Muxie
Since the outbreak of the epidemic, the entire European and American society has made the already rift-filled society even more rifted due to fierce disputes over prevention and control measures. Governments believed that the rapid launch of new mRNA vaccines would cause the infection number to drop rapidly, return to normal social life, and bridge social rifts. However, when the vaccine is administered on a large scale in the whole society, its defense against viral infection is far less effective than the experimental data. This has brought the choice of the entire epidemic prevention policy back to the crossroads. In order to control the spread of the virus and reduce hospitalization, severe illness and mortality, Western governments have put a lot of effort into increasing the vaccination rate. Various disguised mandatory vaccination policies have also brought about a series of discussions on ethics . However, for natural science issues such as vaccines, any ethical thought experiment must be based on the latest achievements of evidence-based science/medicine. Different evidence-based scientific conclusions will lead to completely different ethical judgments. It is precisely because the new technology of mRNA vaccines still has too much uncertainty from the perspective of evidence-based medicine that it has led to a huge confrontation in ethical discussions. This article tries to get a glimpse of this debate through the two topics of forced vaccination and boosting.
Herve immunization as a prerequisite for compulsory vaccination
At the end of July this year, two professors from the Institute of Economic Ethics at the University of St. Gallen, Switzerland, published a commentary article titled "Discrimination against unvaccinated persons is ethically reasonable" in Germany's Zeit Online. As soon as this sensational article was published, it exploded on the German media. Although the fuse of the debate is the issue of "discrimination", the main topic of the whole text is about mandatory vaccination of vaccines. From the question, it is not difficult to see the attitude of the two professors towards this, that is, to support mandatory vaccination of vaccines. And this topic is undoubtedly the most insulting of all the debates about mRNA vaccines.
From the perspective of medical ethics , there are three main reasons to support mandatory vaccination: 1) The "harm principle" of mil . There is a famous saying in " on Freedom ", "The only purpose of power being able to legitimately interfere with any member of the civilized community is to prevent him from harming others." Vaccination is not only about self-protection, but also about protection for others. If an individual is not vaccinated, it will harm others in the community, especially those who cannot achieve self-protection (people who cannot be vaccinated due to medical contraindications or those who cannot develop expected immunity after vaccination due to disorders of the immune system); 2) achieve herd immunity. It means that after a high proportion of people in the community gained immunity, it greatly reduced the prevalence of infectious diseases in the community, and made those who were not vaccinated also receive indirect protection. Anyone in the community’s decision to refuse vaccination will not affect the protection of the group, but if many people make such a choice, herd immunity will eventually be weakened and the community will be hurt by the disease outbreak. Due to the inexclusion and non-competitiveness of herd immunity, Alberto Giubilini, a bioethicist at Oxford University, called herd immunity a social common interest; 3) preventing free riding. Because herd immunity is the common interest of society, it is fair to achieve herd immunity by equally sharing the responsibility of individual members of society to avoid some people from hitching a ride. It can be seen that these three ethical principles actually revolve around herd immunity. If vaccination does not produce herd immunity, that is, the virus can continue to spread in the community, then the vaccinated person can still harm others. Therefore, the damage principle is not true. Once herd immunity, as a common social interest, cannot be achieved, there will be no free-ride problem.
In the article "Discrimination", the two authors mainly invoked the "harm principle" as the premise for compulsory vaccination. In order to weaken the bad impression of forced vaccination, they carefully distinguished between "voluntary vaccination" (Impfpflicht) and "forced vaccination" (Impfzwang).It is also believed that this vaccination obligation can be easily derived from utilitarian or from Kant 's obligation ethics. State coercion is only a regulatory force, and only when people fail to fulfill their moral responsibilities will the regulatory force begin to be activated, and the principle of harm is the source of legitimacy of government intervention. However, they also agree that any ethical discussion about vaccines must be based on medical evidence of vaccines. The article mentioned that there are three medical prerequisites required for the establishment of a vaccination obligation: 1) The side effects of the vaccine on the vaccinated person are extremely limited; 2) Compared with other measures, the cost-effectiveness ratio of vaccination (Kosten-Nutzen-Analyse) is the best; 3) Vaccination can not only reduce the probability of one's own illness, but also greatly reduce the infection of third parties. The two professors confidently believed that "the scientific evidence of these three conditions is clear." A positive evaluation of these three conditions has become the medical basis for ethical discussions by most philosophers who support mandatory mRNA vaccination. However, these three conditions are by no means scientifically clear as the two philosophers said. As a result, the ethical basis of forced vaccination was also shaken. The safety of
mRNA vaccine has been controversial. Those who refuse to vaccinate or those who hesitate to vaccination will challenge them in two ways. First, they question the reported side effects and death cases nowadays are greatly underestimated. Second, those who refuse to receive the vaccine are worried about the long-term impact that may occur in the future. At the end of October, the star of Bayern Munich , Kimmich (Joshua Kimmich ), was involved in a public opinion storm. He revealed in an interview that he has not been vaccinated so far because of concerns about the possible long-term effects of the vaccine. There are two completely different voices in the medical community regarding this issue.
On November 3, 2021, in Ohio, USA, local children began to receive the new crown vaccine .
Because of the uncertainty factors mentioned above, when considering mRNA vaccination, it is necessary to make a trade-off in terms of risks and benefits of vaccination in different age groups. According to the large amount of existing data, the threat of the virus to people has decreased dramatically with the decrease of age (the IFR of infection mortality among people over 80 is about 8%, and the mortality rate among children under 9 is only 0.0016%), and the risk of vaccination increases with the decrease of age. Therefore, a certain age point is the critical point of the risk-return ratio. This is also the reason why European and American countries are very cautious when giving vaccination advice for minors. From the risk-benefit perspective alone, it is not suitable for forced vaccination for everyone. Therefore, three scholars from Oxford University (Alberto Giublini, Sunetra Gupta, Carl Heneghan) called for a focused protection vaccination strategy to implement a focused protection vaccination strategy. Children should not be regarded as tools for adults to achieve herd immunity. They have been sacrificed too much during this pandemic.
Although Peter Singer, a famous bioethics professor at Princeton University, also demonstrated the rationality of forced COVID-19 vaccination from the personal risk-benefit framework. However, his argument does not take into account the differences in risk-benefits across age groups. Singer uses the seat belt theory as an example. He believes that in many cases, people cannot correctly assess very small risks to themselves. Given that the cost of forced seat belts is negligible, a reasonable calculation of one's own interests shows that it is unreasonable to not wear seat belts. This mandatory rule allows millions of people to avoid regretting their unreasonable behavior. Professor Singer also used this logic to justify the judgment of compulsory vaccines. However, the example of seat belts is not suitable for imparting mRNA vaccine vaccination. First, seat belts are zero risk, while mRNA vaccines are not; second, seat belts have the same risk-to-benefit ratio for all ages, while vaccines have huge differences.
In addition, from the perspective of safety (risk), there is a simpler ethical basis to refute mandatory vaccination, that is, the current mRNA vaccine is still in the experimental stage.You can't force everyone to participate in a medical experiment, or taking part in a medical experiment cannot become a human obligation. Ms. Ruth Baumann-Hölzle, an ethicist at Swiss , repeatedly emphasized this in an interview with various media.
Compared with the safety issues of vaccines, vaccines cannot reduce third-party infections and easily destroy the basis of forced vaccination. There are billions of mRNA vaccinations worldwide, but the spread of the virus has not stopped as expected. On the British aircraft carrier Queen Elizabeth, 1,600 officers and soldiers on the ship were completely vaccinated and strictly abide by sanitation rules, but 100 people were still infected with the virus. , Singapore , whose national vaccination rate reaches 85%, is now experiencing the most serious infection wave since the outbreak. A new study published in the European Journal of Epidemiology at the end of September summarized the above phenomenon. The study analyzed data from 68 countries around the world and 2947 counties in the United States. The authors have come to the preliminary conclusion that higher vaccination rates do not lead to lower viral infection rates, both at the county level and at the national level.
Due to the weak infection protection of mRNA vaccines, this has completely changed the way of discussion on vaccination ethics. epidemiology professor Jay Bhattacharya believes that in the case where the mRNA vaccine produced by Moderna and Pfizer cannot promote herd immunity, vaccination involves more personal interests (vaccines can greatly reduce the severity and mortality rate), rather than social common interests. So, it's just a personal health issue, not a public health issue. Government officials do not have a greater moral authority to regulate vaccination, just as they would not interfere with chemotherapy in cancer patients. Professor Hendrik Streeck, director of the Institute of Virology at the University of Bonn, also expressed a similar view in his long commentary for Le Monde, "We often hear from politicians that unvaccination is responsible for the deceased. This statement is wrong. Both vaccinated and unvaccinated, we are in a pandemic. We can both continue to spread the virus... Vaccines are protection for ourselves, not protection for others." Since others cannot be protected, every individual has no social obligation to get vaccinated.
However, a new study published by Imperial University in the Lancet shows that patients with breakthrough vaccine infections have viral loads comparable to those of unvaccinated patients, but the former's viral load drops significantly faster than the latter. This new discovery will cause debate on new vaccination ethics: Does this new study add another basis for compulsory vaccination? Because, although vaccinated patients will also spread the virus the same way, their transmission time has been greatly shortened compared with those who have not been vaccinated. Are public health issues back? The author does not want to have a more complicated discussion here.
Of course, some people will refute this view from the perspective of medical resource occupation. They would think that even if mRNA vaccines fail to contribute to herd immunity, vaccination is a public health issue, not just an individual health issue. Because infected patients may occupy too much medical resources, affecting other patients' right to receive treatment. However, such a view may be the key to opening Pandora's box. Because smoking can also cause a large number of patients and occupy a large amount of medical resources. According to statistics from WHO , the number of deaths from tobacco worldwide exceeds 8 million (of which 1.2 million non-smokers die from second-hand smoke). High-salt and high-sugar diets can also lead to a large number of hospitalized cases. Due to these bad living habits, the occupation of the medical system may exceed that of new crown patients every year. If the mandatory vaccination of vaccines is implemented on the grounds of occupying medical resources.So, for the same reason, is it necessary to force the closure of all tobacco companies? Should we also force everyone's daily sugar and salt intake be managed?
boost (Nudge) and vaccination
In the article "Discrimination", the "discrimination" mentioned by the two authors is actually a "boosting" method. For example, the government "inspires" unvaccinated people to get vaccinated by setting barriers to entry into public life. Since mandatory vaccination is ethically unrealistic, boosting has become the best way to improve the vaccination rate. "Boostering" was first proposed by two professors from , Richard Thaler and Cass Sunstein, from , , and Cass Sunstein. In the book "Booster: How to Make the Best Decisions About Health, Wealth and Happiness", they point out that individual choices usually do not happen in a vacuum, they are often shaped by a selection framework. Boost means using this framework to make subtle changes in the environment, so that cognitive processes (behaviors and choices) that are conducive to the expected results are automatically stimulated. For example, supermarkets place foods like chocolates, such as children, in a height of their sight to boost their purchases. In real life, commercial institutions, governments and various institutional organizations are changing the behavior and choice of their service objects through various cheap and simple means of boosting, thereby inducing the most positive and reasonable results for both parties. Of course, this kind of behavioral scientific induction method is non-compulsive.
The Behavioral Insight Group (BIT) established in the UK in 2010 is the first government agency in the world to apply behavioral science to policy. In collaboration with government and other stakeholders, the team hopes to use behavioral insights to “improve people’s lives and communities.” In a document called “Space of Mind: Influencing Behaviors through Public Policy,” a comprehensive introduction to the psychological approaches to BIT deployment is provided. They believe these strategies can achieve "induce citizens in a low-cost, low-pain way...to take new ways of action by adapting to our thinking and behavior." In the fight against the pandemic, there is also a behavioral insight team called SPI-B under the UK's top team of experts, the Crisis Science Advisory Board (SAGE). The group mainly implements boosting through information transmission. The messages they convey mainly include fear (amplifying the perceived level of threat), inner shame (shaping compliance with epidemic prevention rules into a new virtue), and peer pressure (pressure from peers to those who do not follow the rules).
September 22, 2021, Tyne Newcastle, UK, students are vaccinated. The UK National Health Service (NHS) and local school-age vaccine service centers have begun vaccinating children aged 12 to 15 based on the recommendations of four UK chief medical officers.
Before entering the discussion of boosting and vaccination, the author will briefly describe the effects of boosting from fear and the consequences it has. The following is documented in a March 2020 SPI-B meeting minutes, “There is a need to improve the level of perception of personal threats…it is necessary to use tough emotional information.” Similar words also appear in a document from the German Ministry of Interior. "To achieve the expected deterrence effect (gewünschte Schockwirkung), we must adopt the following narrative: "Many seriously ill patients were taken to the hospital by their relatives, who were turned away and died in pain at home." Data from multiple studies show that the occupancy rate of hospital beds in Germany in 2020 was the lowest in the past few years. Behavioral scientists know that frightened people are prone to obedience. Therefore, we can see that fear is not just an unexpected by-product of the epidemic. It is a government policy that induces people to comply with epidemic prevention regulations by creating fear. Mainstream media plays an important role in delivering this message of fear. Not only in the UK, but also in Europe and the United States, media outlets continuously convey the message of fear through clever selection of numbers and images.
A study by Manuel Schabus, a professor of psychology at the University of Salzburg, Austria, , also confirmed that mainstream media is very effective as a booster tool. It successfully amplifies people's perception of risk. Shabs conducted a large-scale questionnaire on about 4,000 Germans of different age groups. According to subsequent statistical analysis, he found that the respondents overestimated the risk of severe illness after infection by 7 to 38 times (similar studies have also been found in other European and American countries and have reached similar conclusions). There is a very unique question in this questionnaire: he asked the respondents the source of information on the epidemic. The research results found that people who obtain information from public (mainstream) media miscalculated the risk by three times higher than those who obtained information from private (independent) media.
However, the effectiveness of fear propaganda has brought unexpected reactions. According to a large analysis of COVID-19 hospitalized cases in the United States, obesity, diabetes complications, and anxiety/fear are the strongest risk factors for severe cases. Has the media’s fear boost indirectly caused many people to die from COVID-19? In addition, in Western European powers like the United Kingdom, each country has more than one million patients with mental illness. The ongoing "fear propaganda" has deteriorated the health of these patients. Triage has occurred in most psychological clinics and mental hospitals in Europe - only those with severe suicidal tendencies or attempted suicide can receive medical help. This kind of boost from "good intention" originally wanted to change people's behavior through fear, and ultimately reduce people's infection and death. In real-life operations, whether it reduces death or increases death may be a question that will never be evaluated. Of course, this boost brings undeniable ethical issues. Unbeknownst to people, dragging them into a huge psychosocial experiment, seriously damaging their health directly or indirectly. Does this violate the important principle in disguise in the Nurnberger Kodex, namely the principle of subject voluntary subjects in medical experiments? In addition, can the government put young people in danger in order to protect high-risk groups (study shows that young people are far more affected by mental illness than the elderly)?
Given the experimental nature of the mRNA vaccine and its inability to achieve herd immunity, compulsory vaccination does not have an ethical basis. Therefore, governments of various countries can only adopt various boosting measures to increase the vaccination rate of the whole nation. However, Professor Taylor, the "father of the booster", published a commentary article in " New York Times " in August this year, making a slightly surprising point. In the article, he said that in order to increase the vaccination rate of COVID-19 vaccine, it is not enough to use only a boost method and some mandatory means must be used. By Professor Taylor’s definition, boosting is to gently guide people without restrictions or financial incentives. So, many of the policies adopted now—providing free meals for vaccinators, cash rewards, and restricting unvaccinated people to participate in public life—all go beyond the most classic definition of boosting. However, in past discussions of medical ethics, the boundaries of the concept of "boost" have been broadened by the academic community. Giulini mentioned that “we can consider the concepts of incentives and restrictions more broadly than the definitions of Taylor and Sanstein.” So, in this article, in addition to thorough mandatory vaccination, various other restrictions (contained mandatory vaccination) or economic incentives are seen as a vaccine boost.
On the surface, boosting has fewer restrictions on people's freedom than forced vaccination, but if we carefully explore the ethical assumptions behind the two, we will come to a completely different conclusion. Forced vaccination is based on Mill's "harm principle", and the boost presets a "free will paternalistic " (libertarian patriarchalism). The principle of harm emphasizes that as long as a person's actions do not harm others, the government has no right to take any intervention. The patriarchal system believes that people often cannot make choices that are most beneficial to their own and social interests. Therefore, it is necessary for the government to make appropriate interference in human behavior in order to maximize its interests.However, this soft patriarchy seems to open the door to omnipresent interference in freedom and rights. Therefore, there is no ethical difference in whether it is to promote vaccination or to force vaccination to infringe on people's freedom.
support to boost more aggressive scholars will believe that compulsory vaccination is morally preferable. For example, Markus Gabriel, a professor in the Department of Philosophy at the University of Bonn, believes that “it is much better than trying to get people vaccinated with gentle or less tenderness now to try to get people vaccinated by various techniques.” Mandatory vaccination is at best just an infringement of a person's rights, while boosting can lead to violations of various rights - entering public places, using public transportation, working and education, etc. Moreover, according to the medical data of existing vaccines, compulsory vaccination is not completely untenable in ethical terms. Of course, some other scholars have completely taken the lead in the medical ethics perspective and still believe that boosting has a smaller impact on freedom. Jubilini still insists that helping vaccination is in line with the "minimum restrictive principle" in public health ethics. This principle covers two meanings: first, to enforce the policy to achieve herd immunity (if herd immunity is possible); second, to achieve herd immunity with the smallest vaccinated population. If we only consider it from a medical perspective, the means of promoting are still a smaller restrictive measure than compulsory vaccination.
August 9, 2021, in Berlin, Germany, local people were listening to music while waiting to get the COVID-19 vaccine at the Arena Treptow Vaccination Center in Berlin.
Of course, boosting vaccination not only brings tension between medical ethics and socio-political ethics. At the same time, it has also caused a stir within medical ethics. First of all, vaccine boosting may be contrary to ’s informed consent principle . Gavin Morgan, a psychologist at SPI-B, UCL , has a brief reflection on boosting, "All the pandemic information released by the NHS of the UK National Health Service (NHS) has solicited opinions from the Nudge unit. This is not just to make communication clearer, but to boosting in a ‘invisible hand’ way. What I worry about is the problem of manipulation. From my perspective, the problem with boosting is that it has an established agenda. They don’t just provide information, but have clear goals in one direction, which can be misleading." Such a "aggregation" - increasing the vaccination rate, also emerged as the boost to vaccination.
To achieve this goal, the NHS sends different messages to people of different age groups. For the older adults, they take advantage of “regret expectations”, “If you are not vaccinated, it’s a pity that your mortality rate will be about 3 times higher.” For young people, they put moral pressure on them, "Only after you get vaccinated can everyone live a normal life." All this information has nothing to do with the medical use of the vaccine. Similar situations have occurred in the German-speaking world. Professor Wolf-Dieter Ludwig, chairman of the German Drug Council (AcdÄ), once revealed that he talked about the possible long-term risks of mRNA vaccines in an interview with the Austrian Broadcasting Corporation (ORF). However, when the TV station broadcast the interview, it deleted this part of the content. Professor Karl Lauterbach, the health official of the Social Democratic Party, has repeatedly promoted mRNA vaccines with "riskofrei".
The communication of this information is either completely unrelated to the medical effect of the vaccine, or partially conceals the uncertainty of the vaccine (people often make false assumptions that if you tell them information about the uncertainty of the vaccine, they will become more suspicious. A study by Max-Planck-Institut für Bildungsforschung, a research in the Max-Planck Institute for Human Development, which is under the Max-Planck Institute for Bildungsforschung, Germany, refutes this assumption that people are more willing to get vaccinated when the public is fully informed of the uncertainty of the vaccine. The public has the ability to deal with uncertainties). The concealment of key information violates the principle of informed consent as the cornerstone of modern medical ethics. This principle requires that people can make rational decisions about medical intervention without being influenced by emotional or subconscious manipulation.These boosting measures are designed to manipulate people's emotions and subconsciousness, so that the health department can achieve its intended goals.
Secondly, the boost also destroys trust. Martin Kulldorff, an epidemiology professor at Harvard , mentioned 12 basic public health principles that have been forgotten during the pandemic on his personal social media. Article 9 of them is: "Public health is about trust. To gain public trust, public health officials and the media must be honest and trust the public. Humiliation and fear should not be used in a pandemic." Effective public health depends on trust, and trust is always two-way. However, boosting destroys this trust in both directions at the same time. On the one hand, the "soft patriarchal system" behind the boost is preset, and elite groups always know better than every individual what is a better choice for him. That is, public health officials do not trust the public. They always believe that the public is not aware of the benefits of vaccines for them. On the other hand, boosting has also caused the public to lose trust in public health officials (scientists). Because "scientists" have made natural science a tool to promote, making natural science a servant of psychology and behavioral science . Science is no longer faithful to its research objects, but serves other purposes. The deterioration of natural science quality has also indirectly led to the rise of various conspiracy theories, and then scientists in turn accuse the public of believing in conspiracy theories. Science and the public are trapped in a vicious cycle of unsolvable consequences. In this political-psychology game, the two have become the biggest losers together.
boosting methods not only create the above-mentioned ethical problems, but some may even accelerate the spread of the virus in public places. For example, some states in Germany have promoted the replacement of 3G rules with 2G rules (3G is German, geimpft has been vaccinated, genesen has recovered, getestet has tested the initial letter of the three words, and 2G has removed the "tested"). The 3G rules allow the above three types of people to freely enter and exit public places, while the 2G policy completely deprives the right to enter public places without vaccination. This is a very strict boosting method and is the ultimate pressure on unvaccinated people. However, from the perspective of epidemic prevention, 3G seems to be more preferable than 2G. Because, people who test negative can ensure that they do not carry the virus, while those who are vaccinated cannot. Vaccination is protection for oneself, while testing is protection for others. At a hearing in the North Rhine-Westphalia State Assembly, Professor Streke and Professor Christiane Woopen from the Department of Philosophy at the University of Bonn criticized such a policy that “the persons who are tested are safer than the persons who are vaccinated.”
With the launch of the mRNA vaccine, the disputes surrounding it have never stopped. All ethical advice and policy choices are on tightrope. Because it not only involves medical issues, but also affects our lives in all aspects. No one has a complete perspective to balance all the gains and losses. In any case, you have more sympathetic understanding of any view that appears in the discussion.
References:
1. Peter Singer, Why vaccination should be compulsory, https://www.smh.com.au/ national/why-vaccination-should-be-compulsory-20210808-p58gtk.html
2. Thomas Beschorner and Martin Kolmar, Eine Diskriminierung von Ungeimpften ist ethisch gerechtfertigt,https://www.zeit.de/gesellschaft/2021-07/corona-impfung-pflicht-ethik-massnahmen-grundrechte
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Editor: Zhu Fan
Proofreading: Zhang Yan
