Should people get vaccinated for the sake of others? What could ground—and limit—the normative claim that people ought to do so? In this paper, we propose a reasons-based consequentialist account of vaccination for the benefit of others. We outline eight harm-based and probabilistic factors that, we argue, give people moral reasons to get vaccinated. Instead of understanding other-directed vaccination in terms of binary moral duties (i.e., where people either have or do not have a moral duty to get vaccinated), we (...) develop a scalar approach according to which people can have stronger or weaker moral reasons to get vaccinated in view of the moral good of vaccination. One advantage of our approach is that it can capture why a person might have strong moral reasons to get vaccinated with Vaccine A, but only weak moral reasons to get vaccinated with Vaccine B. We discuss theoretical strengths of our approach and provide a case study of vaccination against COVID-19 to demonstrate its practical significance. (shrink)

In their thoughtful article, Malm and Navin (2020) raise concerns about a potentially unjust generational welfare tradeoff between children and adults when it comes to chicken pox. We share their c...

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. (shrink)

Public health policies often require individuals to make personal sacrifices for the sake of protecting other individuals or the community at large. Such requirements can be more or less demanding for individuals. This paper examines the implications of demandingness for public health ethics and policy. It focuses on three possible public health policies that pose requirements that are differently demanding: vaccination policies, policy to contain antimicrobial resistance, and quarantine and isolation policies. Assuming the validity of the ‘demandingness objection’ in ethics, (...) we argue that states should try to pose requirements that individuals would have an independent moral obligation to fulfil, and therefore that are not too demanding. In such cases, coercive measures are ethically justified, especially if the interventions also entail some benefits to the individuals; this is, for example, the case of vaccination policies. When public health policies need to require individuals to do something that is too demanding to constitute an independent moral obligation, states have an obligation to either provide incentives to give individuals non-moral reasons to fulfil a certain requirement – as in the case of policies that limit antibiotic prescriptions – or to compensate individuals for being forced to do something that is too demanding to constitute an independent moral obligation – as in the case of quarantine and isolation policies. (shrink)

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. (shrink)

Babylon 5, like other great sci-fi franchises, touched on important ethical questions. Two ethical conundrums relating to the series’ main characters included providing life-saving treatment to a c...

There is a need for all industries, including healthcare, to reduce their greenhouse gas emissions. In anaesthetic practice, this not only requires a reduction in resource use and waste, but also a shift away from inhaled anaesthetic gases and towards alternatives with a lower carbon footprint. As inhalational anaesthesia produces greenhouse gas emissions at the point of use, achieving sustainable anaesthetic practice involves individual practitioner behaviour change. However, changing the practice of healthcare professionals raises potential ethical issues. The purpose of (...) this paper is twofold. First, we discuss what moral duties anaesthetic practitioners have when it comes to practices that impact the environment. We argue that behaviour change among practitioners to align with certain moral responsibilities must be supplemented with an account of institutional duties to support this. In other words, we argue that institutions and those in power have second-order responsibilities to ensure that practitioners can fulfil their first-order responsibilities to practice more sustainably. The second goal of the paper is to consider not just the nature of second-order responsibilities but the content. We assess four different ways that second-order responsibilities might be fulfilled within healthcare systems: removing certain anaesthetic agents, seeking consensus, education and methods from behavioural economics. We argue that, while each of these are a necessary part of the picture, some interventions like nudges have considerable advantages. (shrink)

The Covid-19 pandemic has led to a health crisis of a scale unprecedented in post-war Europe. In response, a large amount of healthcare resources have been redirected to Covid-19 preventive measures, for instance population-wide vaccination campaigns, large-scale SARS-CoV-2 testing, and the large-scale distribution of protective equipment to high-risk groups and hospitals and nursing homes. Despite the importance of these measures in epidemiological and economic terms, health economists and medical ethicists have been relatively silent about the ethical rationales underlying the large-scale (...) allocation of healthcare resources to these measures. The present paper seeks to encourage this debate by demonstrating how the resource allocation to Covid-19 preventive measures can be understood through the paradigm of the Rule of Rescue, without claiming that the Rule of Rescue is the sole rationale of resource allocation in the Covid-19 pandemic. (shrink)

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. (shrink)

Preventive vaccination can protect not just vaccinated individuals, but also others, which is often a central point in discussions about vaccination. To date, there has been no systematic study of self- and other-directed motives behind vaccination. This article has two major goals: first, to examine and distinguish between self- and other-directed motives behind vaccination, especially with regard to vaccinating for the sake of third parties, and second, to explore some ways in which this approach can help to clarify and guide (...) vaccination debates and policy. I propose conceiving of vaccination in terms of three basic elements: the vaccination decision-maker, the vaccine recipient and the primary beneficiary. I develop a taxonomy based on the relations between these elements to distinguish four kinds of vaccination: self-protective, paternalistic, altruistic and indirect. I finally discuss the case of human papillomavirus vaccine regulation for men and women to show how each kind of vaccination is associated with and raises specific ethical questions. (shrink)

The potential for vaccines to prevent the spread of infectious diseases is crucial for vaccination policy and ethics. In this paper, I discuss recent evidence that the current COVID-19 vaccines have only a modest and short-lived effect on reducing SARS-CoV-2 transmission and argue that this has at least four important ethical implications. First, getting vaccinated against COVID-19 should be seen primarily as a self-protective choice for individuals. Second, moral condemnation of unvaccinated people for causing direct harm to others is unjustified. (...) Third, the case for a harm-based moral obligation to get vaccinated against COVID-19 is weak. Finally, and perhaps most significantly, coercive COVID-19 vaccination policies (e.g., measures that exclude unvaccinated people from society) cannot be directly justified by the harm principle. (shrink)

Bioethics, Volume 36, Issue 6, Page 687-698, July 2022.

The devastating impact of the COVID‐19 (coronavirus disease 2019) pandemic is prompting renewed scrutiny of practices that heighten the risk of infectious disease. One such practice is refusing available vaccines known to be effective at preventing dangerous communicable diseases. For reasons of preventing individual harm, avoiding complicity in collective harm, and fairness, there is a growing consensus among ethicists that individuals have a duty to get vaccinated. I argue that these same grounds establish an analogous duty to avoid buying and (...) eating most meat sold today, based solely on a concern for human welfare. Meat consumption is a leading driver of infectious disease. Wildlife sales at wet markets, bushmeat hunting, and concentrated animal feeding operations (CAFOs) are all exceptionally risky activities that facilitate disease spread and impose immense harms on human populations. If there is a moral duty to vaccinate, we also should recognize a moral duty to avoid most meat. The paper concludes by considering the implications of this duty for policy. (shrink)

Global consumption of antibiotics has accelerated the evolution of bacterial antimicrobial resistance. Yet, the risks from increasing bacterial antimicrobial resistance are not restricted to human populations: transmission of antimicrobial resistant bacteria occurs between humans, farms, the environment and other reservoirs. Policies that take a ‘One Health’ approach deal with this cross-reservoir spread, but are often more restrictive concerning human actions than policies that focus on a single reservoir. As such, the burden of justification lies with these more restrictive policies. We (...) argue that an ethical justification for preferring One Health policies over less restrictive alternatives relies on empirical evidence as well as theory. The ethical justification for these policies is based on two arguments: (i) comparatively greater effectiveness, and (ii) comparatively better tracking of moral responsibility. Yet the empirical assumptions on which these claims rest are limited by existing empirical knowledge. Using livestock farming as an example, we suggest that scientific research into characterising antimicrobial resistance and linking practices to outcomes ought to be guided (at least in part) by the imperative to supply the context-specific data needed to ethically justify preferring a One Health policy over less restrictive alternatives. (shrink)

Individualist ethical analyses in the enhancement debate have often prioritised or only considered the interests and concerns of parents and the future child. The collectivist critique of the human enhancement debate argues that rather than pure individualism, a focus on collectivist, or group-level ethical considerations is needed for balanced ethical analysis of specific enhancement interventions. Here, I defend this argument for the insufficiency of pure individualism. However, existing collectivist analyses tend to take a negative approach that hinders them from adequately (...) contributing to balanced ethical analysis, and often leads to a prohibitive stance. I argue this is due to two common problems with collectivist analyses: inappropriate acceptance of individualist assumptions, and failure to appropriately weigh individual vs collective ethical considerations. To further develop the collectivist critique in the enhancement debate, I suggest we may look to collectivism in public health ethics, which avoids these problems. (shrink)

A particularly strong reason to vaccinate against transmittable diseases, based on considerations of harm, is to contribute to the realization of population-level herd immunity. We argue, however, that herd immunity alone is insufficient for deriving a strong harm-based moral obligation to vaccinate in all circumstances, since the obligation significantly weakens well above and well below the herd immunity threshold. The paper offers two additional harm-based arguments that, together with the herd immunity argument, consolidates our moral obligation. First, we argue that (...) individuals should themselves aim not to expose others to risk of harm, and that this consideration becomes stronger the more non-vaccinated people there are, i.e., the further we are below herd immunity. Second, we elaborate on two pragmatic reasons to vaccinate beyond the realization of herd immunity, pertaining to instability of vaccination rates and population heterogeneity, and argue that vaccinating above the threshold should serve as a precautionary measure for buttressing herd immunity. We also show that considerations of harm have normative primacy in establishing this obligation over considerations of fairness. Although perfectly sound, considerations of fairness are, at worst secondary, or at best complementary to considerations of harm. (shrink)

Seasonal influenza poses a significant public health risk in many countries worldwide. Lower immunity and less influenza virus circulating during the pandemic has resulted in a significant increase in cases since the lifting of COVID-19 restrictions in 2022. The seasonal influenza vaccine offers effective protection and is safe for use in large numbers of the population. This article asserts that a moral obligation to vaccinate against influenza can be understood as an Institutional Duty of Rescue. The traditional understanding of the (...) Duty of Rescue encounters issues with force and scope, making it difficult to apply to rescue cases in general, as well as being overdemanding for the individual agent. An Institutional view of the Duty of Rescue addresses these difficulties, looks at the wider context of rescue and leaves room for discussion on collective, preventative rescue measures. This makes the concept well suited to supporting a moral obligation to vaccinate against influenza as part of a collective effort on the part of institutional organisations. (shrink)

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. (shrink)

Vaccine mandates are coercive because they impose penalties, such as fines, criminal sanctions, or job loss. However, they are not as coercive as physical force. Mandates c...

Would compulsory treatment or vaccination for Covid-19 be justified? In England, there would be significant legal barriers to it. However, we offer a conditional ethical argument in favour of allowing compulsory treatment and vaccination, drawing on an ethical comparison with external constraints—such as quarantine, isolation and ‘lockdown’—that have already been authorised to control the pandemic. We argue that, if the permissive English approach to external constraints for Covid-19 has been justified, then there is a case for a similarly permissive approach (...) to compulsory medical interventions. (shrink)

This paper seeks to investigate and assess a particular form of relationship between the State and its citizens in the context of the COVID-19 pandemic, namely that of obedience to the law and its related right of protest through civil disobedience. We do so by conducting an analysis and normative evaluation of two cases of disobedience to the law: (1) healthcare professionals refusing to attend work as a protest against unsafe working conditions, and (2) citizens who use public demonstration and (...) deliberately ignore measures of social distancing as a way of protesting against lockdown. While different in many aspects, both are substantially similar with respect to one element: their respective protesters both rely on unlawful actions in order to bring change to a policy they consider unjust. We question the extent to which healthcare professionals may participate in civil disobedience with respect to the duty of care intrinsic to the medical profession, and the extent to which opponents of lockdown and confinement measures may reasonably engage in protests without endangering the lives and basic rights of non-dissenting citizens. Drawing on a contractualist normative framework, our analysis leads us to conclude that while both cases qualify as civil disobedience in the descriptive sense, only the case of healthcare professionals qualifies as morally justified civil disobedience. (shrink)

This paper seeks to investigate and assess a particular form of relationship between the State and its citizens in the context of the COVID-19 pandemic, namely that of obedience to the law and its related right of protest through civil disobedience. We do so by conducting an analysis and normative evaluation of two cases of disobedience to the law: (1) healthcare professionals refusing to attend work as a protest against unsafe working conditions, and (2) citizens who use public demonstration and (...) deliberately ignore measures of social distancing as a way of protesting against lockdown. While different in many aspects, both are substantially similar with respect to one element: their respective protesters both rely on unlawful actions in order to bring change to a policy they consider unjust. We question the extent to which healthcare professionals may participate in civil disobedience with respect to the duty of care intrinsic to the medical profession, and the extent to which opponents of lockdown and confinement measures may reasonably engage in protests without endangering the lives and basic rights of non-dissenting citizens. Drawing on a contractualist normative framework, our analysis leads us to conclude that while both cases qualify as civil disobedience in the descriptive sense, only the case of healthcare professionals qualifies as morally justified civil disobedience. (shrink)

On 26 January 2021, while announcing that the country had reached the mark of 100,000 deaths within 28 days of COVID-19, UK Prime Minister Boris Johnson said that he took “full responsibility for everything that the Government has done” as part of British efforts to tackle the pandemic. The force of this statement was undermined, however, by what followed: -/- What I can tell you is that we truly did everything we could, and continue to do everything that we can, (...) to minimise loss of life and to minimise suffering... -/- Taking these sentiments together, it was hard to avoid the conclusion that the government took responsibility only for doing everything right. Such an admission of responsibility, accommodating no admission of error or wrongdoing, is not really about responsibility at all. Indeed, the UK’s pandemic response has been marked from its earliest days by a shifting of focus from institutional responsibility to personal responsibility for individual UK residents. -/- This paper explores the relationship between these two sites of responsibility—the institutional and the personal—in the context of the sort of pandemic that is ongoing as we write. Section 2 offers some initial definitions and discussions of key terms. Section 3 outlines how these two ideas interact in principle during such emergencies. Section 4 turns to the ‘non-ideal’ implications for personal responsibility of failures of institutional responsibility. While our focus is on the specific context with which we are most familiar, the UK governmental approach, where appropriate we also include examples from other states. (shrink)

Liberty-restricting measures have been implemented for centuries to limit the spread of infectious diseases. This article considers if and when it may be ethically acceptable to impose selective liberty-restricting measures in order to reduce the negative impacts of a pandemic by preventing particularly vulnerable groups of the community from contracting the disease. We argue that the commonly accepted explanation—that liberty restrictions may be justified to prevent harm to others when this is the least restrictive option—fails to adequately accommodate the complexity (...) of the issue or the difficult choices that must be made, as illustrated by the COVID-19 pandemic. We introduce a dualist consequentialist approach, weighing utility at both a population and individual level, which may provide a better framework for considering the justification for liberty restrictions. While liberty-restricting measures may be justified on the basis of significant benefits to the population and small costs for overall utility to individuals, the question of whether it is acceptable to discriminate should be considered separately. This is because the consequentialist approach does not adequately account for the value of equality. This value may be protected through the application of an additional proportionality test. An algorithm for making decisions is proposed. Ultimately whether selective liberty-restricting measures are imposed will depend on a range of factors, including how widespread infection is in the community, the level of risk and harm a society is willing to accept, and the efficacy and cost of other mitigation options. (shrink)

The public health benefits of herd immunity are often used as the justification for coercive vaccine policies. Yet, ‘herd immunity’ as a term has multiple referents, which can result in ambiguity, including regarding its role in ethical arguments. The term ‘herd immunity’ can refer to (1) the herd immunity threshold, at which models predict the decline of an epidemic; (2) the percentage of a population with immunity, whether it exceeds a given threshold or not; and/or (3) the indirect benefit afforded (...) by collective immunity to those who are less immune. Moreover, the accumulation of immune individuals in a population can lead to two different outcomes: elimination (for measles, smallpox, etc) or endemic equilibrium (for COVID-19, influenza, etc). We argue that the strength of a moral obligation for individuals to contribute to herd immunity through vaccination, and by extension the acceptability of coercion, will depend on how ‘herd immunity’ is interpreted as well as facts about a given disease or vaccine. Among other things, not all uses of ‘herd immunity’ are equally valid for all pathogens. The optimal conditions for herd immunity threshold effects, as illustrated by measles, notably do not apply to the many pathogens for which reinfections are ubiquitous (due to waning immunity and/or antigenic variation). For such pathogens, including SARS-CoV-2, mass vaccination can only be expected to delay rather than prevent new infections, in which case the obligation to contribute to herd immunity is much weaker, and coercive policies less justifiable. (shrink)

In 2017, Carson and Flood outlined a general duty to be vaccinated, arguing from Catholic social teaching on justice, love, solidarity and the common good. This necessarily relied on assumptions about the typical nature of vaccination, assumptions which do not always hold true in concrete situations. I identify twelve criteria that, where they hold, strengthen the particular duty to be vaccinated, and, if not met, weaken or reverse it. These pertain to the biological agent which vaccination aims to protect against, (...) the vaccine and its supply, the costs and benefits of vaccination to the individual and society, and the alternative courses of action. The two-way relationship between the moral duty to be vaccinated and vaccine mandates is discussed. Individuals and policy-makers need to know these criteria – and be provided the necessary information to evaluate vaccination against them – in order to make a truly rational judgement. (shrink)

This article proposes a novel defense of vaccine mandates: such policies are justifiable because they protect the capabilities of individuals who cannot cultivate individual immunity against infection. We begin by considering a nearby argument that has recently enjoyed popularity, which claims individuals have an enforceable obligation to get vaccinated because they have benefited from community protection (often referred to as ‘herd immunity’), and thus they ought to do their fair share in sustaining that public good by getting vaccinated. We object, (...) however, that this kind of argument misstates the ethical basis for vaccine mandates because community protection primarily protects unvaccinated people. We contend that the duty to vaccinate is not fundamentally an obligation to make a fair contribution to a public good from which vaccinated people benefit, but a duty to protect the wellbeing of otherwise vulnerable third parties. We flesh out our view by drawing on Martha Nussbaum's capabilities approach. (shrink)

The rise in vaccine hesitancy in high-income countries has led some to recommend that certain vaccinations be made compulsory in states where they are currently voluntary. In contrast, I contend that legal coercion is generally inappropriate to address the complex social and psychological phenomenon of vaccine anxieties.