall and make sure their children receive needed vaccinations as infants and again prior to the start of school, still don’t want to take the COVID vaccine. All despite the fact approximately 99% of deaths in America due to COVID are found among those unvaccinated. It seems irrational not to avail oneself of this life-saving intervention.

Even some government officials — in those areas where the vaccination rate is low, and the spread of the variant is high — are growing more outspoken about their constituents’ health decisions. Senate minority leader, Mitch McConnell (R-KY), has reiterated in public that for those who can be vaccinated to do so. (His state, Kentucky, has a lower-than-average vaccination rate.) The Governor of Alabama, Kay Ivy, recently said that this is now an epidemic of the unvaccinated in her state, further stating that you just can’t teach “common sense.”

But alongside these pleas are plenty of name-calling, finger-pointing, and blaming — all of which may be smokescreens for the fact that we don’t really know how to message the vaccine’s appeal to remaining holdouts. We continue to assume that humans are consistent in making rational choices, and when we believe they have not done so, we have a tendency to throw up our hands. We think that stupid decisions are made by stupid people. The truth, however, is that we aren’t consistent in making rational choices; irrationality abounds, and it has nothing to do with stupid. The same people who buy lottery tickets also buy insurance. Why? Cognitive science and the felicific calculus of Jeremy Bentham may both give us a peek into why we make decisions as we do, whether they are rational ones or not.

In the 18th century, Bentham formulated the “felicific calculus” which stated that an event can be assigned a value (typically numeric) as to its utility or worth. That worth was measured in terms of the amount of happiness or pleasure the event would bring people; the more happiness, the better the decision that caused it, and the more rational it would be seen. This mathematical algorithm measured pleasure or pain in terms of several facets; among them were the pleasure or pain’s intensity, its duration, the probability of its occurrence (and reoccurrence), and the number of people affected. While being mathematically sound, philosophically appealing in many ways, and rational, for most day-to-day decisions the calculus was impractical. Adapting a thought experiment originally posed by cognitive scientist/mathematician Amos Tversky however, may help us understand from a cognitive perspective why people are so inconsistent when making decisions.

Example 1. Let’s say that your local health department has projected that 600 people will get the Delta variant of COVID-19 in your hometown of 6,000 people.

There is a proposed treatment, A, and if applied it will save 200 people. 

There is another proposed treatment, B, and if applied, there will be 1 chance in 3 that 600 people will be saved, and 2 chances in 3, that no one will be saved.

Which treatment would you choose?

When presented with the original problem, most people chose treatment A where there is a surety that 200 people will live.

Example 2. Now, let’s say that the health department again predicts that 600 people in your hometown of 6,000 will get the Delta variant of COVID-19.

There are 2 treatments, A and B.

If treatment A is applied, 400 people will die.

If treatment B is applied there are 2 chances in 3 that all 600 will be lost, and I chance in 3 that no one will be lost.

Which treatment would you choose?

When presented with the original problem, most people chose treatment B.

Notice, however, that 200 people survive in each case. Despite this, in case one, treatment A was chosen as the better alternative, while in case two, treatment B was chosen. Why, when the probabilities and outcomes are the same, did A get chosen one time and B the other time? It’s the way the cases are presented, or framed. In the first scenario, the probabilities are presented in terms of lives saved (gains), and in scenario two the probabilities are framed in terms of lives lost (losses). We focus on the number of lives saved in either case, whether it’s a “sure bet” or the better probability.

Currently, public messaging regarding vaccinations focuses on lives lost rather than the number of lives saved. If we reframe messaging to focus on lives saved (gains) instead of lives lost (losses), the application of Tversky’s thought experiment might get us over the hump and on our way to achieving herd immunity. The felicific calculus of Bentham applies as well; perhaps a mathematical algorithm makes more sense to us homo sapiens in this case. Think of the number of persons who would experience happiness and pleasure instead of pain over a long period of time, plus the freedom from worry that the Delta could re-infect us. Correctly framing the message seems to be one effective and scientific way to help people manage the inherent irrationality that comes with being human.

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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.

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Considered Position: On Voluntary Non-Vaccination – Real World Complications

photograph of child among masked crowd

This piece concludes a Considered Position series that examines our evolving moral duty to those choosing to remain unvaccinated. To see the earlier segments, start here (Part II).

In Part I of this series I tried to explain the moral intuition that I have less reason to engage in precautionary social-distancing behavior once those who are unvaccinated are unvaccinated by choice rather than because they could not access the vaccine. This intuition, I argued, is explained by the fact that justice mainly requires us to give people reasonable options for safety and does not require us to make others safe.

In Part II, I looked at what it takes for an option to be reasonable, and we realized that this is often sensitive to the reasons that someone does not want to get a vaccine. If someone’s objection to the vaccine is reasonable, then justice may still require me to adopt precautionary behavior.

In both posts, I idealized the questions at hand. I ignored real life complications, and just tried to identify the abstract principles involved. For that reason, my cases were often unrealistic, involving such absurdities as the unvaccinated engaging in moral blackmail or people taking pills to make themselves allergic to the vaccine.

In this final post, I want to turn to the real world and look at some of the complications which make this a difficult ethical question.

Complication 1: We judge the reasonableness of others in biased ways

We saw in Part II that if the other person has reasonable grounds for refusing the vaccine, then justice still requires me to protect them by social distancing (even if their grounds are mistaken). One challenge, however, is that we tend to be biased in our own assessments of what are reasonable grounds.

Consider, for example, the following two suggested grounds of vaccine hesitancy:

Skepticism 1: Distrust of a Racist Healthcare System

Some Black people in the U.S. are reluctant to get a vaccine due to distrust of the American medical system. While this is sometimes attributed to historical injustices, like the Tuskegee study, it is more plausibly explained by current disparities in health care treatment. (It also, as a whole, might just be overblown; but we will put that aside for now.) The thought might go as follows:

“As Ben Almassi has argued in the context of organ donation, there are good grounds, given persistent racial health inequities, for Black people in the U.S. to distrust that the medical system has their best interest at heart. But if one has good reason to distrust the health system, then one also has good reasons to distrust the recommendations of the health system. This is especially true because we know that drugs and vaccines can sometimes affect different racial groups differently, and we also know that Black people tend to be massively underrepresented in vaccine trials (even when those rates are reported).”

Skepticism 2. Distrust of the Liberal Narrative 

Some conservatives are reluctant to get the vaccine due to distrust in the way that mainstream media portrays medical information. They might say things like:

“Putting aside worries that the COVID threat was overhyped to sink former President Trump’s reelection chances; we have seen a systematic tendency for the media to provide unreliable coverage on how to respond to the vaccine in order to fit its preferred political narrative. First, we see the same caseloads suggest different reactions depending on who is in charge. The week after President Biden was sworn in, long before any change in policy could have altered risk, blue states began opening up and schools began seriously trying to return students to in-person education. That was true, even though the absolute case numbers were still worse than they were in the summer when everyone insisted things needed to be shut down under President Trump.

Then, of course, ‘the Scientists’ consistently lauded Democratic governors like Andrew Cuomo and panned Republican governors like Ron Desantis. And yet, we have consistently found that the media narrative was backwards. Florida, despite an extremely old population, came out of the pandemic pretty well, with a much stronger economy, and with many more kids staying in school. This is not just cherry-picking. Republican states, on average, had fewer deaths and caused significantly less damage to the economy. Then ‘the scientists’ told us to take our kids out of school, but didn’t object to massive unmasked Black lives matter protests. ‘The scientists’ told us not to wear masks, until they needed a social symbol for purposes of public shaming.”

I bring up these two explanations of skepticism, not because I find them equally plausible, but because I don’t find them equally plausible. Intuitively, I find the first reasonable and the second ludicrous. But here is the issue: it’s hard to identify any objective reason the first is more reasonable. Sure, it fits better with my own preferred political narrative; but I think there are decisive objections to both lines of reasoning, and I don’t think the errors in one are in any sense more egregious than the errors in the other.

The danger, then, is that I am more sympathetic to members of what I see as my political in-group. But that differential in sympathy means I’m especially likely to inconsistently apply a standard as squishy as ‘reasonable.’

I don’t have a good solution here, and so just advise extreme caution when you label political allies reasonable or when you label political opponents unreasonable.

Complication 2: Immunization isn’t up to some people

While there are few, if any, groups in the U.S. for whom it would be dangerous to get the vaccine. There is some evidence that immunocompromised patients, while they can safely get the vaccine, do not always produce the required antibodies.

Similarly, there is a group of people in the U.S. who cannot choose to vaccinate: children. This is true in the limited sense that the vaccines are not currently approved for use in children below the age of 16. But it is also true in the sense that, even once the FDA approves the vaccine for children, children cannot choose to be vaccinated without a parent’s permission. Unvaccinated children, then, might not be unvaccinated by any choice of their own.

These are important complications, but I’m not sure that on their own they would show you must socially distance until we reach herd immunity (on the hypothesis that there are a large percentage of vaccine skeptical holdouts). Children are far less susceptible to COVID-19, and only a very small portion of the population are severely immunocompromised. Given these facts, the threat posed to children and the immunocompromised is far smaller than the risk posed by pre-pandemic activities when most people did not have access to the vaccine. Certainly, you should engage in some precautionary measures, especially if you know you are likely to be around someone who is immunocompromised. But it is unclear that those are any different than the ordinary obligations one has during flu season.

Complication 3: Deception and consent

One further complication is that deception tends to undermine voluntariness. For example, if I lie to you about the results of a surgery, then your consent to that surgery does not actually constitute voluntary consent. Similar issues arise about sexual consent.

Or suppose you told your friend that you would pick them up from the airport. But then I, just for the fun of it, lie to you and tell you that your friend’s flight was delayed, that they were not able to reach you, and that they don’t need a ride after all. If you don’t pick your friend up from the airport, then breaking the promise was involuntary. It was involuntary because I am the one who bears responsibility for your failure.

Now, if it is true that deception can undermine voluntariness, then one worry we might have is that there may be a good number of people who refuse the vaccine because they were lied to, and if so, it is those who lied who bear the actual responsibility for the non-vaccination.

One reason this is an important point to notice, is because a lot of people are especially likely to think that those with unreasonable reasons for refusing the vaccine accept those reasons because they are being lied to by their media ecosystem. Thus, many on the left think the vaccine hesitancy on the right is ludicrous, but those same people on the left are also likely to think that Fox News, OAN, or Newsmax, are systematically deceiving their viewers. Similarly, many on the right think that concerns of racism are blown way out of proportion, but those same people on the right are also likely to think that mainstream media organizations — like CNN or The New York Times — are providing systematically distorted information on those very issues.

Indeed, it is not just cases of outright lying that might trigger a shift in responsibility. Not only do I preclude the voluntariness of your action by lying to you, I do the same thing if I tell you something false when I should have known better. If I tell you something false but am really honestly trying to tell you the best I know, then your actions are still voluntary. You made the choice to trust me in good faith. But if I am not acting in good faith myself, then I am the one at fault when you err.

Conclusion

So once vaccines are widely available (such that the unvaccinated are mostly unvaccinated by choice) but before we reach herd immunity (due to widespread vaccine hesitancy) can you return to pre-pandemic behavior?

As we’ve seen, this is a difficult question. However, it seems likely that the right answer is generally yes. For the most part, because it is reasonable to expect people to get the vaccine, it is reasonable to return to behaviors that would be safe were others to be vaccinated. This is true, even without factoring in the fact that the vaccinated are very unlikely to spread COVID. And so, it does seem like justice allows life to return to normal.

However, we have also learned an important moral lesson about what it takes to justly live together in a society. For justice to allow us to return to pre-pandemic activities, it does not just require the vaccine to be widely available. It also depends on other people being able to voluntarily refuse the vaccine. And as it turns out, there are complicated ways in which we can undermine the voluntariness of other’s actions. When we are not fastidious about what we tell others, we risk undermining their own capacity to make voluntary choices. If I thoughtlessly spread misinformation or repeat something as fact that I am only pretty sure of, then I undermine one of the fundamental building blocks of our system of justice.

My own testimonial irresponsibility undermines the voluntariness of those who believe me in good faith. And systems of justice largely depend on the mutual voluntariness of everyone’s choices. This is one reason why lying and bullshitting are such profound moral wrongs. It is not just that others end up with some wrong beliefs (we all have a bunch of misguided convictions), but that other people are rendered, in a sense, passive in relation to your choices. By breaking down even a small portion of the reciprocal norms of justice, you don’t just lie to another but partially bring the whole system of justice down on top of you.

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Considered Position: On Voluntary Non-Vaccination – Types of Reasons

photograph of masked and unmasked people in a crowd

This piece is part of a Considered Position series that examines our evolving moral duty to those choosing to remain unvaccinated. To see the earlier segments, start here.

Hopefully pretty soon, my state, Florida, will reach the point that anyone who wants to be vaccinated can be vaccinated. In Part I of this series, I argued that once we reach that point, I have fewer reasons of justice to engage in aggressive social distancing. After all, everyone has the option to get the vaccine and so protect themselves from whatever risks I impose by my everyday activities.

In that argument, however, I ignored an important variable in our assessment of justice: why are people not getting vaccinated? This is important because different reasons give rise to different duties on my end.

To see this, let’s start with a particularly extreme contrast of cases:

Coordinated Moral Blackmail: Suppose that herd immunity requires that 80% of the population get vaccinated. But while 60% of the population are excited to return to normal and immediately get vaccinated, the other 40% coordinate together and refuse to get vaccinated until their demands are met. The 40% realize that the other 60% don’t want to put anyone’s health at risk, and so they refuse to receive the free vaccine unless the other 60% agree to collectively pay each person in the 40% camp three hundred dollars. By engaging in ordinary, non-social distancing activities, the 60% will put some people at risk. However, the only people who will be put at risk are those who voluntarily refuse to get vaccinated as a tool of moral blackmail.

Widespread Deadly Allergy: Suppose that herd immunity requires that 80% of the population get vaccinated. Let us also suppose that one of the weird things about this vaccine is that it produces a severe, possibly fatal, allergic reaction in people with peanut allergies. But while 60% of the population have no allergies and so get the vaccine, the other 40% all have severe peanut allergies and so forgo vaccination until a safer vaccine is approved. By engaging in ordinary, non-social distancing activities, the 60% will put some people at risk. However, the only people who will be put at risk are those who voluntarily refuse to get vaccinated because the vaccination is not worth the risk of anaphylaxis.

I presume that you share my intuitions about these two cases. In the first case, the 60% have no reasons of justice to forgo returning to pre-pandemic life. But in the second case, the 60% still have reasons to social distance. Indeed, I would think that the 60% in the second case have duties pretty similar to the duties we would have if the vaccine were only available to 60% of the population.

Normally, if someone voluntarily chooses to forgo the vaccination that changes my duty of justice. However, it only makes a difference to duties of justice if we can reasonably expect the person to get the vaccine.

It is unreasonable to expect someone to take a very risky vaccine, just as it would be unreasonable to expect a family to bankrupt themselves to buy the vaccine. But such pragmatic concerns are not the only relevant ones. For instance, if it is unethical to get the vaccine, say because it was produced by slave labor, then again if the majority of the population refuse the slave made vaccine, justice requires me to continue to maintain pandemic precautions.

If it would be a mistake to get the vaccine, then I am still bound by the same norms of justice to engage in precautionary behaviors. If people truly believe that they should not get the vaccine, then I can’t reasonably expect them to vaccinate.

But what if instead people falsely believe there is a problem with vaccines? Well, in that case things become more complicated. There are two kinds of error that could explain why one thinks a right action is wrong, both of which are described by Elizabeth Anscombe. First, one might be wrong about the ‘facts on the ground,’ the circumstantial descriptions of what is going on — for instance, one might think the vaccine is less safe than it is, or one might falsely think it is produced by slaves. Second, one might be wrong about the moral implications of those ‘facts on the ground.’ For instance, one might know the risk is tiny, but have the false principle that one cannot be expected to undergo even the smallest possible risk for the public good. Following a convention that I use in my own work, let’s call the first an error about circumstantial facts and the second an error of classificatory facts.

Error 1: Mistakes about Circumstance

The COVID vaccines are not, on the whole, very risky. The consensus judgment of the medical community is that the vaccines, like most vaccines, are safe and effective. But even if the vaccines are safe, some people might believe them to be unsafe. And this raises a question of whether such honest beliefs change my own reasons of justice.

Widespread Error of Belief: Suppose that herd immunity requires that 80% of the population get vaccinated. But while 60% of the population get the vaccine, truly believing that vaccines are safe and effective, 40% of the population mistakenly believe that the vaccine is dangerous. By engaging in ordinary, non-social distancing activities, the 60% will put some people at risk. However, the only people who will be put at risk are those who voluntarily refuse to get vaccinated as a result of mistaken beliefs.

In this case, does justice require me to forgo pre-pandemic activities? To answer this question, we need to know more information. In particular, we need to know why people have the false belief.

Suppose that preliminary scientific studies, incorrectly, suggest that the vaccine is unsafe for pregnant women. This information is widely announced and the majority of scientists and doctors accept the result. As it turns out, however, the conclusion is the result of a subtle mathematical error that no one has yet noticed.

If the best scientific evidence suggests that pregnant women should not get the vaccine, then it is clearly unreasonable for you to expect pregnant women to get the vaccine. It does not matter that the studies are wrong, because you cannot expect the average person to realize that the studies are wrong. If this is right, then at least some of the time false beliefs about matters of circumstance (such as the safety of belief), really do make it unreasonable for me to expect you to be vaccinated.

But not all mistaken factual beliefs work that way. Now imagine someone who is profoundly lazy and just assumes vaccines are unsafe. Because they are lazy and do not care about public health, they never bother to do any research to check whether their assumption is right.

We can accept that the person really thinks that the vaccines are unsafe. And we can further accept that the person cannot, by a voluntary act of will, get herself to believe the vaccines are unsafe (for instance, you cannot, at this very moment, choose to believe there is an elephant behind you even if I offered you five hundred dollars to form the belief).

So suppose our imagined interlocutor says: “I’m not getting a vaccine because I really believe they are unsafe; ultimately I don’t choose what I believe, so you can’t blame me for not getting vaccinated.” Is this right? Does the fact that we cannot choose our own beliefs mean we cannot be blamed for our false beliefs?

Elizabeth Anscombe, in her article “On Being in Good Faith,” argues this line of thought is mistaken. While good faith belief can make one’s behavior reasonable. A good faith belief, in the sense that excuses behavior, requires more than you really believing the thing you say you believe:

“Consider a rash and uncharitable judgement which led one to slander someone gravely. One does not – usually at least—say to oneself ‘Now I will judge rashly’ or ‘I am determined, rash as it is, to judge that so-and-so’- one simply judges rashly. What does ‘in good faith’ mean? If it means that one has not got one’s tongue in one’s cheek, is not consciously lying or hypocritical, then good faith is not enough to exonerate. If it is enough to exonerate, then the slander uttered under the influence of a rash and passionate conviction is not a statement made in good faith. . . . Thus good faith or sincerity are either not much good as a defence, or not so easily assured as we might think at first. . . . ‘He ought to have realised…’, ‘He ought to have thought of…’, ‘He had no business to suppose that…’, ‘He ought to have found out…’, are phrases that bear witness to the fact that a man’s beliefs do not suffice to justify him so long as he acts accordingly.”

What Anscombe is arguing is that one can be responsible for false beliefs if we could have expected you to know the truth. If the reason you have a false belief is because the entire scientific community is mistaken, we can’t expect you to know any better. But if the reason you have a false belief is because you are too lazy to do research, then of course we can blame you for your error.

If I accidentally kill a child because I didn’t know they had a deadly carrot allergy, then I’m usually not responsible for that death. However, if the only reason I don’t know about the allergy is because I skipped our camp’s health and safety meeting, then I am at least somewhat responsible. I can’t object that ‘I didn’t know,’ because I should have known.

The same principle applies to vaccines. If you have a false belief that might make your non-vaccination reasonable, but it only does so if we could not have expected you to know better.

Error 2: Mistakes about Classification

What about cases of moral ignorance? That is, someone knows all the ‘facts on the ground,’ but she mistakenly thinks that those facts mean she should not take the vaccine.

Some philosophers think moral ignorance is unique, that while circumstantial ignorance can excuse, moral ignorance never can. Other philosophers disagree. (I discussed that debate at length in a previous Prindle Post.)

In this context, however, it seems that moral ignorance is probably not unique. That is because we want justice to allow for at least some moral pluralism. If there are no reasonable, though false, moral principles; then the project of democratic pluralism is in serious danger. If we want to live together in society with at least some level of deep moral disagreement; then we should acknowledge the reasonability of people acting on at least some moral principles we think are wrong.

Now, in our society we don’t have widespread reasonable moral ignorance preventing us from reaching herd immunity. But there are at least some real-life cases where it is reasonable to wrongly refuse a vaccine on moral grounds. A good example is those who don’t want to take a vaccine that was created via use of aborted fetal tissue. This seems to me to be to be too morally fastidious, but the reasoning is not unreasonable, and I do not think we can expect people to never make that error.

Conclusion

The reason that people refuse the vaccine matters. If they are right to refuse it, then one is just as responsible to take precautionary actions as one was before the vaccine became available. If they are wrong to refuse, then the question becomes whether or not it is reasonable to expect them to take the right action. If their incorrect refusal is explained by a reasonable form of circumstantial or moral ignorance, then justice continues to make the same demands.

Continue to Part III – “Real World Complications”

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Considered Position: On Voluntary Non-Vaccination – The Difference Voluntariness Makes

photograph of people walking and biking in masks

This piece begins a Considered Position series that examines our evolving moral duty to those choosing to remain unvaccinated.

My state, Florida, recently opened up COVID vaccinations to everyone. This does not quite mean that anyone who wants to be vaccinated can be vaccinated. There are still a limited number of vaccines available, so not everyone who wants to get vaccinated has been able to schedule an appointment. But we are getting close to the point where those who remain unvaccinated are unvaccinated by choice.

This raises a question: does the fact that the vulnerable choose to remain vulnerable make a moral difference to what precautions I should observe? I have the strong intuition that this does make a moral difference; it intuitively seems that imposing risks on the unvaccinated is not as bad when the unvaccinated are unvaccinated by choice. (The evidence increasingly suggests that the vaccinated cannot really spread COVID-19, and if that is confirmed it will render much of this practical discussion moot. However, the underlying philosophical questions are important and worth investigating.)

But is my intuition that I can be less cautious correct? 

In this, and two subsequent posts, I will try to answer that question. Each post will be dedicated to one part of an answer.

  • Part I: What principle underlies the intuition that the voluntariness of non-vaccination makes a difference to my own actions? And is that principle a true moral principle?
  • Part II: Does it matter why others are choosing not to be vaccinated? Are there differences, for example, in how careful I should be around someone who avoids vaccination because they think COVID-19 is overblown or around a pregnant mother concerned about the lack of trial data in pregnant women?
  • Part III: How do the complexities of real life complicate the moral calculation? What are the implications of the fact that children cannot get the vaccine without a parent’s permission? And is someone’s choice really voluntary if that person was lied to about the safety of vaccines?

In this first post, I want to investigate what principle might underlie my intuition that I have fewer obligations of caution to those who are voluntarily unvaccinated. To identify the principle at work, it will be useful to start with a simple argument that voluntariness should not make any difference. The thought goes as follows:

  1. During the pandemic, I avoid certain behaviors — such as licking doorknobs — to avoid spreading illness and death.
  2. If someone forgoes vaccination, the reason they forwent vaccination makes no difference to their susceptibility to illness and death.
  3. So, people being unvaccinated by choice makes no difference to my reason to avoid certain behaviors.

Let us call this the ‘simple utilitarian perspective.’ The simple utilitarian thinks that because voluntarily refusing a vaccine conveys no immunological protection, the fact people voluntarily forgo the vaccine makes no difference to my moral calculation. If you are in a community where 40% of people are unvaccinated by choice and I am in a community where 40% of people are unvaccinated because of a limited supply of vaccines, then the simple utilitarian says we are in a morally equivalent position.

The Utilitarian Explanation of the Difference

I call this the ‘simple utilitarian perspective’ because there is a perfectly good utilitarian argument against this reasoning. It is true that it makes no difference to my own risk whether I cannot get a vaccine or whether I choose to not get a vaccine; in either case I am unvaccinated. However, that does not mean that if you compare a random person who could not get the vaccine to a random person who chose to not get the vaccine, that the average risk is the same. Assuming people are at least somewhat rational, people at higher risk are more likely to choose to be vaccinated.

Even if utilitarians only ultimately care about happiness, they still will place some value on freedom. When people are free to make their own choices, they can make choices that are best for themselves. The elderly are at greater risk than the young are. As such the elderly are more likely to choose to vaccinate. Similarly, those who are very healthy — and without any risk factors for COVID-19 — are more likely to forgo vaccination because their risks of contracting it are smaller.

All this means that it’s probably safer to resume licking doorknobs once everyone had the choice to get the vaccine because those at highest risk will also be vaccinated at the highest rates.

Going Beyond the Utilitarian Answer  — This might partly explain my intuition, but it cannot be the whole story. This is because my intuition persists, even when I know the utilitarian explanation does not apply; for example, even if I know that the person is forgoing a vaccine for a reason unrelated to personal risk — like because ‘vaccines don’t fit with their personal style’ — I still intuitively feel I have less reason to be cautious.

Distributed Responsibility 

Part of the intuition is explained, I think, by the fact that people who are unvaccinated by choice will share some of the responsibility when they get sick.

If the only way to prevent people from getting sick is if I stop licking doorknobs, then by licking doorknobs I take on complete responsibility for their illnesses. However, if there are two ways to prevent people getting sick — I stop licking doorknobs or they get vaccinated — then at worst I am only partially responsible. They share in responsibility by declining the vaccine.

If we imagine other more ordinary behaviors, like frequent grocery shopping rather than doorknob licking, then the other person actually bears most of the responsibility for getting sick. It seems more reasonable to ask them to get vaccinated than to ask me to stay indefinitely in lockdown; the more reasonable the choice you reject, the more responsible you are for the consequences of that rejection.  (This, then, is why you might feel I am mostly responsible if I really were licking doorknobs; licking doorknobs was not a reasonable thing to be doing in the first place.)

This idea, that the choices of others can mitigate our own responsibility is prominent in both ethics and law. I like how Christine Korsgaard presents the idea in her discussion of our responsibility for the consequences of lying:

“In a Kantian theory our responsibility has definite boundaries: each person as a first cause exerts some influence on what happens, and it is your part that is up to you. If you make a straightforward appeal to the reason of another person, your responsibility ends there and the other’s responsibility begins. But the liar tries to take the consequences out of the hands of others; he, and not they, will determine what form their contribution to destiny will take. By refusing to share with others the determination of events, the liar takes the world into his own hands, and makes the events his own.”

Going Beyond the Distributed Responsibility Answer — But if this is the explanation of the intuition, then we have a problem. There is something morally vicious about someone who is solely concerned with avoiding responsibility. The virtuous reason to take precautions is not to avoid responsibility for someone’s death, it is to save people’s lives.

To see this, let’s look at an example from my own life (an example I still look back on with shame).

Years ago, an acquaintance of mine expressed an intent to commit suicide. I became deeply distressed, was unsure how to proceed, and grew paralyzed by indecision. So, I reached out to two mentors of mine, both of whom had experience working with suicidal people.

Reaching out was the correct thing to do; I did not know how best to offer help. The problem was the reason I reached out for help. Ultimately, it was not so that I could better support this acquaintance. Rather, I was racked by anxiety about messing up and becoming responsible for the person’s death. I reached out to these mentors because I knew that it would be irresponsible to not follow their advice. Deep down, I wanted to reach out because that way, even if the person did kill herself, at least I would not be blameworthy.

Why think this is morally perverse? Most simply because my own guilt was not the important good at stake in the choice. The thing that mattered was my acquaintance getting the help she needed; decreasing my own culpability if things went badly was not anywhere near as important! (For a more detailed discussion of the way in which a concern for our own responsibility distorts our moral reasoning, see Elizabeth Anscombe’s article “On Being in Good Faith.”)

Reasons of Justice

Even though we should not be strongly motivated by a concern to avoid responsibility; there is a close connection between what we should do and what we would be responsible for not doing. So, this difference in how responsible I would be if someone gets sick might not explain why I have weaker reasons to take precautions, but it is evidence that my reasons are weaker.

But if I do have weaker reasons, then that must mean that my reasons to take precautions are not quite so simple as I have reasons to keep people from getting sick. And this is the key to unlocking the puzzle. While I do have reasons to lower the risk that other people get sick, I have especially important reasons of justice to give people control over their own risk.

Before the vaccine is widely available, if I go around engaging in ordinary risky activities, I impose risks on others that they cannot reasonably avoid. They have no control over whether what I do poses a risk to them. As such, it is reasonable to expect me to forgo certain activities for the sake of maintaining some minimal freedom for others.

After the vaccine is widely available, however, the risks I impose on others are risks that can be reasonably avoided. Others have control over how large a risk my frequent grocery shopping imposes on them. People have the option of safety. Whether they take that option makes some difference to my reasons for infrequent grocery shopping; but it is a less stringent reason than my reasons of justice to avoid imposing unavoidable risks.

Justice is that virtue which enables us to live our own life in community with others; as such, it is the virtue that sets boundaries on what I can choose, where those boundaries mutually accommodate the choices of others. We can drive faster now that every car comes equipped with seatbelts. Why? Not because everyone always uses their seatbelts, but because everyone having access to seatbelts ensures that everyone has a free option that allows them to maintain their previous level of safety even as I start driving faster on highways.

Justice is focused on whether people have choices of health, and not whether people are healthy. For example, justice requires that we provide those who are starving with food, but it does not require us to force feed someone who refuses to eat. Were this not true, then justice could actually harm our ability to live our own life in concert with others by giving rise to certain kinds of moral blackmail. Suppose I have no objection to being vaccinated and a high personal risk tolerance. As such, I insist that unless you pay me one hundred dollars I will not go and get a vaccine. If your duties of justice meant that as long as I forgo the vaccine, you cannot return to pre-pandemic activities, then I would be able to hold your actions hostage by means of your duty of justice.

Justice, of course, is not the only virtue. I also have duties of charity. And indeed, one of the things that makes charity so demanding is precisely that it opens us up to this kind of moral blackmail. To love another person requires caring about even their self-made misery. Charity is not ultimately about living your own life; it demands instead that you live, at least in part, for others. This is why charity is such a high and holy virtue; and in turn why even if everyone who forgoes a vaccination does so for entirely voluntary reasons, that does not end all duties of precaution.

Conclusion

Of course, in real life things are a little more complicated. For example, some people are forgoing the vaccine for trivial reasons while others seem to have reasonable concerns. Does my duty of justice change depending on why others are not being vaccinated? That will be the topic of Part II.

Continue to Part II – “Types of Reasons”

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AstraZeneca, Blood Clots, and Media Reporting

photograph of patients waiting in gym to be vaccinated

In some ways, it seems like most respectable news media have begun to take science more seriously and to take greater care in making sure that claims about COVID are fact-checked and that misinformation is debunked. But there is more to scientific communication than getting the facts right. Often it is the selection, arrangement, and emphasis of facts that matter most and holds the greatest sway over the average person’s comprehension of scientific matters. This can have very serious consequences such as the coverage of the AstraZeneca vaccine and its potential to cause vaccine hesitancy. Does the media have a responsibility to be more careful in how they cover scientific issues?

Not long after the AstraZeneca vaccine was approved in many nations, reports in March indicated that some who took the vaccine developed blood clots. Since then, over thirteen nations have either halted the rollout of the vaccine or limited its usage. While such clots can be lethal, they are treatable. However, the more important consideration is the lack of evidence that the vaccine causes clots and the limited number of cases. There is no direct evidence of a connection between the vaccine and the development of a blood clot. Despite this, the European Medicines Agency in its review of  over 80 cases has concluded that unusual blood clots should be listed as a rare side effect. However, it is the rarity of the symptoms which is even more important. Less than one hundred people out of 20 million people who have received the vaccine have developed blood clots.

This is actually lower than what you’d normally see from unvaccinated people, and in the meantime COVID itself can lead to clots showing up in “almost every organ.” All of this leaves regulators with an inductive risk scenario: if they say that the vaccine is safe, and it isn’t many people could develop clots and potentially die; if they that the vaccine isn’t safe, and it is then it will slow down the rollout of the vaccine and many more people could die. In fact, the experts have been pretty clear that in terms of risk management, the benefits of the AstraZeneca vaccine still outweigh the risks. In other words, even if the vaccine does cause blood clots, the rates are so low that the risk of people dying is far higher if you don’t use the vaccine than if you do. This is why experts have been critical about the suspensions as a “stupid, harmful decision” that will likely lead to more avoidable deaths and will make people more hesitant to get vaccinated. As Dr. Paul Offit of the Vaccine Education Center has said, “While it’s easy to scare people, it’s very hard to unscare them.”

Yet, despite the risk being small and possibly treatable, and the fact that experts have determined that it is still better to use the vaccine anyways, the news media hasn’t been helpful in covering this issue. For example, the Canadian media has chosen to cover (apparently) every case of a blood clot developing despite the messaging ultimately being the same. One story notes, ‘“While this case is unfortunate, it does not change the risk assessment that I have previously communicated to Albertans,’ Dr. Deena Hinshaw said during a teleconference,” while the other reports, “‘We have been very transparent that there could be one case per 100,000,’ he said. ‘We knew this could happen.’” In other words, this is a situation where statistically the formation of a blood clot is expected in limited numbers but is considered acceptable because it is still such a limited risk compared to the much larger benefits. So, it is simply unhelpful to report each confirmed case of something that is expected anyways. After all, we are told that the contraceptive pill carries a greater risk of developing a blood clot, so why cherry-pick cases?

As statistician David Spiegelhalter has suggested, the scare over blood clots has demonstrated our “basic and often creative urge to find patterns even where none exist.” Unsurprisingly, a majority of unvaccinated Canadians now report being uncomfortable with potentially receiving the AstraZeneca vaccine. All of this relates to the moral responsibilities of the media in covering scientific topics where it isn’t merely a matter of reporting facts but reporting them in context. While the media has been “on a crusade against COVID vaccine skepticism” and promoting science-based medicine, to some the selective skepticism of the media has led to charges of hypocrisy as “the press has made a habit of giving finger-wagging lectures about ‘following the science,’ they need to consistently practice what they preach.” Afterall, the media doesn’t choose to report every case of someone who gets a blood clot from a contraceptive.

In fairness, while no one is suggesting that the risk of clots should be ignored, there may be good reason to raise alarm. As The Atlantic reports,

“The risk of a dangerous vaccine reaction could be very real, if also very rare—and major European vaccine authorities have not, in fact, been overcautious, political, or innumerate in responding to this possibility…regulators must address the possibility (still unproved) that perhaps one in every 1 million vaccinated people could have a potentially fatal drug reaction—as more than 1 million vaccine doses are being injected each day in Europe alone.”

In other words, there is a real risk (even if small) and morally speaking it is important to have a public conversation about risks and how to manage them. The public should be aware of the risk and how those risks are appraised. However, the issue has become confused owing to a lack of scientific literacy as well as the media choosing to focus on individual and personal cases. Instead, a more constructive topic of focus could have been on the larger moral issue of managing risk in the face of uncertainty such as when and how to use the precautionary principle.

This isn’t the only case recently where cherry-picking media coverage has proven problematic. Recently a study found that media coverage of COVID-19 in the US has been excessively negative compared to international media. A separate study has found that a significant number of Americans (mostly those who lean Democratic) were likely to overexaggerate the risks of COVID. Further, it is becoming increasingly evident that developing scientific literacy is more difficult than thought, and presenting novel scientific findings in news is problematic anyways. So, if those in the news media wish to present a scientifically-informed picture of public affairs, it is morally imperative that greater attention be paid to the context in which scientific findings are reported.

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Underrepresentation in Clinical Trials and COVID-19

photograph of vaccine waiting line

There have long been concerns about underrepresentation in the clinical trials of medical products, and there has been a large push for the testing of COVID-19 vaccines to be more inclusive due to the urgency of the problem and danger the virus poses to all of us. The current situation presents an opportunity to assess the previous model that tended to emphasize efficiency — doing the most good for the most amount of people as quickly as possible, often in the interests of speeding production — at the cost to underrepresented groups continually having to use medical products not specifically designed for them.

Historically, both medical professionals and clinical trial participants were primarily men. Making up more than half of the population, women were drastically underrepresented in medicine. This underrepresentation resulted in vast differences in healthcare for men and women. This is important because men and women present different symptoms of disease. Since men have largely been the sample for clinical trials of medical products, there is far more medical knowledge about how men present symptoms of various diseases. This makes diagnosis for women more difficult, and it makes their symptoms seem abnormal.

The underrepresentation of women in clinical trials also impacts the treatment of diseases. When male cells, male animals, and men are the basis of clinical trials, researchers are looking only at the effects on one-half of the population. Often, when women were included in these trials, their data was not analyzed separately or significantly, so differences in experiences were not addressed. After trials, women would take medicine that had not been optimized for them, which could result in negative health consequences. For example, Ambien, a sleep aid, was not tested for differences in effects on men and women. When Ambien became available for use, the slower metabolism of women meant that the drug stayed in their systems longer than men, so the dose was too high for women.

One reason for the low representation of women in clinical trials is that researchers worried that women’s reproductive cycles and hormones would overcomplicate the study and provide confounding variables. However, these variables are part of the reason why men and women both need to be included in clinical trials. When hormonal fluctuations and reproductive cycles are not taken into account, it is uncertain exactly how a medical product will work.

Another reason women were often excluded from clinical trials was fear of harming fertility. In 1977, the FDA recommended  women of childbearing age do not participate in clinical trials for fear that medical products may harm a fetus in the event that the woman became pregnant. This recommendation was put into place after exposure to some drugs caused birth defects. In the past, little research was done about women’s health that did not relate to reproductive health. Fertility seemed to be the primary concern about women’s health, so it was treated as more important than the potential benefits of including women in clinical trials.

The FDA reversed this recommendation in 1993 over ethical concerns about prioritizing the fetus over the potential benefits of including women in clinical trials. The recommendation’s reversal was also related to concerns about autonomy. When the FDA put forth the recommendation, they made it significantly more difficult for women who wanted to participate in clinical trials to do so. Despite some women not wanting children or simply valuing the advancement of women’s health more than any potential negative health effects they may face, women were excluded from trials. The FDA attempted to address safety concerns, but ultimately changed their recommendation because of the constraints on personal choice. While there remain safety concerns, women can now choose to participate in clinical trials.

Due to the urgent nature of the pandemic, ensuring that the vaccine is viable for as many people as possible is a priority. To achieve this, clinical trials have been more inclusive of many medically underrepresented groups, such as pregnant women, minorities, and people with certain medical conditions. Pregnant women can choose to participate in the clinical trials for the vaccine far earlier than they are able to for most medical products. This is partly due to the funding for vaccine development and the higher risk that pregnant women face with COVID-19.

In the future, it is uncertain whether medically underrepresented groups will continue to have the same participation they currently enjoy. While it is clear that these groups ought to have more representation in clinical trials, some medical professionals have concerns about funding and time. Most medical products do not have the funding that the COVID-19 vaccine has. Lower funding limits the number of people who can participate in a clinical trial. Additionally, there are time constraints. When a medical product is necessary, it is important that it is released as soon as possible. Knowledge of the potential health risks for different groups must be weighed with the benefits of releasing the medical product as soon as possible. Often, this means that the human trials consist of healthy men and women with no other conditions being the primary subjects. Later, the effects for individuals with various health conditions may be tested as well, but this is rarely made a priority.

The history of discrimination in clinical trials forces us to consider whether efficiency in the production of a medical product designed for the greatest number of people is truly fair when it means that persistently underrepresented groups continue to suffer from a lack of viable medical products tailored to their particular needs.

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Why Anti-Vaxxers Are (Kind of) Like Marxists

image of anti-vaxx protestor

On February 26th, the second-oldest Roman Catholic archdiocese in the United States issued an official statement warning church members about their COVID-19 vaccine options; in particular, it labeled the recently approved, single-dose vaccine from Johnson and Johnson “morally compromised as it uses the abortion-derived cell line in development and production of the vaccine as well as the testing.” In the following days, numerous representatives of Catholic dioceses around the country chimed in to agree, not actually forbidding the pious from being vaccinated, but rather advising that “If one has the ability to choose a vaccine, Pfizer or Moderna’s vaccines should be chosen over Johnson & Johnson’s.”

To those unfamiliar with Catholic dogma, this warning is likely peculiar: what do abortion practices (which the Roman Catholic church officially, if not pragmatically, opposes) have to do with vaccinations? But this critique of vaccines is far from unique to conservative Catholic clergymen: for some time, critics of vaccines in general have lobbied pro-life sentiments as anti-vaccination arguments: my goal here is not necessarily to respond to abortion-based anti-vaccine rhetoric, but rather to demonstrate what else that kind of thinking might require someone to believe.

In short, it’s kind of Marxist.

Let’s back up and explain some things first. The “vaccinations-are-pro-abortion” (or even the less severe “some-vaccines-are-tainted-by-abortion”) argument is rooted in the fact that several vaccines, including Johnson and Johnson’s one-shot COVID-19 treatment, have been developed, in part, by using celluar tissue taken from an aborted fetus in the 1960s. Understandably, biomedical research often requires human tissue samples for many reasons, but it can be difficult to collect and store cellular material in a way that is both efficient and effective for long-term use; typically, human cells die too quickly to be used in long-term experiments, but fetal human cells are not only inherently capable of reproducing themselves indefinitely, but scientists have developed techniques to intentionally grow them in cellular cultures in a way that effectively “immortalizes” them. So, medical researchers studying how to cure ailments ranging from Alzheimer’s Disease to spinal cord injuries to multiple kinds of cancer to, yes, diseases susceptible to vaccinations will typically rely on several immortalized cellular lines that have been cultivated for decades in order to test their experiments.

It is not the case that the Johnson and Johnson vaccine — or any other vaccine, for that matter — contains aborted fetal tissue (that is to say: absolutely no one is receiving literal fetal cells in their arm when they get their COVID shot). Nor is it the case that abortions are being done in order to develop vaccines today (each of the cell lines now in use, such as the MRC-5 and WI-38 cultures, originate in abortions performed in the mid-20th century — often for separately tragic reasons, such as the rubella epidemic of the 1960s).

But this is not to say that there are no moral questions that arise about the use of fetal cell lines (or any other human culture) in contemporary research contexts. For example, the HEK-293 line used in the development of several COVID-19 vaccines may have come from an abortion in 1973, but its exact origination is unclear and it is entirely possible that the original cells were collected from the remains of a spontaneous miscarriage. Either way, despite the fact that HEK-293 cells have been used to develop a wide variety of medical advances and medications (including many of the various antipsychotics today used to treat diseases like schizophrenia and bipolar disorder), the original donor of those cells (or their family) has never been compensated for their contribution to an industry enjoying billions of dollars of profit. Similarly, the story of Henrietta Lacks, an African-American woman diagnosed with terminal cervical cancer in 1951, is a terrible example of how biomedical research can be built on a blatant injustice: after doctors collected a sample of Lacks’ cells without her knowledge, they discovered that the cells unexpectedly possessed the same kind of propensity for “immortalization” that makes fetal cells so useful, so they patented and commercialized the “HeLa” cell line. Despite never receiving Lacks’ consent for her cells to be used in this way (much less compensating her for her donation), the HeLa line has developed into one of the most useful (and lucrative) cell cultures on the market today; Lacks’ family never even knew the cultures existed until two decades after her death.

Setting those issues aside for now, what can we make of the claim that the conditions under which a commodity is manufactured can irrevocably taint the commodity itself with immorality? This is, I take it, a core complaint of the pro-life critic of vaccine development practices: the goals of vaccine deployment might be laudable enough (namely, reducing the spread of disease), but the methods of doing so are, arguably, associated with something purportedly inexcusable. For some, the difference between contemporary abortions and contemporary immortalized fetal cell lines originating in initially-unrelated abortions a generation ago might be sufficient to distinguish morally between pro-life commitments and vaccination acceptance — that is to say, someone could easily be a critic of elective abortion and consistently still believe that modern vaccination programs are morally acceptable. (It is worth noting that several outspoken pro-life American religious leaders, including Robert Jeffress, Al Mohler, and Franklin Graham have spoken out recently in support of COVID-19 vaccination programs.)

But let’s suppose that this is inconsistent (as many of Graham’s fans argued after he publicly surmised that Jesus would be pro-vaccine); what might we be committing ourselves to if we affirm that the use of fetal cell lines in their development hopelessly entangles vaccines within a morass of morally unacceptable problems?

Firstly, it seems like we would also need to reject many additional medical advances made over the last five decades. Anyone who rejects a vaccination against the novel coronavirus (or any other disease) because of the abortion-based critique of vaccinations I’ve been discussing will seemingly also need to reject treatments for conditions ranging from various cancers, diabetes, Parkinson’s disease, and macular degeneration to Alzheimer’s, paralysis, strokes, organ transplants, and medications for a wide variety of conditions. Without some special reason to think that vaccines are uniquely susceptible to being morally tainted via their tenuous association to past abortions, it is unclear why one could be an anti-vaxxer and not also a critic of many other elements of modern medicine.

Secondly, this whole conversation reminds me of the broader Marxist critique of capitalism in general. In his essay “Estranged Labor,” Marx introduces the idea that, under capitalism, workers are alienated from multiple things, including the products of their labor, their fellow human beings, and even themselves. A society split into different class-divisions, Marx says, necessarily prevents certain people (workers) from being able to live lives as fully realized human beings, creating and enjoying both cultural artifacts and the other people within our cultural relationships. In later works, like the first volume of Capital, Marx would develop the further critique that capitalism is not only alienating but exploitative because it, by design, transfers the value created by the labor of workers to the pockets of business-owners; for one example, consider the connection between Jeff Bezos’ wealth and the often-cataloged, but rarely-prevented dehumanization of workers in Amazon distribution centers (another is the dangerous abuses regularly perpetrated against both human workers and nonhuman animal victims in factory farms). Nowadays, this critique is sometimes summarized in the sloganized observation that there exists “no ethical consumption under capitalism” — although Marx himself never wrote those words, it is a (somewhat oversimplified) distillation of his broader point: the conditions under which capitalism operates necessarily spreads a taint of moral corruption throughout the entire line of commodity production in a manner that should provoke us to rethink the structuring of that productive system as a whole.

Of course, if someone is apt to think that products are, in a sense, insulated from the moral conditions of their production, then they would be able to quickly reject the Marxist critique of capitalism. Notice that there is at least one person who can’t do this, though: the person who accepts that vaccines are necessarily morally tainted because of the conditions of their production.

In short, if someone is inclined to believe that their pro-life commitments require them to think that vaccines are morally tainted, then they are seemingly required (upon pain of inconsistency) to believe that their anti-abuse commitments will require them to believe that many additional products, including anything produced on a factory farm and, perhaps, even all products produced by capitalists, are morally tainted as well.

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Scarce Goods and Rationalization

photograph of crowded waiting room

A friend of mine recently posted on Facebook asking for insight into “the ethics of (1) getting vaccinated as quickly as possible for the common good and (2) not using privilege to be vaccinated ahead of vulnerable people.”

Many responded with arguments along the lines of, “by getting a vaccine you are contributing to herd immunity, so it is a good thing to do.” Others linked to this New York Times ethics column in which Dr. Appiah argues that the advantage of easy management means that people should get vaccines when they can get them (and not worry too much about whether others might need them more), and further that by getting the vaccine “you are contributing not just to your own well-being but to the health of the community.”

Another friend recently mentioned in a group chat how she was able to get a vaccine that, technically, she did not yet legally qualify for (since Florida is only officially vaccinating K-12 educators, and not college instructors). I demurred, saying it’s important as healthy youngish people to wait our turn, and a third friend argued that even if you are not the ideal person to get the vaccine, you should still get it if you can since more vaccines are better than fewer and you can help protect others by getting vaccinated.

Assessing the Arguments

The Herd Immunity Argument — The thing that unites all these replies is the thought that by getting the vaccine you are helping to protect others. But in these cases, that is probably wrong. I want to be clear. I am not denying that more people being vaccinated contributes to herd immunity. What I am denying is that my friends getting a vaccine contributes to more people being vaccinated.

Right now the vaccines are a scarce good. If I do not get a vaccine, someone else will get that particular injection. As such, in getting a vaccine I have not actually done anything to increase the percentage of the population that is vaccinated, I have simply made sure that I, rather than someone else, am part of that vaccinated percentage.

The Waste Rejoinder — Some commenters on Facebook mentioned that some vaccines go to waste. But for the most part the vaccine distribution process has sorted itself out. While a good number of vaccines were being wasted in January, we are now in mid-March and the number wasted is utterly tiny in comparison to the number used. The odds that if you do not get a vaccine that the vaccine will end up in the trash is extraordinarily small.

So sure, if you happen to be in a situation where the alternative to not getting a vaccine is throwing it away, then get the vaccine. But unless you know that to be the alternative, you should not think that in getting the vaccine you are heroically contributing to solving the problem.

Speed of Distribution — While no one in the threads mentioned this argument, there is something that could be said for skipping the line. Even if someone else would have gotten that same vaccine, it’s possible it would have taken longer for the vaccine to get in someone’s arm. Now, it’s true that at this point the states are not sitting on nearly as large a vaccine stockpile as they were originally. But it is still the case that some vaccines, while they are not being wasted, are taking longer than ideal to end up in someone’ arm. Indeed, this seems to be happening where I am in Tallahassee.

But the problem is, this was not the situation either of my friends were in. Sure, this situation might be more common than the wasted vaccine situation. But it will still be rare (and indeed, markets are such that this waste usually does not last very long; soon after that article about Tallahassee was published demand at the site increased).

The Lesson

Now, I don’t want to argue that it is wrong to get the vaccine if you have the chance to do so. Probably sometimes it’s right and sometimes it’s wrong. As is often the case, it all depends on the details.

Instead, I want to suggest that we need to be careful to not convince ourselves that our selfish acts serve an altruistic motive. I think it’s probably ok to be somewhat selfish. It’s reasonable to care more about saving your own life than  the lives of a stranger (even Aquinas agreed as much). But I think when you are prioritizing your own good over the good of others, it’s important to recognize that that is what you are doing.

So if I get the vaccine perhaps that is ok. But I should recognize that if I get the vaccine someone else will not. I should also recognize that since I am young and healthy, that other person probably would have gotten more value from the protection than I did. The question, as far as altruism goes, is how do I compare to the average person getting a vaccine these days? Am I younger than the average person who would get the vaccine instead of me? Then probably it is better that the other person gets it. Am I healthier than the average person who would get the vaccine instead of me? Then probably it is better that the other person gets it.

The thing is, we have strong biases in favor of rationalizing our own selfish acts. Thus, we often look for reasons to think doing the thing we want is also good in general. This is a very dangerous tendency. People often accept really bad arguments, if those really bad arguments help them think well of their own selfish activity. This should scare us, and make us all a little more self-critical about our moral reasoning anytime we come up with plausible reasons for thinking the thing we want to do is also the best thing for the world as a whole. Remember, we all have a tendency to think that way, even when the act is merely selfish.

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Incentivizing the Vaccine-Hesitant

photograph of covid vaccination ampoules

Since the beginning of the COVID-19 pandemic, vaccine hesitancy has remained a constant concern. Given expectations that a vaccine would be found, experts always anticipated the problem of convincing those who distrust vaccines to actually get inoculated. A great many articles coming from the major news outlets have aimed at addressing the problem, discussing vaccine hesitancy and, in particular, trying to determine the most promising strategy for changing minds. In The Atlantic, Olga Khazan surveys some of the methods that have been proposed by experts. Attempts to straightforwardly correct misinformation seems to have proven ineffective as they can cause a backfire effect where individuals cling to their pre-existing beliefs even more strongly. Others instead suggest that a dialectical approach might be more successful. In The Guardian, Will Hanmer-Lloyd argues that we should refrain from blaming or name-calling vaccine-hesitant individuals or “post on social media about how ‘idiotic’ people who don’t take the vaccine are” because “it won’t help.” Similar to this “non-judgmental” approach that Hanmer-lloyd recommends, Erica Weintraub Austin, Professor and Director of the Edward R. Murrow Center for Media & Health Promotion Research at Washington State University, and Porismita Borah, Associate Professor at Washington State University, in The Conversation propose talking with vaccine-hesitant people and avoiding “scare-tactics.” Among the things that can help is providing “clear, consistent, relevant reasons” in favor of getting vaccinated while at the same time discussing what constitutes a trustworthy source of information in the first place.

In spite of all these good suggestions, to this day, Pew Research reports that only 60% of Americans would probably or definitely get a vaccine against COVID-19. Though confidence has been on the rise since September, this still leaves a concerning 40% unlikely to pursue vaccination. It is perhaps in light of these facts that a recent proposal is beginning to gain traction: incentivizing people by offering prizes. Ben Welsh of the LA Times reports that the rewards proposed include “Canary home security cameras, Google Nest entertainment systems, Aventon fixed-gear bicycles and gift cards for Airbnb and Lyft.”

But is it right to give out prizes to lure the initially unwilling to seek vaccination?

The answer depends on the moral system to which you subscribe. You might think that given the seriousness of the current circumstances it is especially crucial to get as many folks vaccinated as possible, and that the means of accomplishing this task are of secondary importance. This would be a consequentialist view according to which the moral worth of an action depends on the outcomes it produces. One might feel the force of this line of argument even more when considering that the consequences of vaccine hesitancy can carry dangers not only for the individuals refusing to get vaccinated but for the rest of us as well. Just recently, a Wisconsin pharmacist purposefully made unusable 57 vials of vaccine that could have been used to vaccinate up to 500 people because of a belief they were unsafe. So considering how significant the impact of vaccine-distrust can be, it is understandable that one might employ even unusual methods – such as prizes – to convince those who remain reluctant to join the queue.

On the other hand, if you do not feel the force of this outcome-based argument, you might think that there is something to say about the idea that changing people’s behavior does not necessarily change people’s beliefs. In this sense, offering a prize might not do much to alleviate the distrust they feel towards vaccination or the government. Consider another example. Suppose you do not believe that exercising is good. Yet your best friend, who instead does believe in the positive aspects of exercising, convinces you to go running with her because the view from the hill where she runs is stunning. In that sense, you may eventually elect to go running, but you will not do it because you are now a believer in exercising. You will go running just so that you can admire the view from the hill, without having changed your beliefs about exercise.

What is the problem of not changing people’s beliefs? You might be tempted to think that there is no problem, if you believe that the end result is all that matters. But even in that case, it is beliefs that drive our actions, and so as long as individuals still believe that vaccines are not to be trusted, giving out prizes will only be a marginal and temporary solution that fails to address the deeper, underlying issue. The worry is that someone who may opt to get vaccinated upon receiving a gift card is not deciding to get vaccinated for the right kind of reason. This argument picks out a distinction famously known in philosophy between right versus wrong kinds of reasons. The philosophical debate is complex, but, in general, when it comes to believing something, only epistemic, evidence-based reasons represent good reasons for actions. Should one, instead, come to act on the basis of reasons that have more to do with, say, wishes or desires, those would represent the proper kinds of reasons.

So what is the solution here? Well, there is no solution, as is often the case when it comes to philosophical positions that are fundamentally at odds with one another. But here is the good news: looking at the ways in which real life events connect with philosophical issues can help us figure out what we think. Examining issues in this way can prove useful in isolating the features that may help us understand our own particular commitments and convictions. Thinking through these tensions for ourselves is what allows us to decide whether we think the proposal to encourage vaccination efforts by offering prizes is a legitimate one.

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The Ethics of Vaccination Passports

photograph of couple presenting passport

The light at the end of the tunnel appears to finally be approaching after a year of the COVID-19 pandemic. Now that multiple vaccines are available in most countries and roll-out plans are ongoing, albeit at a slow pace in the United States, questions about getting back to “normal” are starting to be asked. Chief among these are ones regarding the most restricted activity with COVID-19, as well as the most sought after: international travel. After many countries restricted their borders with the United States due to COVID-19, it seems that Americans are itching to fly across oceans to enjoy the vacations that were cancelled in 2020. Now, countries must ask how travel can occur safely, or at least how the risk of spreading the coronavirus across international borders, which started the pandemic in the first place, might be limited. One possible solution being considered by multiple countries is a “vaccination passport.” Providing certification for those having received full vaccination would streamline things so that those inoculated against the virus might have privileged access to enter countries, ride on airplanes, and potentially even use gyms or enter bars.

The concept of only allowing entrance of persons with certain vaccines is not foreign. The World Health Organization issues the Yellow Card for people who have been vaccinated against certain deadly diseases in order to prevent the outbreak of those diseases in certain countries. The Yellow Card, then, is very similar to the suggested vaccine passport, except that COVID-19 raises a number of pressing questions concerning accessibility. Throughout this pandemic, minorities have been disproportionately affected by the virus. Facing systemic racism in the U.S., minorities have been less likely to receive adequate healthcare, to possess the necessary housing needed for quarantining, and to enjoy employment opportunities that might offer work-from-home options. Now that vaccines have been rolling out, it is the same situation: neighborhoods that faced the worst consequences of the coronavirus are now being the last to be vaccinated. While some countries might have very strong vaccine roll-out programs, the United States quickly fell behind the Trump administration’s goal of 20 million vaccines by the end of 2020 by about 17 million. Now, the Biden administration has committed to 100 million vaccinations in the first 100 days. Unfortunately, he first has to patch together a tremendous nation-wide effort in a country that has a very complex and privatized healthcare system — a system which has created many issues for Americans trying to get the vaccine.

It is, however, not only a question of access and who can get the vaccine, but also about considering the situation of those who can’t. At the very beginning of vaccine roll-out, it appeared that some Americans with allergies would simply not be able to get the vaccine because of the risk of anaphylactic shock, which can be deadly. If vaccine passports were required to enter some countries, then some people would simply be unable to enter them for an uncertain amount of time. It could take years before countries loosen restrictions or vaccine providers provide an alternative with different ingredients than those that currently make up the dose. There is also the question of what form the vaccine passport would take. Many countries are interested in a digital card that people could access through their phones. While many people may have access to a smart phone capable of holding documentation of a vaccination, plenty of people still do not have access to that technology, either out of choice or because it is not an affordable option. Technology then becomes just another barrier to international travel.

The main motivation behind these passports is an understandable desire to return to the feeling of living in a “normal” society, where people can move fairly freely throughout the world. Just the desire to travel is one that many people across the world share as it allows them to form meaningful relationships and connections with people both different and similar to themselves — a good the pandemic has stripped from us. Before we can get back to a sense of “normal,”  however, it is important to remember that this pandemic is far from over, especially in the United States. It would make sense, therefore, to have some sort of system set up to prevent people from spreading the virus across countries and continents. These passports raise important concerns about equality in access to medical, technological, and human goods. Many people would be left behind if these passports were to be implemented without addressing the fact that different populations do not have the same access to goods. Vaccine passports would effectively create a 2-tier citizenship hierarchy with those who have been lucky enough to receive full vaccination the freedom to move about in the world and take advantage of unique offerings that would even include public facilities. A great many people, and more importantly those already vulnerable and marginalized, will continue to be restricted in their movements and will lack access to the same opportunities that those with the vaccine would enjoy. This pandemic has already aggravated many inequalities and injustices between populations in the world, and a vaccine passport threatens to further codify this unjustified unequal treatment.

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Time to Let Up or Double Down?

photograph of woman with face mask sitting in large, empty street dining area

Rollout of COVID-19 vaccines represents a significant step in combating the pandemic, one that will likely alter people’s behavior to this global health crisis in significant fashion. With a vaccine on the horizon, risk assessment can change in two very different ways:

On the one hand, it can alter the risk associated with individual behaviors. For instance, with a risky behavior, the prospect of safety can reduce the perspective of associated risk. Here we could think of jumping out an airplane, which seems less risky because there is a parachute. With a vaccine in circulation, taking one’s chances with exposure can seem a more reasonable thing to do. Vaccination will (hopefully) mean there will be fewer people contracting it, lowering the impact on the societal concerns overall. This means risk is assessed in short-term frames: if every risk of exposure over 4 months compares to 12 months, one could think that they might as well lighten restrictions.

On the other hand, the prospect of a vaccine can alter the way we assess risk in a long-term context. When fighting a disease with a radical course of treatment, having an indeterminate time frame versus a given length of time to “push through” makes a great deal of difference. When the end point is unclear, it makes sense to consider harsh conditions unrealistic or unreasonable. In less dire cases, say a highly demanding and stressful workload at work, the expected length of time makes a significant difference in deliberation. Altering the long-term structure of your life around such demands can seem less than feasible, and compromises in meeting those demands can make a great deal of sense. It can make less sense, on the other hand, if the heightened demands are only for a short period of time and come with an important payoff.

With a vaccine in sight, much rests on how the adjustments to daily life given the risk of exposure are reassessed. One reason many give for not complying with state restrictions is that the virus is just something we “have to learn to live with,” or that it is a new way of life. Treating the vaccine as a parachute, as a dialing down of the harm associated with individual actions that put others at risk of contracting the virus, increases danger until the vaccine can come into effect. Letting up on the adjustments to behavior continues to do all the harms that have been associated with the spread of the virus: the deaths, the long-term effects of contracting the virus, the impact on our healthcare system, the systemic impact on the most marginalized populations, the destruction of our economy due to essential workers becoming ill, etc. These effects will not stop simply because of the prospect of a vaccine. The goals remain the same as they have been since February.

With the prospect of improving the fight against the pandemic, the reasonable choice could actually be to double down because we lose one reason to avoid the restrictions. The counterargument that pushes that long-term restrictions will harm the economy, will undermine the values in daily lives, etc. has been weakened considerably as we are now facing a short-term sacrifice for a long-term reward. But until inoculation reaches critical mass, we can’t point to our parachute to justify a refusal to exert effort in pursuit of our shared end goal.

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Why I Am Not like You: The Ethics of Exceptions

photograph of long line of people queuing to enter store

Consider two different arguments. The first that it was okay for me to travel in early December, the second that I should be given early access to a COVID vaccine.

My Travel: I understand that traveling was irresponsible in general, and that it was important that people not do so. Had COVID been happening in any other year I would have not traveled at all during the holiday season. But since it was this year, I had good reasons to carve out an exception for myself. First, it was really important for my girlfriend to meet my parents in person before we could get engaged, most people did not have such major life plans put on hold by the inability to travel over the holidays. Second, my grandfather is not doing well and so the consequences of delaying a visit could not be known. Third, this was the first time in six years my parents were back in the states for Christmas. Fourth, my girlfriend and I could take steps to minimize the risk: we drove instead of flying, we could travel in between the Thanksgiving and Christmas rushes, we both got tested before the trip, and I was able to aggressively quarantine the week before traveling.

My Vaccine: While I should not get the vaccine before the elderly, I should get it before it is open to the general public. First, I am teaching an in-person class in the spring and doing so, at least in part, because the state government of Florida is pushing to increase the percentage of college classes taught in-person in the spring. I offered to teach in person to help out, but it seems like the least that the state government could do after I agree to be around (I expect) irresponsible undergraduates is help make sure I have access to a vaccine. Second, I have been extremely aggressive in my social distancing. This means I should get the vaccine early since a) I have already taken on more inconvenience than most to help protect the public good and b) I’m more responsible than most, so I’ll be a larger drain on the economy if I remain unvaccinated. Third, I’m hoping to get married fairly soon, and that is an important life event that should qualify me for some priority.

— — —

I think the first argument is pretty good and the second one pretty bad. I really should not get priority vaccine access, but I think it was OK for me to travel in early December. But what I want to discuss in this post are some of the challenges in identifying when you should be an exception to a general rule.

Each argument tries to make out that I am, in some sense, special. And if you are going to exempt yourself from a rule you think others should generally follow, then you need to provide a compelling explanation for what makes your case unique. This follows from a deep moral principle about the moral equality of persons (one of the principles Immanuel Kant was getting at in his first formulation of the categorical imperative).

Suppose I don’t want to wait in line at the coffee shop. Can I jump the line? No. If ‘not wanting to wait’ was an adequate reason for anyone to cut in line, then everyone would cut in line (since basically no one wants to wait). But if everyone cut in line, then there would no longer be any line at all. My impatient cutting in line relies on the patient waiting of everyone else.  But here we bring in our deep moral principle: I am not special, which is to say that if I should get to do something, other people should as well. So if ‘not wanting to wait’ is a good reason for me, it must be a good reason for everyone. Since we have already seen it cannot be a good reason for everyone, we can conclude it is not a good reason for me.

So, if I want to cut in line, then I had better have a special reason to do it — a reason that will not apply to everyone else as well. Suppose I arrive at the hospital with a child suffering an anaphylactic shock. I see there is a long line of people waiting to get their severed thumbs reattached (I’ll leave it to you the reader to explain the sudden epidemic of thumb severings).

Here it is permissible for me to cut in front of people waiting to get their thumbs reattached. It is permissible because my reason for cutting will not generalize. If we changed the case so the line was all other parents with children suffering anaphylaxis, then it would not be permissible to cut (since we would otherwise return to our original problem).

Okay, so to carve out an exception there must be something unique about me. Well, there are things that are fairly unique about me, does that mean I should get to jump the vaccine line?  Well no. It was not just that anaphylaxis was different from a severed thumb, it also needed to be  more important. A broken leg, just because it is a different injury, would not make it okay to cut in line.

And here we come to a problem. While there are some things unique to me that suggest I should take precedence, basically everyone has some reason why they should be an exception. Sure, I’m hoping to get married but others, who are about to have their first child, will need to spend some time in a hospital and could really use the in-person support of grandparents. Sure, I’m teaching in person, but others are taking (more than one) classes in person. Syndrome was right, if everyone is special, no one is — at least in the sense that if everyone can identify reasons why they should be able to skip to the front of the line, then no one gets to skip.

And indeed, even if I decided I really was more special than others, it is still probably a bad idea to let me jump in line. That is because we, as a general rule, do not want society making thousands of fine-grained decisions comparing every possible special exception. It opens up far too many possibilities for bias and corruption, and besides that, it becomes democratically problematic because it is impossible to adequately articulate the thousands of priority decisions to the citizenry.

Alright, so I should not get to cut the vaccine line.

But what about my choice to visit my parents in early December? I think most people should stay home, but I also really thought I had a better reason to travel than others. Is that enough to justify my exception.

Not quite, there are two complications I need to consider.

First, I need to factor in my biases. Lots of biases may play a role, but let’s just look at an availability bias. I know the details of my life quite well; I do not know the details of yours. Thus even if my case looks more exceptional to me, that might not be because it is, but just because my own specialness is easier to see.

Second, even if I factor in all those biases and still think I’m exceptional, there is a problem with taking that as sufficient to make an exception. That is because I’m not only making a first-order decision, I’m also making a second-order decision. I’m not only deciding that my case is exceptional, I’m also regarding myself as a competent judge to decide on my own exception. This creates a problem because I expect most people are biased, and so if most people decide for themselves whether they should be an exception, far too many will make the wrong choice.

One way to see this problem is to note that others will disagree with me about what is an important reason for an exception. Let’s explain this with an analogy. Something like over 90% of teachers believe they are above average. Now, this might be that teachers are biased (I expect that is likely), but there is another explanation. Perhaps Anne and Barnie are above average lecturers and Chloe and Darius are above average mentors. Anne and Barnie think lecturing is the most important part of teaching (thus why they spent time getting good at lecturing) and Chloe and Darius think mentoring is the most important part of being a good teacher (thus why they invest so much in mentoring students). Here, even if each of them accurately judges how good they are at various teaching techniques, we will still get everyone thinking they are an above average teacher.

Similarly, if everyone decides for themselves whether they should be an exception. We could well end up with many people thinking they are one of only a few who deserve an exception. Not because they are wrong about any of the details, but simply because different people have different priorities. So even if 100% of people think only the 5% of people with the most pressing reasons to travel should travel, you could still easily get 30% or 40% people honestly deciding they fall in the 5%.

Of course, I think my priorities are right. I think I am better at thinking these things through then the average person. But is that enough to let myself treat myself as an exception? Probably not, since I also think that others think their priorities are right, and I expect that others think that they are better than average at thinking these issues through. So the question I am forced to ask is not just, am I better at making decisions, but rather should anyone who thinks they are better at making decisions be allowed to decide for themselves. If my answer to that latter question is no, then it might still be wrong to carve out the exception.

So was I wrong to travel in early December? It is hard to say. On the one hand, I really do think I had a good reason to do so. But on the other hand, I do not think most people should get to carve out their own exceptions just because they think the exception is warranted (of course, maybe it is not actually hard to say but I just do not want to admit I made the wrong choice).

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Duties to Vaccinate, Duties to Inform

image of 2021 with vaccine vial and syringe representing two of the numbers

The news these days has been dominated by information about the development of a vaccine for COVID-19, something that has felt like the first really good bit of news pertaining to the pandemic since it started. While there is reason for optimism, however, it is not as though the deployment of a vaccine will end the pandemic overnight: in addition to logistical problems of production and distribution, recent research suggests that it may still be possible that vaccinated individuals could spread the disease, even if they themselves will not contract it. As such, it’s not as though we can all just throw our masks in the garbage and start going to music festivals the day the vaccines start to roll out. This is not to say that things won’t get better, but that it might take a while.

You would think that the development of a vaccine would be universally regarded as good news, and that pretty much everyone would want to get vaccinated. However, when surveyed, large portions of the US population have responded that they would be hesitant to receive a vaccine, or else would outright refuse it. These numbers have varied over the months: according to the PEW research center, in May 27% said they would “probably not” or “definitely not” get the vaccine, while that number increased to 49% in September, before going back down to 39% in November. It’s not clear whether these numbers will change as more information becomes available, however; similarly, when people actually start receiving the vaccine and seeing that it’s not dangerous one might expect these numbers to go down.

Reasons for current levels of skepticism vary: while much has been made about the wildest conspiracy theories floating around Facebook – Bill Gates is trying to mind control you, or something – it seems more likely that the majority of skeptics are driven more by concerns about making the best decisions given limited information, combined perhaps with a distrust of medical experts. The question then becomes how we can best communicate scientific information to those who are skeptical. Indeed, this is a problem that we have been facing since the pandemic started: first it was information regarding the need for social distancing, then for wearing masks, and now for getting vaccinated. While at no point have we found the magic solution, it is worth considering what our roles in this process should be.

I think we have a certain obligation in this regard: beyond getting the vaccine itself, we also ought to try to inform others as best we can.

Here’s why I think this. Part of the problem in communicating information to a lot of skeptical people is that it will be difficult to find sources of information that everyone finds trustworthy. To try to address this concern, former presidents Barack Obama, George W. Bush, and Bill Clinton have stated that they would all receive the vaccine on camera to show that it is safe, with the goal of appealing to as politically diverse a population as possible. Given that a number of issues surrounding COVID-19 have become politicized, this seems like a good strategy: if those on one side of the political spectrum are less likely to trust someone from the other side, then having representatives of both sides together to present a unified message may help convince a larger audience.

(Other campaigns seem less promising: Trump, for instance, reportedly attempted to develop videos to be played on YouTube promoting the vaccine using only celebrities that were not critical of Trump or some of the causes that he does not support, such as having voted for Obama in the past or being in favor of gay rights. The number of people who met these criteria turned out to be very short.)

While trust can be affected by one’s general political position, there are additional divisions that may affect who one deems trustworthy. This can be seen in recent polls measuring Americans’ willingness to receive the vaccines that target more specific demographics. For instance, some have expressed concern that Black Americans may be particularly prone to skepticism regarding the vaccine, prompting members of various Black communities to attempt to communicate the importance of getting vaccinated. In an even more specific study, one recent poll reported that over half of New York City firefighters would refuse a vaccine. Here union leaders seem to be going in the wrong direction, stating that they would not require first respondents to be vaccinated, and that they would respect the decisions of their members.

We can see, then, that while major figures like former U.S. presidents may be seen as trustworthy sources, there is also a role for less prominent individuals to convey information to skeptical individuals. Given the importance of having as many people receive the vaccine as possible, the duty to try to inform others extends, I think, to pretty much everyone: while not everyone is a community leader, one may nevertheless be considered a trustworthy source of information by one’s friends and family, and may be able to communicate such information more effectively than former presidents or celebrities, given that one may share more values with those one is close to. When it comes to the COVID vaccine, then, one’s obligations may extend beyond just getting the vaccine oneself, and may include duties to help inform others.

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This for That: Trading Vaccinations for Stimulus Checks

photograph of gloved hand offering syringe and vaccine vial

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.

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Who Should Get the Vaccine First?

photograph of doctor holding syringe and medicine for vaccination

As at least one COVID-19 vaccine is scheduled to enter clinical trials in the United States in September, and Russia announced that it will be putting its own vaccine into production immediately, it seems like an auspicious moment to reflect on some ethical issues surrounding the new vaccines. Now, if we could produce and administer hundreds of millions of doses of vaccine instantaneously, there would presumably be no ethical question about how it ought to be distributed. The problem arises because it will take a while to ramp up production and to set up the capacity to administer it, so the vaccine will remain a relatively scarce resource for some time. Thus, I believe that there is a genuine ethical question here: namely, which moral principles ought to govern who gets the vaccine when there is not enough to go around and the capacity to administer it remains inchoate? In this column, I will weigh the pros and cons of a few principles that might be used.

One fairly straightforward principle is that everyone is equally deserving of treatment: everyone’s life matters equally, regardless of their race, gender, or socioeconomic status. The most straightforward way of fulfilling the principle is to choose vaccine recipients at random, or by lot. The trouble with this method is that, although it arguably best adheres to the principle of equality, it also fails to maximize the good. We know that not everyone is equally vulnerable to the virus; choosing vaccine recipients by lot would mean that many vulnerable people would die needlessly at the back of the line.

One way of defining “the good” in medical contexts is in terms of quality-adjusted life years, or “QALYs.” One QALY equates to one year of perfect health; QALY scores range from 1 to 0. If our aim in distributing the vaccine is to maximize QALYs, then we would prioritize recipients for whom a vaccine would make the greatest difference in terms of QALYs. Since the vaccine would make the greatest difference to members of vulnerable groups, we would tend to put these groups at the front of the line. We could also combine the principle of maximizing QALYs with the equality principle by selecting individual members of each group by lot while shifting all members of vulnerable groups to the front of the line.

While the principle of maximizing QALYs would in this way help the most vulnerable, it might be open to the objection that it neglects those who perform particularly important social functions. These perhaps include government officials and workers in essential industries who cannot shelter in place. One justification for prioritizing these individuals would be that since they contribute more to the functioning of society, they are entitled to a greater level of protection from threats to their productivity, even if giving them the vaccine first would fail to maximize QALYs. Another idea is that prioritizing such individuals maximizes overall well-being, rather than QALYs: more people benefit if society functions well than if members of vulnerable groups live longer. In a sense, then, we can view the dispute between the principle of maximizing QALYs and the principle of rewarding social productivity as a dispute between two ways of defining “the good.”

Finally, we might consider using the vaccine to reward those who have made significant contributions to social welfare in their lives, both on the grounds of intrinsic desert and to provide incentives for individuals to make similar contributions in the future. For example, we might decide that, between two individuals A and B for whom the vaccine would make an equal difference in terms of QALYs, if A is a war veteran, retired firefighter, teacher, and so on, then A ought to receive the vaccine first. One troubling feature of using this criterion is that owing to past discriminatory policies, this principle might heavily favor men over women. On the other hand, men may already be favored over women by the principle of maximizing QALYs, since they appear to be more vulnerable to COVID-19.

A final suggestion is just to let the market decide who will get the vaccine. But it’s hard to see how that idea is compatible with any of the normative principles discussed in this column. This method of distribution will not maximize QALYs or reward those who make or have made significant contributions to social welfare, and it seems at odds with the notion that all lives matter equally — in effect, it expresses the idea that the lives of the wealthy matter more.

Here is my proposal, for what it’s worth. If the disease were deadlier and there was not effective basic protection against transmission, then we would have to worry much more about the ability of government and essential industries to function without the vaccine. Luckily, COVID-19 does not pose such a threat. This means that operationalizing the principle of maximizing QALYs probably also would maximize overall social well-being, despite prioritizing vulnerable groups over essential workers and non-vulnerable groups. As I suggested above, we ought to select individual members of groups by lot, so as to affirm their basic equality. And in cases where we would make a roughly equal difference in terms of QALYs, we ought to favor the would-be recipient who has made a significant contribution to social welfare in their lives.

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The Ethics of Philosophical Exemptions

photograph of syringe and bottle of antiobiotics

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.