How far should we go in protecting and promoting public health? Can we force people to give up unhealthy habits and make healthier choices, or does everyone have the right to decide their own lifestyle? Should we stop treating smokers who refuse to give up smoking? Should we put a tax on fatty foods and ban vending machines in schools to address the obesity epidemic? Should parents be required to have their children vaccinated? Are some of our screening programmes unethical (...) Downs syndrome screening, for example or should we be screening people for more conditions, such as Huntington disease? Such questions are at the heart of public health ethics. Holland shows that to understand and debate these issues requires philosophy: moral philosophies, such as utilitarianism and deontology, as well as political philosophies such as liberalism and communitarianism. And philosophy informs other aspects of public health, such as epidemiology and health promotion. The aim of this book is to provide a lively, accessible and philosophically informed introduction to such issues. It is an ideal textbook for students taking courses in public health ethics. And since this book develops systematic discussions of issues in public health ethics, there is also much here to engage and challenge the more advanced reader. (shrink)

We argue that individuals who have access to vaccines and for whom vaccination is not medically contraindicated have a moral obligation to contribute to the realisation of herd immunity by being vaccinated. Contrary to what some have claimed, we argue that this individual moral obligation exists in spite of the fact that each individual vaccination does not significantly affect vaccination coverage rates and therefore does not significantly contribute to herd immunity. Establishing the existence of a moral obligation to be vaccinated (...) despite the negligible contribution each vaccination can make to the realisation of herd immunity is important because such moral obligation would strengthen the justification for coercive vaccination policies. We show that two types of arguments—namely a utilitarian argument based on Parfit’s Principle of Group Beneficence and a contractualist argument—can ground an individual moral obligation to be vaccinated, in spite of the imperceptible contribution that any single vaccination makes to vaccine coverage rates. We add a further argument for a moral obligation to be vaccinated that does not require embracing problematic comprehensive moral theories such as utilitarianism or contractualism. The argument is based on a “duty of easy rescue” applied to collectives, which grounds a collective moral obligation to realise herd immunity, and on a principle of fairness in the distribution of the burdens that must be borne to realise herd immunity. (shrink)

Proponents of vaccine mandates typically claim that everyone who can be vaccinated has a moral or ethical obligation to do so for the sake of those who cannot be vaccinated, or in the interest of public health. I evaluate several previously undertheorised premises implicit to the ‘obligation to vaccinate’ type of arguments and show that the general conclusion is false: there is neither a moral obligation to vaccinate nor a sound ethical basis to mandate vaccination under any circumstances, even for (...) hypothetical vaccines that are medically risk-free. Agent autonomy with respect to self-constitution has absolute normative priority over reduction or elimination of the associated risks to life. In practical terms, mandatory vaccination amounts to discrimination against healthy, innate biological characteristics, which goes against the established ethical norms and is also defeasible a priori. (shrink)

Mainstream moral theories deal with situations in which the outcome of each possible action is well-determined and knowable. In order to make ethics relevant for problems of risk and uncertainty, moral theories have to be extended so that they cover actions whose outcomes are not determinable beforehand. One approach to this extension problem is to develop methods for appraising probabilistic combinations of outcomes. This approach is investigated and shown not to solve the problem. An alternative approach is then developed. Its (...) starting-point is that everyone has a prima facie moral right not to be exposed to risk. However, this right can be overridden if the risk-exposure is part of an equitable system for risk-taking that works to the advantage of the individual risk-exposed person. (shrink)

Governments around the world have faced the challenge of how to respond to the recent outbreak of a novel coronavirus disease. Some have reacted by greatly restricting the freedom of citizens, while others have opted for less drastic policies. In this paper, I draw a parallel with vaccination ethics to conceptualize two distinct approaches to COVID-19 that I call altruistic and lockdown. Given that the individual measures necessary to limit the spread of the virus can in principle be achieved voluntarily (...) as well as through enforcement, the question arises of how much freedom governments ought to give citizens to adopt the required measures. I argue that an altruistic approach is preferable on moral grounds: it preserves important citizen freedoms, avoids a number of potential injustices, and gives people a much-needed sense of meaning in precarious times. (shrink)

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: natural immunity is superior to ‘artificial’ vaccine-induced immunity simply because it is ‘natural’ and 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. There are no data in this work. (shrink)

With evidence of vaccine hesitancy in several jurisdictions, the option of making COVID-19 vaccination mandatory requires consideration. In this paper I argue that it would be ethical to make the COVID-19 vaccination mandatory for older people who are at highest risk of severe disease, but if this were to occur, and while there is limited knowledge of the disease and vaccines, there are not likely to be sufficient grounds to mandate vaccination for those at lower risk. Mandating vaccination for those (...) at high risk of severe disease is justified on the basis of the harm principle, as there is evidence that this would remove the grave public health threat of COVID-19. The risk–benefit profile of vaccination is also more clearly in the interests of those at highest risk, so mandatory vaccination entails a less severe cost to them. Therefore, a selective mandate would create fairness in the distribution of risks. The level of coercion imposed by a mandate would need to be proportionate, and it is likely that multiple approaches will be needed to increase vaccine uptake. However, a selective mandate for COVID-19 vaccines is likely to be an ethical choice and should be considered by policy-makers. (shrink)

Moralization is a social-psychological process through which morally neutral issues take on moral significance. Often linked to health and disease, moralization may sometimes lead to good outcomes; yet moralization is often detrimental to individuals and to society as a whole. It is therefore important to be able to identify when moralization is inappropriate. In this paper, we offer a systematic normative approach to the evaluation of moralization. We introduce and develop the concept of ‘mismoralization’, which is when moralization is metaethically (...) unjustified. In order to identify mismoralization, we argue that one must engage in metaethical analysis of moralization processes while paying close attention to the relevant facts. We briefly discuss one historical example and two contemporary cases related to COVID-19 that we contend to have been mismoralized in public health. We propose a remedy of de-moralization that begins by identifying mismoralization and that proceeds by neutralizing inapt moral content. De-moralization calls for epistemic and moral humility. It should lead us to pull away from our tendency to moralize—as individuals and as social groups—whenever and wherever moralization is unjustified. (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)

Vaccination can protect vaccinated individuals and often also prevent them from spreading disease to other people. This opens up the possibility of getting vaccinated for the sake of others. In fact, altruistic vaccination has recently been conceptualized as a kind of vaccination that is undertaken primary for the benefit of others. In order to better understand the potential role of altruistic motives in people’s vaccination decisions, we conducted two focus group studies with a total of 37 participants. Study 1 included (...) three focus groups on the subject of HPV vaccination for boys. Study 2 included three focus groups on the subject of pertussis and measles vaccination for childcare workers. We found substantial evidence of other-regarding motives across all focus groups, which suggests that altruistic motives could be an important factor when it comes to people’s vaccination decisions. We address the significance of these findings for vaccination policy surrounding HPV vaccination for boys and vaccination for childcare workers. We also extend the findings to normative work on vaccination for the sake of others more generally. (shrink)

Vaccination is a highly effective public health strategy that provides protection to both individuals and communities from a range of infectious diseases. Governments monitor vaccination rates carefully, as widespread use of a vaccine within a population is required to extend protection to the general population through “herd immunity,” which is important for protecting infants who are not yet fully vaccinated and others who are unable to undergo vaccination for medical or other reasons. Australia is unique in employing financial incentives to (...) increase vaccination uptake, mainly in the form of various childcare payments and tax benefits linked to timely, age-appropriate vaccination. Despite relatively high compliance with the childhood vaccination schedule, however, the Australian government has determined that rates should be higher and has recently introduced policy that includes removing certain tax and childcare benefits for non-vaccinators and formally disallowing conscientious objection to vaccination. In addition, it has raised the possibility of banning unvaccinated children from childcare centres. This article examines the impact of coercive approaches to childhood vaccination and raises the question of the ethical justification of health policy initiatives based on coercion. We consider the current evidence regarding childhood vaccination in Australia, the small but real risks associated with vaccination, the ethical requirement for consent for medical procedures, and the potential social harms of targeting non-vaccinators. We conclude that the evidence does not support a move to an increasingly mandatory approach that could only be delivered through paternalistic, coercive clinical practices. (shrink)

Uncertainty is inherent in new and unexpected viral outbreaks such as the current COVID-19 pandemic. It imposes challenges for health officials in soliciting cooperative behavioural changes based on incomplete information. In this paper, we use evolving mask recommendations in the United States as an example to analyse the ethical importance and practical demonstration of trustworthiness in pandemic messaging and decision-making. We argue that responsible public health interventions in the time of uncertainties requires explicit intersecting ethical considerations both in action and (...) in communication to promote trustworthiness. First, as public health decisions have to be made in the face of incomplete and evolving data, health officials need to exhibit competence while committing to epistemic humility. They can explain the methods used in making and updating mask recommendations as well as explicitly acknowledge the need to incorporate sociocultural and other contextual considerations in translating scientific data into mask recommendations. Second, officials and agencies must uphold and communicate decisional transparency as part of their effort to demonstrate accountability and promote the public’s understanding of the evolving pandemic. Third, especially since both the pandemic and mask recommendations may have disparate impact on different populations, officials should start with the fair implementation of the least restrictive measures that can help reduce harm. (shrink)

Savulescu argues that it may be ethically acceptable for governments to require citizens be vaccinated against COVID-19. He also recommends that governments consider providing monetary or in-kind incentives to citizens to increase vaccination rates. In this response, we argue against mandatory vaccination and vaccine incentivisation, and instead suggest that targeted public health messaging and a greater responsiveness to the concerns of vaccine-hesitant individuals would be the best strategy to address low vaccination rates.

ABSTRACT If we have a duty not to infect others, how far does it go? This question is often discussed with respect to HIV transmission, but reflection on other diseases like influenza raises a number of interesting theoretical issues. I argue that a duty to avoid infection not only yields requirements for persons who know they carry a disease, but also for persons who know they are at increased risk, and even for those who definitely know they are completely healthy. (...) Given the numerous ways in which human interaction facilitates the spread of communicable diseases, a maximum level of precaution would be very demanding – possibly unreasonably demanding. The ‘over‐demandingness problem’ is mostly invoked as a criticism of utilitarianism, as this theory requires moral agents to always maximise general welfare, even at significant cost for themselves. However, I argue that, with respect to precautions against infectious diseases like influenza, utilitarianism is able to avoid the over‐demandingness problem. A contractualist account, on the other hand, whilst able to explain how one's obligations to avoid infection can be limited, given that other persons have opportunities and responsibilities to protect themselves, in the end requires precautions that raise the over‐demandingness problem. (shrink)

There can be little doubt about the ethical imperative to ensure adequate vaccination uptake against certain infectious diseases. In the face of vaccine refusal, health authorities and providers instinctively appeal to coercive approaches or increased education as methods to ensure adequate vaccine uptake. Recently, some have argued that public fear around Ebola should be used as an opportunity for such approaches, should an Ebola vaccine become available. In this article, the author describes the difficulties associated with coercion and education when (...) addressing vaccine opposition. Both coercion and education can cause opposite effects than intended in certain circumstances. The correct area of focus is to address the breakdown in trust within clinical relationships. The author presents suggestions for an approach towards vaccine refusal that may be more promising. (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)

Does a human right to healthcare imply individual obligations to healthy behavior? Or put another way: Is a self-induced condition a relevant criterion for some sort of restriction of this right—like withholding or modifying treatment in circumstances where choices have to be made? For instance, should a drunk driver bear the costs of medical care that he needs after a car accident he has caused? Should there be a difference in healthcare entitlements between the smoker with a heart attack who (...) is seriously overweight and the 60-year old man who has always taken excellent care of himself and is suddenly stricken by leukemia? And how should we think about the risk-taking behavior of all the persons going on a skiing holiday or an exotic hiking trip? a. (shrink)

Effective infectious disease control may require states to restrict the liberty of individuals. Since preventing harm to others is almost universally accepted as a legitimate (prima facie) reason for restricting the liberty of individuals, it seems plausible to employ a mid‐level harm principle in infectious disease control. Moral practices like infectious disease control support – or even require – a certain level of theory‐modesty. However, employing a mid‐level harm principle in infectious disease control faces at least three problems. First, it (...) is unclear what we gain by attaining convergence on a specific formulation of the harm principle. Likely candidates for convergence, a harm principle aimed at preventing harmful conduct, supplemented by considerations of effectiveness and always choosing the least intrusive means still leave ample room for normative disagreement. Second, while mid‐level principles are sometimes put forward in response to the problem of normative theories attaching different weight to moral principles, employing a mid‐level harm principle completely leaves open how to determine what weight to attach to it in application. Third, there appears to be a trade‐off between attaining convergence and finding a formulation of the harm principle that can justify liberty‐restrictions in all situations of contagion, including interventions that are commonly allowed. These are not reasons to abandon mid‐level theorizing altogether. But there is no reason to be too theory‐modest in applied ethics. Morally justifying e.g. if a liberty‐restriction in infectious disease control is proportional to the aim of harm‐prevention, promptly requires moving beyond the mid‐level harm principle. (shrink)