Good reasons to vaccinate: mandatory or payment for risk?

Mandatory vaccination, including for COVID-19, can be ethically justified if the threat to public health is grave, the confidence in safety and effectiveness is high, the expected utility of mandatory vaccination is greater than the alternatives, and the penalties or costs for non-compliance are proportionate. I describe an algorithm for justified mandatory vaccination. Penalties or costs could include withholding of benefits, imposition of fines, provision of community service or loss of freedoms. I argue that under conditions of risk or perceived risk of a novel vaccination, a system of payment for risk in vaccination may be superior. I defend a payment model against various objections, including that it constitutes coercion and undermines solidarity. I argue that payment can be in cash or in kind, and opportunity for altruistic vaccinations can be preserved by offering people who have been vaccinated the opportunity to donate any cash payment back to the health service.

Vaccine mandates for healthcare workers beyond COVID-19.

We provide ethical criteria to establish when vaccine mandates for healthcare workers are ethically justifiable. The relevant criteria are the utility of the vaccine for healthcare workers, the utility for patients (both in terms of prevention of transmission of infection and reduction in staff shortage), and the existence of less restrictive alternatives that can achieve comparable benefits. Healthcare workers have professional obligations to promote the interests of patients that entail exposure to greater risks or infringement of autonomy than ordinary members of the public. Thus, we argue that when vaccine mandates are justified on the basis of these criteria, they are not unfairly discriminatory and the level of coercion they involve is ethically acceptable-and indeed comparable to that already accepted in healthcare employment contracts. Such mandates might be justified even when general population mandates are not. Our conclusion is that, given current evidence, those ethical criteria justify mandates for influenza vaccination, but not COVID-19 vaccination, for healthcare workers. We extend our arguments to other vaccines.

Which features of patients are morally relevant in ventilator triage? A survey of the UK public.

BACKGROUND: In the early stages of the COVID-19 pandemic, many health systems, including those in the UK, developed triage guidelines to manage severe shortages of ventilators. At present, there is an insufficient understanding of how the public views these guidelines, and little evidence on which features of a patient the public believe should and should not be considered in ventilator triage. METHODS: Two surveys were conducted with representative UK samples. In the first survey, 525 participants were asked in an open-ended format to provide features they thought should and should not be considered in allocating ventilators for COVID-19 patients when not enough ventilators are available. In the second survey, 505 participants were presented with 30 features identified from the first study, and were asked if these features should count in favour of a patient with the feature getting a ventilator, count against the patient, or neither. Statistical tests were conducted to determine if a feature was generally considered by participants as morally relevant and whether its mean was non-neutral. RESULTS: In Survey 1, the features of a patient most frequently cited as being morally relevant to determining who would receive access to ventilators were age, general health, prospect of recovery, having dependents, and the severity of COVID symptoms. The features most frequently cited as being morally irrelevant to determining who would receive access to ventilators are race, gender, economic status, religion, social status, age, sexual orientation, and career. In Survey 2, the top three features that participants thought should count in favour of receiving a ventilator were pregnancy, having a chance of dying soon, and having waited for a long time. The top three features that participants thought should count against a patient receiving a ventilator were having committed violent crimes in the past, having unnecessarily engaged in activities with a high risk of COVID-19 infection, and a low chance of survival. CONCLUSIONS: The public generally agreed with existing UK guidelines that allocate ventilators according to medical benefits and that aim to avoid discrimination based on demographic features such as race and gender. However, many participants expressed potentially non-utilitarian concerns, such as inclining to deprioritise ventilator allocation to those who had a criminal history or who contracted the virus by needlessly engaging in high-risk activities.

Race and resource allocation: an online survey of US and UK adults' attitudes toward COVID-19 ventilator and vaccine distribution.

OBJECTIVE: This study aimed to assess US/UK adults' attitudes towards COVID-19 ventilator and vaccine allocation. DESIGN: Online survey including US and UK adults, sampled to be representative for sex, age, race, household income and employment. A total of 2580 participated (women=1289, age range=18 to 85 years, Black American=114, BAME=138). INTERVENTIONS: Participants were asked to allocate ventilators or vaccines in scenarios involving individuals or groups with different medical risk and additional risk factors. RESULTS: Participant race did not impact vaccine or ventilator allocation decisions in the USA, but did impact ventilator allocation attitudes in the UK (F(4,602)=6.95, p<0.001). When a racial minority or white patient had identical chances of survival, 14.8% allocated a ventilator to the minority patient (UK BAME participants: 24.4%) and 68.9% chose to toss a coin. When the racial minority patient had a 10% lower chance of survival, 12.4% participants allocated them the ventilator (UK BAME participants: 22.1%). For patients with identical risk of severe COVID-19, 43.6% allocated a vaccine to a minority patient, 7.2% chose a white patient and 49.2% chose a coin toss. When the racial minority patient had a 10% lower risk of severe COVID-19, 23.7% participants allocated the vaccine to the minority patient. Similar results were seen for obesity or male sex as additional risk factors. In both countries, responses on the Modern Racism Scale were strongly associated with attitudes toward race-based ventilator and vaccine allocations (p<0.0001). CONCLUSIONS: Although living in countries with high racial inequality during a pandemic, most US and UK adults in our survey allocated ventilators and vaccines preferentially to those with the highest chance of survival or highest chance of severe illness. Race of recipient led to vaccine prioritisation in cases where risk of illness was similar.

Vaccination of individuals lacking decision-making capacity during a public health emergency.

This paper explores the ethical challenges in deciding whether to vaccinate individuals lacking the decision-making capacity needed to provide informed consent during a public health emergency like COVID-19. The best interests standard ordinarily governs such decisions, which under the law in jurisdictions like England, Wales and Singapore takes into account the individual's past wishes and present preferences. However, in a public health emergency, the interests of third parties become more salient: those whom the unvaccinated individual might expose to infection have an interest in the individual's being vaccinated. While current mental capacity law has not been interpreted to take such public health considerations into account, we argue that such considerations are nevertheless ethically relevant, and can legitimately be weighed up alongside other considerations such as the preferences of the individual and impacts on their health. This is most relevant for individuals lacking decision-making capacity who have previously declined or presently resist vaccination. The public health impact of vaccination may in some instances be enough to outweigh preferences of the individual and justify providing vaccination against their past or present wishes.

Funder priority for vaccines: Implications of a weak Lockean claim.

The development of some COVID-19 vaccines by private companies like Moderna and Sanofi-GSK has been substantially funded by various governments. While the Sanofi CEO has previously suggested that countries that fund this development ought to be given some priority, this suggestion has not been taken seriously in the literature. Considerations of nationalism, sustainability, need, and equitability have been more extensively discussed with respect to whether and how much a country is entitled to advance purchase orders of the vaccine under conditions of absolute scarcity. Yet, little attention has been paid to whether prior investment into developing a vaccine entitles a country to some priority with respect to these orders. Moreover, while not a majority view, some survey results show that a significant minority of the populace does endorse some view like this. This article argues that the minority have a point: recognizing funder countries some priority is justified by the weak Lockean claim (WLC). According to the WLC, the fact that someone has contributed to the development of something gives them some entitlement to the resultant product. This article will defend the WLC, and address objections to the argument, including those pertaining to questions of historical injustice and medical need. This argument does not imply an unconstrained entitlement. Rather, contribution to development is one morally relevant factor that must be tempered by and weighed against potentially more substantial claims to priority based on need, equity, and other considerations.

Proportionality, wrongs and equipoise for natural immunity exemptions: response to commentators.

We would like to thank each of the commentators on our feature article for their thoughtful engagement with our arguments. All the commentaries raise important questions about our proposed justification for natural immunity exemptions to COVID-19 vaccine mandates. Thankfully, for some of the points raised, we can simply signal our agreement. For instance, Reiss is correct to highlight that our article did not address the important US-centric considerations she helpfully raises and fruitfully discusses. We also agree with Williams about the need to provide a clear rationale for mandates, and to obtain different kinds of data in support of possible policies.Unfortunately, we lack the space to engage with every one of the more critical comments raised in this rich set of commentaries; as such, in this response, we shall focus on a discussion of hybrid immunity, which underlies a number of different arguments evident in the commentaries, before concluding with some reflections responding to Lipsitch's concern about the appropriate standard of proof in this context.

COVID-19 differentiated measures for unvaccinated individuals: The need for clear goals and strong justifications.

Numerous countries and jurisdictions have implemented differential COVID-19 public health restrictions based on individual vaccination status to mitigate the public health risks posed by unvaccinated individuals. Although it is scientifically and ethically justifiable to introduce such vaccination-based differentiated measures as a risk-based approach to resume high-risk activities in an ongoing pandemic, their justification is weakened by lack of clarity on their intended goals and the specific risks or potential harms they intend to mitigate. Furthermore, the criteria for the removal of differentiated measures may not be clear, which raises the possibility of shifting goalposts without clear justification and with potential for unfairly discriminatory consequences. This paper seeks to clarify the ethical justification of COVID-19 vaccination-based differentiated measures based on a public health risk-based approach, with focus on their deployment in domestic settings. We argue that such measures should be consistent with the principal goal of COVID-19 vaccination programmes, which is to reduce the incidence of severely ill patients and associated healthcare burdens so as to protect a health system. We provide some considerations for the removal of vaccination-based differentiated measures based on this goal.

Governing Global Antimicrobial Resistance: 6 Key Lessons Fromthe Paris Climate Agreement

[...]mitigating the threat posed by AMR requires a recognition of how embedded social structures and incentives drive antimicrobial use across sectors. [...]escalating commitments through national AMR action plans, which outline each country's AMR goals and planned actions, will likely increase the effectiveness of global AMR efforts. Fifth, like the Intergovernmental Panel on Climate Change guiding the Paris Agreement, ongoing AMR action would be best informed by a regular and independent stock-taking to evaluate existing measures and advise on evidence-informed adjustments.11,12 This endeavor must (1) recognize that different ways of knowing constitute the global knowledge base, (2) ensure that using evidence to inform adjustments that work does not detract from the inherently political questions of works for what purpose and for whose benefit, and (3) come with a commitment to equitable evidence generation and prioritization. Striking a panel to assess the global knowledge base on these terms will ensure that global, regional, and national goals and policies are continually informed by the best available evidence and are in line with leading practices.12 Finally, an enduring international legal agreement could institutionalize requires new legal mechanisms beyond those available through the World Health Organization, the Food and Agriculture Organization of the United Nations, the World Organization for Animal Health, and the United Nations Environment Program, which are limited to the area-specific mandates of each institution.

Vaccine suspension, risk, and precaution in a pandemic.

In early 2021, cases of rare adverse events were observed in individuals who had received the Astra Zeneca COVID-19 vaccine. Countries around the world differed radically in their policy responses to these observations. In this paper, we outline the ethical justification for different policy approaches for managing the emerging risks of novel vaccines in a pandemic. We begin by detailing the precautionary approach that some countries adopted, and distinguishing ethical questions regarding the management of known and unknown risks. We go on to outline the harms of adopting a highly precautionary approach in a pandemic context, and explain why an appropriate policy approach should accommodate the benefits as well as the risks of vaccination. In the final section, we outline three policy approaches that can accommodate the different benefits of vaccination, whilst taking into account the harms of precaution. Whilst we do not set out to defend one particular policy approach, we explain how different moral theories lend different degrees of support to each of these different approaches. Our analysis elucidates how fundamental value conflicts in public health ethics played out on the global stage of vaccine policy.

The unnaturalistic fallacy: COVID-19 vaccine mandates should not discriminate against natural immunity.

COVID-19 vaccine requirements have generated significant debate. Here, we argue that, on the evidence available, such policies should have recognised proof of natural immunity as a sufficient basis for exemption to vaccination requirements. We begin by distinguishing our argument from two implausible claims about natural immunity: (1) natural immunity is superior to 'artificial' vaccine-induced immunity simply because it is 'natural' and (2) it is better to acquire immunity through natural infection than via vaccination. We then briefly survey the evidence base for the comparison between naturally acquired immunity and vaccine-induced immunity. While we clearly cannot settle the scientific debates on this point, we suggest that we lack clear and convincing scientific evidence that vaccine-induced immunity has a significantly higher protective effect than natural immunity. Since vaccine requirements represent a substantial infringement of individual liberty, as well as imposing other significant costs, they can only be justified if they are necessary for achieving a proportionate public health benefit. Without compelling evidence for the superiority of vaccine-induced immunity, it cannot be deemed necessary to require vaccination for those with natural immunity. Subjecting them to vaccine mandates is therefore not justified. We conclude by defending the standard of proof that this argument from necessity invokes, and address other pragmatic and practical considerations that may speak against natural immunity exemptions.

Which Vaccine? The Cost of Religious Freedom in Vaccination Policy.

We discuss whether and under what conditions people should be allowed to choose which COVID-19 vaccine to receive on the basis of personal ethical views. The problem arises primarily with regard to some religious groups' concerns about the connection between certain COVID-19 vaccines and abortion. Vaccines currently approved in Western countries make use of foetal cell lines obtained from aborted foetuses either at the testing stage (Pfizer/BioNTech and Moderna vaccines) or at the development stage (Oxford/AstraZeneca vaccine). The Catholic Church's position is that, if there are alternatives, Catholic people have a moral obligation to request the vaccine whose link with abortion is more remote, which at present means that they should refuse the Oxford/AstraZeneca vaccine. We argue that any consideration regarding free choice of the vaccine should apply to religious and non-religious claims alike, in order to avoid religion-based discrimination. However, we also argue that, in a context of limited availability, considering the significant differences in costs and effectiveness profile of the vaccines available, people should only be allowed to choose the preferred vaccine if: 1) this does not risk compromising vaccination strategies; and 2) they internalize any additional cost that their choice might entail. The State should only subsidize the vaccine that is more cost-effective for any demographic group from the point of view of public health strategies.

Provide Vaccines, Not Require Immunity or Vaccination Passports For Now.

In principle, mandatory vaccination in employment could be justified in certain circumstances. These include: (1) the availability of safe and effective vaccination; (2) if alternative, less coercive strategies did not work; and, (3) the costs to the individual were proportionate. However, in COVID-19, the long term safety of vaccines is yet to be established. Vaccines should be made available by employers, and voluntary vaccination encouraged.

The 'Ethical' COVID-19 Vaccine is the One that Preserves Lives: Religious and Moral Beliefs on the COVID-19 Vaccine.

Although the COVID-19 pandemic is a serious public health and economic emergency, and although effective vaccines are the best weapon we have against it, there are groups and individuals who oppose certain kinds of vaccines because of personal moral or religious reasons. The most widely discussed case has been that of certain religious groups that oppose research on COVID-19 vaccines that use cell lines linked to abortions and that object to receiving those vaccine because of their moral opposition to abortion. However, moral opposition to COVID-19 vaccine research can be based on other considerations, both secular and religious. We argue that religious or personal moral objections to vaccine research are unethical and irresponsible, and in an important sense often irrational. They are unethical because of the risk of causing serious harm to other people for no valid reason; irresponsible because they run counter to individual and collective responsibilities to contribute to important public health goals; and in the case of certain kinds of religious opposition, they might be irrational because they are internally inconsistent. All in all, our argument translates into the rather uncontroversial claim that we should prioritize people's lives over religious freedom in vaccine research and vaccination roll out.

After the Pandemic: New Responsibilities.

Seasonal influenza kills many hundreds of thousands of people every year. We argue that the current pandemic has lessons we should learn concerning how we should respond to it. Our response to the COVID-19 not only provides us with tools for confronting influenza; it also changes our sense of what is possible. The recognition of how dramatic policy responses to COVID-19 were and how widespread their general acceptance has been allowed us to imagine new and more sweeping responses to influenza. In fact, we not only can grasp how we can reduce its toll; this new knowledge entails new responsibilities to do so. We outline a range of potential interventions to alter social norms and to change structures to reduce influenza transmission, and consider ethical objections to our proposals.

Ethics of genomic passports: should the genetically resistant be exempted from lockdowns and quarantines?

Lockdowns and quarantines have been implemented widely in response to the COVID-19 pandemic. This has been accompanied by a rise in interest in the ethics of 'passport' systems that allow low-risk individuals greater freedoms during lockdowns and exemptions to quarantines. Immunity and vaccination passports have been suggested to facilitate the greater movement of those with acquired immunity and who have been vaccinated. Another group of individuals who pose a low risk to others during pandemics are those with genetically mediated resistances to pathogens. In this paper, we introduce the concept of genomic passports, which so far have not been explored in the bioethics literature. Using COVID-19 as an illustrative example, we explore the ethical issues raised by genomic passports and highlight differences and similarities to immunity passports. We conclude that, although there remain significant practical and ethical challenges to the implementation of genomic passports, there will be ways to ethically use them in the future.