1 00:00:01,000 --> 00:00:10,000 Hello, I'm Katrien Devolder. This is thinking out loud conversations with leading philosophers from around the world on topics that concern us all. 2 00:00:10,000 --> 00:00:14,000 This is a special edition on ethical questions raised by the Corona pandemic. 3 00:00:14,000 --> 00:00:18,600 The world is anxiously waiting for a vaccine against COVID 19. 4 00:00:18,600 --> 00:00:22,000 But even if we have a vaccine initially, its availability will be limited. 5 00:00:22,000 --> 00:00:29,000 So the question arises, who should be vaccinated first? Dr. Alberto Guibilini, senior research fellow at the Oxford Uehiro. 6 00:00:29,000 --> 00:00:36,690 Centre for Practical Ethics and the Welcome Centre for Ethics and Humanities is an expert on the ethics of vaccination. 7 00:00:36,690 --> 00:00:44,000 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. 8 00:00:44,000 --> 00:00:49,000 So can you just explain to us why many people think this should be the case? 9 00:00:49,000 --> 00:00:59,280 So, yes, basically what we want from the future vaccination policies will be to maximise the benefit of the COVID-19 vaccine, 10 00:00:59,280 --> 00:01:01,800 given that available to the beginning will be limited. 11 00:01:01,800 --> 00:01:08,700 When we talk about maximising the benefit, we need to consider what it means to benefit the population. 12 00:01:08,700 --> 00:01:16,000 So health care delivery, for example, is one of the most important aspect of the, well, the collective well-being. 13 00:01:16,000 --> 00:01:24,330 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. 14 00:01:24,330 --> 00:01:35,000 There is also a principle of reciprocity at stake. So people working in health care delivery are exposed to higher risks during this pandemic. 15 00:01:35,000 --> 00:01:45,000 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. 16 00:01:45,000 --> 00:01:52,370 So suppose we all agree that health care workers should get priority access to COVID 19 vaccinations. 17 00:01:52,370 --> 00:02:01,110 Who should go next? Again, we want to maximise the benefit, but we don't really know how this vaccine will work. 18 00:02:01,110 --> 00:02:06,000 So we will. We don't know exactly how we can maximise the benefit for the population. 19 00:02:06,000 --> 00:02:19,650 Normally, with most other drugs or most started medical technologies, the criterion adopted is prioritising patients based on need. 20 00:02:19,650 --> 00:02:28,290 Because often people who need a technology or a drug the most are also the ones who would benefit from it the most. 21 00:02:28,290 --> 00:02:34,050 So often the reason overlapping between the need and maximisation of expected benefit. 22 00:02:34,050 --> 00:02:36,000 However, these two criteria can come apart. 23 00:02:36,000 --> 00:02:43,700 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. 24 00:02:43,700 --> 00:02:49,260 So the most vulnerable people which are the elderly and those with some underlying 25 00:02:49,260 --> 00:02:54,750 conditions might not be the ones who benefit the most from the direct use of vaccines, 26 00:02:54,750 --> 00:03:01,380 because we don't know whether the vaccine will be more effective on these people than on other groups. 27 00:03:01,380 --> 00:03:14,910 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. 28 00:03:14,910 --> 00:03:22,050 So if you want to maximise the benefit of vaccination policies about with regard to the flu vaccine, 29 00:03:22,050 --> 00:03:29,610 there are strong reasons to prioritise or to target children, even if children are the ones who are, 30 00:03:29,610 --> 00:03:37,290 in an important sense, less likely to benefit from the flu vaccine because the flu is very unlikely to pose serious risks on children, 31 00:03:37,290 --> 00:03:40,500 but can pose a serious risk on the on the elderly. 32 00:03:40,500 --> 00:03:48,180 So even if children are not the ones who will benefit the most from the vaccine, there are strong reasons for giving them. 33 00:03:48,180 --> 00:03:50,000 So prioritising them in accessing the flu vaccine, 34 00:03:50,000 --> 00:03:59,000 because in that way you could build up more easily immunity to the collective level and therefore better protect also the elderly, the vulnerable. 35 00:03:59,000 --> 00:04:05,820 We don't know whether the COVID-19 vaccine will be like the flu vaccine. In this respect, it might be. 36 00:04:05,820 --> 00:04:12,000 And if that's the case, we need to be prepared to prioritise and access to the vaccine accordingly. 37 00:04:12,000 --> 00:04:18,540 Some people may, of course, be concerned that if we organise vaccination policy that way, 38 00:04:18,540 --> 00:04:24,960 that we're actually using children as a means to protect a vulnerable population. 39 00:04:24,960 --> 00:04:29,190 And some people may objected to that. Do you think that's a justified concern? 40 00:04:29,190 --> 00:04:36,840 I think it's a legitimate concern, but I don't think it represents a reason against prioritising children. 41 00:04:36,840 --> 00:04:42,460 If that's the most effective policy. Well, first of all, we need to distinguish. 42 00:04:42,460 --> 00:04:48,220 Between treating children or any group has means and treating them as mere means. 43 00:04:48,220 --> 00:04:54,000 So normally what's taken to be impermissible is treating individuals as mere means. 44 00:04:54,000 --> 00:05:00,640 So this is what Kantian ethics says. And we treat people as a mere means. 45 00:05:00,640 --> 00:05:08,530 When we do something to them in order to benefit someone else, that either harms these people. 46 00:05:08,530 --> 00:05:13,000 Or that we do without obtaining these people's consent. 47 00:05:13,000 --> 00:05:17,000 The COVID-19 vaccine is unlikely to harm children. 48 00:05:17,000 --> 00:05:24,000 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. 49 00:05:24,000 --> 00:05:31,600 But there is some small risk. Whether this makes it impermissible to target children depends on what benefit we can gain. 50 00:05:31,600 --> 00:05:39,000 So there must be some proportion between the risk we are imposing on them and the benefit that we would be obtaining. 51 00:05:39,000 --> 00:05:42,000 So if the benefit is worth the small risk, 52 00:05:42,000 --> 00:05:50,000 then it might be permissible to treat children even as mere means, despite what Kantian ethics says. 53 00:05:50,000 --> 00:05:54,190 In order to gain a significant benefit at the collective level. 54 00:05:54,190 --> 00:06:01,000 After all, this is something that we already do in some other areas of healthcare, for example, bone marrow donation. 55 00:06:01,000 --> 00:06:13,060 Often we use children as donors for bone marrow, for their siblings, for example, if another compatible donor cannot be found. 56 00:06:13,060 --> 00:06:24,430 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. 57 00:06:24,430 --> 00:06:28,000 And this is considered acceptable because the benefits. 58 00:06:28,000 --> 00:06:35,350 Is proportions, so the benefit does justify imposing, the small discomfort and the small at risk. 59 00:06:35,350 --> 00:06:39,640 But even if we think about this specific context of these pandemics. 60 00:06:39,640 --> 00:06:49,000 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. 61 00:06:49,000 --> 00:06:56,310 Keeping schools closed, for example, or preventing children from going out and play in the playground with their friends or socialising. 62 00:06:56,310 --> 00:07:05,000 So these restrictions have been quite harmful to children in terms of education gaps or development, 63 00:07:05,000 --> 00:07:11,460 more in general, because preventing children from socialising with their mates is quite a burden on children. 64 00:07:11,460 --> 00:07:17,700 So these things have been done. These measures have been implemented not so much to benefit children because children are relatively safe. 65 00:07:17,700 --> 00:07:22,230 They're not at high risk from community. But to protect other groups of people. 66 00:07:22,230 --> 00:07:25,740 So an important sense we already have. 67 00:07:25,740 --> 00:07:29,760 We have already used children as means or even as mere means. 68 00:07:29,760 --> 00:07:38,100 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. 69 00:07:38,100 --> 00:07:48,210 Yeah, and another concern people might have is that, of course, children cannot give sort of valid consent to being vaccinated. 70 00:07:48,210 --> 00:07:56,000 And then people might think, well, such a vaccination policy, one that you propose, may actually violate their autonomy. 71 00:07:56,000 --> 00:08:00,460 And that's problematic. What do you think about that objection? 72 00:08:00,460 --> 00:08:04,740 So the objection, again, is legitimate because autonomies are relevant. 73 00:08:04,740 --> 00:08:09,660 Perhaps the most relevant principle in contemporary health care ethics. 74 00:08:09,660 --> 00:08:19,290 However, in order to violate someone's autonomy, it's necessary that this individual has autonomy in the relevant sense. 75 00:08:19,290 --> 00:08:27,660 Now, children, young children normally are not deemed competent to make autonomous decisions so often when 76 00:08:27,660 --> 00:08:34,000 the vast majority of cases decisions about the health of children are made by their parents. 77 00:08:34,000 --> 00:08:40,620 So children's autonomy cannot be violated in this case because children do not have the capacity to make 78 00:08:40,620 --> 00:08:47,760 autonomous decisions in a way that is considered acceptable by contemporary standards of medical ethics. 79 00:08:47,760 --> 00:08:53,550 So when autonomy is not a relevant consideration in this case, what the matter is, 80 00:08:53,550 --> 00:09:05,520 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. 81 00:09:05,520 --> 00:09:10,000 And this condition seems to be satisfied by vaccines. So you say that the yeah, 82 00:09:10,000 --> 00:09:21,000 concerns about autonomy are legitimate and concerns about using people as a mere means or as a means to benefit others, 83 00:09:21,000 --> 00:09:29,000 is also a relevant consideration. And they then good reasons to choose a different group to prioritise. 84 00:09:29,000 --> 00:09:42,000 So say, for example, we choose people between 16 and 30 years old because we know that these people may transmit COVID-19, 85 00:09:42,000 --> 00:09:52,000 perhaps more rapidly than young children. Perhaps they would benefit themselves from the vaccine more than children because 86 00:09:52,000 --> 00:09:57,690 they're at a slightly higher risk than young children and they're autonomous. 87 00:09:57,690 --> 00:10:01,960 So at least we can ask them and they can give their permission to be vaccinated. 88 00:10:01,960 --> 00:10:11,490 So all the concerns raised in the case of prioritisation of children would sort of be circumvented when we selected a different group. 89 00:10:11,490 --> 00:10:15,300 So are there any reasons to just choose a different group then? 90 00:10:15,300 --> 00:10:25,650 Yes. So other things being equal, of course, is preferable to choose a group that can consent to being vaccinated. 91 00:10:25,650 --> 00:10:32,460 However, in this case, the main consideration is effectiveness. 92 00:10:32,460 --> 00:10:35,970 So is we can maximise the benefit. So there are two things to consider. 93 00:10:35,970 --> 00:10:37,000 First. 94 00:10:37,000 --> 00:10:47,250 If the vaccine works better on children and if vaccinating children is the best way of achieving collective immunity more rapidly then children. 95 00:10:47,250 --> 00:10:51,690 I think children ought to be prioritised anyway, even if they cannot make autonomous decisions. 96 00:10:51,690 --> 00:10:56,660 Second, even if you want to target people who can make autonomous decisions. 97 00:10:56,660 --> 00:11:02,090 What matters ultimately is that these people do actually make the autonomous decisions. 98 00:11:02,090 --> 00:11:12,230 We want them to make. So they actually get vaccinated, which raises the issue of whether the vaccination policy will have to be mandatory. 99 00:11:12,230 --> 00:11:21,890 So if we think that. Mandatory evacuations policies are justified because otherwise people will not get vaccinated. 100 00:11:21,890 --> 00:11:31,520 Then again, no consideration about autonomy is not that important because we want people to get vaccinated and if necessary, 101 00:11:31,520 --> 00:11:34,000 we want them to get vaccinated whether they want it or not. 102 00:11:34,000 --> 00:11:42,380 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. 103 00:11:42,380 --> 00:11:50,030 The role of autonomy is not as important as health care, ethics or clinical involving just difficult decisions, 104 00:11:50,030 --> 00:11:53,900 because vaccination is not just about the individual who gets the vaccine. 105 00:11:53,900 --> 00:12:01,550 It's about protecting other people in the community. Thanks for listening to this thinking out loud interview. 106 00:12:01,550 --> 00:12:04,460 You can also watch the thinking out loud videos on YouTube, 107 00:12:04,460 --> 00:12:14,981 on the Practical Ethics Channel and remain up to date with the thinking out loud Facebook page.