Covid-19 vaccination – the ethical challenges

The news that at least three vaccines are showing positive results is of course, hugely welcome, as is the UK's rapid approval of the Pfizer/BioNTech. Julian Sheather FRSA explores some of the major ethical issues that must be part of the decision-making about the next steps.

After almost a year of pandemic misery, we look poised for relief. Amid sickness, death and economic devastation, a vaccine-shaped break in the clouds has appeared, tantalisingly, on the road ahead. If the scientists are right, the technical challenges of the vaccine are behind us. With the NHS gearing up for mass vaccination, now is the time to eyeball the ethical ones. And they are not trivial.

Vaccinations are among the most important medical innovations in human history. Firebreaks against devastating epidemics, they save millions of lives every year. Ethically, vaccines are slightly unusual ‘treatments’ in being prophylactic: they target the well to prevent future disease. As billions of healthy people will be vaccinated, safety is front and centre. To justify mass treatment, the harms of vaccination need to be trivial compared to the risks of the disease. Institutional trust will also be critical to uptake. As Jennifer Prah Ruger has shown, administrations that fared best during the first wave of the pandemic were high-trust and fairness-oriented. These factors will likely be critical to the success of any vaccination campaign.

The speed with which Covid-19 vaccines have been developed has raised concerns but speed need not be problematic. It is the rigour of the process that matters. Good research can be expedited in an emergency, up to a point. The eyewatering pace of vaccine development has come from the removal of roadblocks that otherwise take years to navigate: securing funding and pre-test regulatory compliance. The use of human challenge studies has also been critical to the pace of development. None of these effect vaccine safety.  Before any vaccine is licensed in the UK, safety will be uppermost in the minds of those good people at the Medicines and Healthcare products Regulatory Authority (MHRA). When it comes to vaccine safety we are in their hands.

Safety is only one ethical aspect. Although the pandemic brutally reminded us how interconnected the world is, vaccine nationalism – the scramble by the richest countries to secure advance vaccine supplies – has reminded us how unequal it is. Even if enough vaccine is available, it does not follow that the poorest countries can afford it. How concerned by this should we be?

If equal suffering creates equal moral claims then, as a matter of justice, the hording of vaccines by the richest countries is unjust. Given that many poorer nations are already labouring under serious health burdens, leaving distribution of vaccines to the market can only deepen already profound global health inequalities. We know however that claims in justice fare poorly in the face of national interest and realpolitik. To the moral claims though we can add strong prudential reasons to distribute the vaccine globally. Billions of people live in poverty. If they are unvaccinated, Covid-19 will circulate uninterrupted among them. Every chance that in such huge populations it will mutate and this terrible viral merry-go-round will start up again. Nationalism is the wrong answer to global health challenges.

Another source of moral concern is profiteering from Covid-19 vaccines. For many of us, the idea that vaccines should be a vehicle for profit is a source of unease.  To develop vaccines at this pace and scale, big pharma has unleashed its enormous global R&D potential, fuelled by private capital. The prize is glittering: the almost unmeasurable public benefits of a vaccine will reward its developer with unimaginable gold. But is this morally acceptable?

Given the terrible suddenness with which the pandemic arrived, we had to respond with the world as it is, not as we might like it to be. Without a reasonable belief in a return on their investment – and their rights to intellectual property – private companies would not have gone after the vaccines. They are primarily limited companies with duties to shareholders, not philanthropic organisations. Nonetheless, the claims of global justice and prudence must not be rejected. While it may be reasonable for pharma to profit selling its vaccine in rich markets, means for distributing it at cost, or less, must be found for resource-poor countries. And this must involve global, state-sponsored, WHO-led co-operation.

Alongside vaccine euphoria we have seen the emergence of ‘vaccine hesitancy’. Not to be confused with the ideological – at times frankly conspiratorial – preoccupations of the ‘anti-vaxx’ movement, hesitancy has more to do with a mix of concerns about safety. Perhaps some of this is an unease among parents exposing their children to the risks of vaccines where they may not, because of their age or developing ‘herd immunity’, be much at risk from the virus. Questions are therefore being asked about some degree of compulsion. Given the health and economic costs of the pandemic, is some form of mandatory approach justified?

In the UK, the only time an individual can be forcibly treated against their informed refusal is under mental health legislation; ordinarily where they present a serious risk of harm to themselves or others. Moving toward compulsory vaccination would represent a seismic change in the relationship between the state, the health professions and citizens. We know that public trust in political institutions is low. A move toward compulsion would put what trust remains under extreme, potentially terminal stress. History also suggests that effective public health interventions are voluntary, participatory and respectful. Compulsion drives resistance, distrust and gaming. There are of course many steps between voluntary consent and forced treatment. Some countries will not allow children to attend public school unless they have been vaccinated. It isn’t compulsory treatment but the costs of not complying can be high.  Public sector employees, particularly in health and social services may well come under contractual or moral pressure to ensure vaccination.

Given the possible downside of more mandatory approaches, in the first instance everything must be channelled toward informed, voluntary participation. It is critical that governments listen and seek to understand and address the sources of vaccine hesitancy. As with all effective public health campaigns, communication is key. Sensitive, targeted programmes ensuring as much community engagement as possible will be essential. If successful, a vaccination campaign can boost trust, champion solidarity, and tackle the virus head on. But the impact of the pandemic has been shattering. And if uptake of the vaccine is too low to be effective, then thought may have to be given to forms of encouragement. But any move to restrict rights must be justified and proportional. Let us fervently hope though that there is enough public spirit, enough residual trust in our institutions and professional practices to make any such move unnecessary.

Julian Sheather is a writer and ethicist. He works for a number of leading national and international medical organisations.