Hello, I'm Katrien Devolder. This is thinking out loud conversations with leading philosophers from around the world on topics that concern us all.
This is a special edition on ethical questions raised by the Corona pandemic.
The world is anxiously waiting for a vaccine against COVID 19.
But even if we have a vaccine initially, its availability will be limited.
So the question arises, who should be vaccinated first? Dr. Alberto Guibilini, senior research fellow at the Oxford Uehiro.
Centre for Practical Ethics and the Welcome Centre for Ethics and Humanities is an expert on the ethics of vaccination.
So I thought he'd be a good person to ask. So there seems to be wide agreement that health care workers should be vaccinated first.
So can you just explain to us why many people think this should be the case?
So, yes, basically what we want from the future vaccination policies will be to maximise the benefit of the COVID-19 vaccine,
given that available to the beginning will be limited.
When we talk about maximising the benefit, we need to consider what it means to benefit the population.
So health care delivery, for example, is one of the most important aspect of the, well, the collective well-being.
So it's important that people working in health care are able to carry out their duties in a way that is safe for themselves and for the patients.
There is also a principle of reciprocity at stake. So people working in health care delivery are exposed to higher risks during this pandemic.
So there is a duty to somehow make up for this by giving them priority in order to be protected from risks as much as possible.
So suppose we all agree that health care workers should get priority access to COVID 19 vaccinations.
Who should go next? Again, we want to maximise the benefit, but we don't really know how this vaccine will work.
So we will. We don't know exactly how we can maximise the benefit for the population.
Normally, with most other drugs or most started medical technologies, the criterion adopted is prioritising patients based on need.
Because often people who need a technology or a drug the most are also the ones who would benefit from it the most.
So often the reason overlapping between the need and maximisation of expected benefit.
However, these two criteria can come apart.
So with the vaccine, there might be a chance that these two criteria would come apart as well because those who need the vaccine the most.
So the most vulnerable people which are the elderly and those with some underlying
conditions might not be the ones who benefit the most from the direct use of vaccines,
because we don't know whether the vaccine will be more effective on these people than on other groups.
So if you think, for example, of the flu vaccine, the flu vaccine is less effective on the elderly and is more effective on young people and children.
So if you want to maximise the benefit of vaccination policies about with regard to the flu vaccine,
there are strong reasons to prioritise or to target children, even if children are the ones who are,
in an important sense, less likely to benefit from the flu vaccine because the flu is very unlikely to pose serious risks on children,
but can pose a serious risk on the on the elderly.
So even if children are not the ones who will benefit the most from the vaccine, there are strong reasons for giving them.
So prioritising them in accessing the flu vaccine,
because in that way you could build up more easily immunity to the collective level and therefore better protect also the elderly, the vulnerable.
We don't know whether the COVID-19 vaccine will be like the flu vaccine. In this respect, it might be.
And if that's the case, we need to be prepared to prioritise and access to the vaccine accordingly.
Some people may, of course, be concerned that if we organise vaccination policy that way,
that we're actually using children as a means to protect a vulnerable population.
And some people may objected to that. Do you think that's a justified concern?
I think it's a legitimate concern, but I don't think it represents a reason against prioritising children.
If that's the most effective policy. Well, first of all, we need to distinguish.
Between treating children or any group has means and treating them as mere means.
So normally what's taken to be impermissible is treating individuals as mere means.
So this is what Kantian ethics says. And we treat people as a mere means.
When we do something to them in order to benefit someone else, that either harms these people.
Or that we do without obtaining these people's consent.
The COVID-19 vaccine is unlikely to harm children.
These are small risks involved. But there are also some benefit because the children will be immune from COVID-19 so there is some benefit.
But there is some small risk. Whether this makes it impermissible to target children depends on what benefit we can gain.
So there must be some proportion between the risk we are imposing on them and the benefit that we would be obtaining.
So if the benefit is worth the small risk,
then it might be permissible to treat children even as mere means, despite what Kantian ethics says.
In order to gain a significant benefit at the collective level.
After all, this is something that we already do in some other areas of healthcare, for example, bone marrow donation.
Often we use children as donors for bone marrow, for their siblings, for example, if another compatible donor cannot be found.
So in this case, we use the child from which we harvest these cells as a means or even as a mere means to save a sibling.
And this is considered acceptable because the benefits.
Is proportions, so the benefit does justify imposing, the small discomfort and the small at risk.
But even if we think about this specific context of these pandemics.
So in an important sense, we have already used children and young people and more generally as means or even as mere means to protect other groups.
Keeping schools closed, for example, or preventing children from going out and play in the playground with their friends or socialising.
So these restrictions have been quite harmful to children in terms of education gaps or development,
more in general, because preventing children from socialising with their mates is quite a burden on children.
So these things have been done. These measures have been implemented not so much to benefit children because children are relatively safe.
They're not at high risk from community. But to protect other groups of people.
So an important sense we already have.
We have already used children as means or even as mere means.
I don't see how vaccinating children could be worse than that from a moral point of view, because from the point of view of children's well-being.
Yeah, and another concern people might have is that, of course, children cannot give sort of valid consent to being vaccinated.
And then people might think, well, such a vaccination policy, one that you propose, may actually violate their autonomy.
And that's problematic. What do you think about that objection?
So the objection, again, is legitimate because autonomies are relevant.
Perhaps the most relevant principle in contemporary health care ethics.
However, in order to violate someone's autonomy, it's necessary that this individual has autonomy in the relevant sense.
Now, children, young children normally are not deemed competent to make autonomous decisions so often when
the vast majority of cases decisions about the health of children are made by their parents.
So children's autonomy cannot be violated in this case because children do not have the capacity to make
autonomous decisions in a way that is considered acceptable by contemporary standards of medical ethics.
So when autonomy is not a relevant consideration in this case, what the matter is,
what we were talking about before is that the intervention is either beneficial to the individual or at least doesn't pose a serious threat of harm.
And this condition seems to be satisfied by vaccines. So you say that the yeah,
concerns about autonomy are legitimate and concerns about using people as a mere means or as a means to benefit others,
is also a relevant consideration. And they then good reasons to choose a different group to prioritise.
So say, for example, we choose people between 16 and 30 years old because we know that these people may transmit COVID-19,
perhaps more rapidly than young children. Perhaps they would benefit themselves from the vaccine more than children because
they're at a slightly higher risk than young children and they're autonomous.
So at least we can ask them and they can give their permission to be vaccinated.
So all the concerns raised in the case of prioritisation of children would sort of be circumvented when we selected a different group.
So are there any reasons to just choose a different group then?
Yes. So other things being equal, of course, is preferable to choose a group that can consent to being vaccinated.
However, in this case, the main consideration is effectiveness.
So is we can maximise the benefit. So there are two things to consider.
First.
If the vaccine works better on children and if vaccinating children is the best way of achieving collective immunity more rapidly then children.
I think children ought to be prioritised anyway, even if they cannot make autonomous decisions.
Second, even if you want to target people who can make autonomous decisions.
What matters ultimately is that these people do actually make the autonomous decisions.
We want them to make. So they actually get vaccinated, which raises the issue of whether the vaccination policy will have to be mandatory.
So if we think that. Mandatory evacuations policies are justified because otherwise people will not get vaccinated.
Then again, no consideration about autonomy is not that important because we want people to get vaccinated and if necessary,
we want them to get vaccinated whether they want it or not.
So, again, when it comes to public health ethics, these are different from what happens in clinical ethics when it comes to public health ethics.
The role of autonomy is not as important as health care, ethics or clinical involving just difficult decisions,
because vaccination is not just about the individual who gets the vaccine.
It's about protecting other people in the community. Thanks for listening to this thinking out loud interview.
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