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The ‘Ethical’ COVID-19 Vaccine is the One that Preserves Lives: Religious and Moral Beliefs on the COVID-19 Vaccine

The ‘Ethical’ COVID-19 Vaccine is the One that Preserves Lives: Religious and Moral Beliefs on... PUBLIC HEALTH ETHICS VOLUME 14 ISSUE 3 2021 242–255 242 • • • The ‘Ethical’ COVID-19 Vaccine is the One that Preserves Lives: Religious and Moral Beliefs on the COVID-19 Vaccine Alberto Giubilini *, Oxford Uehiro Centre for Practical Ethics, University of Oxford Francesca Minerva, Department of Philosophy, University of Milan Udo Schuklenk, Queen’s University Julian Savulescu, Oxford Uehiro Centre for Practical Ethics, University of Oxford; Visiting Professorial Fellow in Biomedical Ethics, Murdoch Childrens Research Institute; Distinguished Visiting International Professorship in Law, University of Melbourne *Corresponding author: Alberto Giubilini, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK. Email: alberto.giubilini@philosophy.ox.ac.uk Although the COVID-19 pandemic is a serious public health and economic emergency, and although effective vaccines are the best weapon we have against it, there are groups and individuals who oppose certain kinds of vaccines because of personal moral or religious reasons. The most widely discussed case has been that of certain religious groups that oppose research on COVID-19 vaccines that use cell lines linked to abortions and that object to receiving those vaccine because of their moral opposition to abortion. However, moral opposition to COVID-19 vaccine research can be based on other considerations, both secular and religious. We argue that religious or personal moral objections to vaccine research are unethical and irresponsible, and in an important sense often irrational. They are unethical because of the risk of causing serious harm to other people for no valid reason; irresponsible because they run counter to individual and collective responsibilities to contribute to important public health goals; and in the case of certain kinds of religious opposition, they might be irrational because they are internally inconsistent. All in all, our argument translates into the rather uncontroversial claim that we should prioritize people’s lives over religious freedom in vaccine research and vaccination roll out. October 2020, COVID-19 has reportedly killed directly Introduction over 1 million people all over the world in slightly less The COVID-19 pandemic should not have been an un- than a year (Musil, 2020). To prevent or contain such outbreaks today, it is ne- expected event, since pandemics or large epidemics peri- odically occurred throughout human history (Garrett, cessary to not only develop safe and effective vaccines but to also do it as quickly as possible and to make them 1994). Indeed, new pandemics are likely to occur again and to be more virulent than this one. The ‘Spanish Flu’ accessible to as many people as possible. This requires pursuing more lines of research at the same time, given pandemic in 1918 killed at least 50 million people and infected 500 million people worldwide. The ‘Black that inevitably many of them will be unsuccessful or would require longer than others to be completed. It is Death’ plague ‘devastated the Western world from 1347 to 1351, killing 25–50% of Europe’s population also important to have different types of vaccines in order to maximize the chances of conferring protection and causing or accelerating marked political, economic, social and cultural changes’ (Gottfried, 1983) Around 75 against new variants of the virus and of conferring ad- equate protection to different population groups. The million people perished at the time (Sandle, 2013). By doi:10.1093/phe/phab018 Advance Access publication on 19 July 2021 V C The Author(s) 2021. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. THE ETHICAL VACCINE 243 longer we go without adequate vaccine supply, the more Canada and Australia. They have condemned research people will die of COVID-19 (or other viruses that might on the COVID-19 vaccine that uses cell lines obtained appear in the future) or of the consequences of pandemic from tissues harvested from aborted foetuses. management measures [such as declaring cancer care (Henceforth, we will refer to such vaccines as ‘vaccines non-urgent, resulting in a spike of people presenting at linked to abortion’.) hospitals with advanced cancer (Ogilvie, 2020)]. Why are human foetal cell lines being used in re- However, the urgency of developing vaccines does not search? One major approach to developing a new vaccine mean that research, development, distribution and vac- for corona virus is to use viral vectors, such as adeno- cination policies may bypass ethical and scientific stand- virus. Johnson and Johnson in the USA and the ards (London and Kimmelman, 2020). ‘As quickly as University of Oxford (partnered with the pharmaceut- possible’ means as quickly as reasonable ethical and sci- ical company AstraZeneca) have used adenovirus entific standards allow. approaches. These require the use of cell lines such as What constitutes an ethical vaccine research and pol- the HEK (human embryonic kidney) 293 cell-line, which icy has recently been the subject of some controversy is derived from tissues of a foetus aborted in 1972 involving religious authorities and scholars defending (Wadman, 2020b). religious freedom, particularly those from the HEK293 cell lines enable the deletion of genes so that Christian tradition. Religious objections are not the the adenovirus vector does not replicate in the vaccinee’s only type of moral objections to certain vaccines. The cells (He et al., 1998; Thomas and Smart, 2005). Thus, arguments we are going to provide in this paper apply to the virus contains the gene which stimulates production a number of religious and non-religious positions on of COVID-19 proteins, which elicit immunity, without vaccine research alike. Actually, as we shall see, the fact overwhelming cells with the virus, which can happen that there are many possible kinds of moral objections to with natural infection. In other words, HEK293 cell lines certain kinds of vaccine research is itself a further reason make vaccine development efficient, because they con- in support of our line of argument, as it makes respect for tain the genetic material necessary to produce the desired freedom of conscience with regard to vaccine choice even more difficult to justify. However, we are going to adenoviruses and that cannot be obtained through ani- focus primarily on religious objections to vaccine re- mal cell lines, and safe, because the resulting adenovirus search that uses foetal cell lines because it has been would not contain the genes that would replicate the more prominent in the debate and because it could po- virus and infect the cells of the vaccinees. tentially influence the vaccination choice of a very large The Pfizer/BioNTech vaccine does not use foetal cell number of people. lines in the development of the vaccine, although it did Ethical considerations, when sound, can legitimately use it to test the vaccine. For those who object to research slow down vaccine development and uptake. Because linked to abortion, it might not be ‘ethically uncontro- slowing down vaccine development and uptake likely versial’, as some have called it (e.g. Sherley and Prentice, results in avoidable deaths, it is important to assess 2020), but to many, it is less controversial than, for ex- whether these ethical considerations are legitimate and ample, the Oxford/AstraZeneca vaccine. It might be what ethical weight they should be given, if any. At the objected that this makes it unnecessary to use vaccines moment, it is difficult to estimate or predict how many using an adenovirus. But this would be a mistake. We people have refused or will refuse a certain vaccine be- need as many different vaccines as possible. Besides, cause of these kinds of personal ethical concerns. The there are serious drawbacks with an mRNA vaccine. It rate may be very different in different countries or cul- must be stored at70 C(94 F) and it can’t be removed tural contexts. But the number is potentially very high at from the fridge more than four times. This severely least in certain contexts, given the number of ethical limits its distribution, especially considering that it issues that vaccine development raises and the number must be administered in two doses. Many countries of followers of certain religions. have already invested and signed agreements for the pro- In particular, two types of concerns have been raised: duction of adenovirus vaccines. For quite some time, about vaccine research itself and about future vaccin- there will be vaccine shortages and because in a pandem- ation policies. ic time is lives, changing vaccine may cost significant With regard to the first, a lot of publicity, including by numbers of lives. The more vaccines are approved, the highly respected scientific journals (Wadman, 2020a), more availability we will have in the shorter term, and has been given to views expressed by some Catholic, Anglican and Greek Orthodox authorities in the USA, the more lives will be preserved. 244 GIUBILINI et al. So how should we evaluate ethical opposition to the vaccines are not available, ‘(e.g. in countries where vac- cines without ethical problems are not made available to use of vaccines which use aborted foetal material in their production? physicians and patients, or where their distribution is The Congregation for the Doctrine of Faith, which is more difficult due to special storage and transport con- taken by the Roman Catholic Church as source of au- ditions, or when various types of vaccines are distributed thoritative teaching, has stated that use of already exist- in the same country but health authorities do not allow ing COVID-19 vaccines derived from tissues harvested citizens to choose the vaccine with which to be inocu- from foetuses after elective abortions can be morally per- lated)’ (Congregation for the Doctrine of Faith, 2020). Besides, freedom of conscience and religious freedom missible (Congregation for the Doctrine of Faith, 2020). However, this consideration is not taken to apply to are not conditional upon adherence to some official doc- trine. Part of the notion of religious freedom is the free- novel research on vaccines. In a letter addressed to the US Food and Drug Administration, and signed by a dom to choose which religious authorities to follow and number of American Bishops, Archbishops, the the dictates of one’s own conscience (thus, for instance, a President of the Catholic Medical Association and a Catholic in Australia might want to follow the recom- group representing socially conservative paediatricians, mendation of the local Archbishop rather than of the Roman authority). the signatories. The issue of conscientious objection to vaccination— ‘strongly urge [the] federal government to ensure that is, the refusal to comply with certain vaccination that fundamental moral principles are followed in requirements because of personal moral or religious the development of such vaccines, most import- views (as opposed to refusal motivated by concerns antly, the principle that human life is sacred and should never be exploited, [and] urgently and re- around safety or effectiveness of vaccines)—has been spectfully implore [the US Government] to not discussed in recent years (e.g. Clarke et al., 2017; only ensure that Americans will have access to a Giubilini et al., 2017; Navin and Largent, 2017; COVID vaccine that is free of ethical concerns, Giubilini, 2019). Some of those who have previously but to encourage and incentivize pharmaceutical defended such a right in the name of religious freedom companies to use only ethical cell lines or proc- or freedom of conscience (e.g. Navin and Largent, 2017) esses for producing vaccines’. have endorsed the stance of these religious leaders with A second concern is that governments should ensure regard to the future COVID-19 vaccine (Navin and that people are left with alternatives to what they con- Redinger, 2020). The general principle regulating con- sider an unethical vaccine. If the state cannot or does not scientious objection to vaccination, according to Mark want to guarantee that an alternative vaccine is available Navin and Mark Largent, is taken to be the following: by allocating research funding accordingly, then, they ‘it is morally justifiable to offer exemptions to argue, a moral conflict can arise between the duty to people who object to general laws for reasons of get vaccinated and the duty not to use unethical vaccines. religious conviction, secular conscience or per- For instance, according to the Catholic Archbishop of sonal integrity. In particular, there are good rea- Sydney Anthony Fisher, ‘those who are troubled by [the sons to exempt people from general laws when COVID-19 vaccine] will either have to acquiesce to the objectors have reasons to object, when imposing the law on objectors would subject them to social pressure to use the vaccine on themselves and their unique burdens and when exemptions policies dependents, or conscientiously object to it’. do not impose costs on third parties’ (Navin It is worth stressing that the Congregation for the and Largent, 2017). Doctrine of Faith has issued a specific document stating the moral permissibility for Catholics to use COVID-19 Along the same lines, Navin and Redinger have re- vaccines linked to abortion in the current situation. cently argued that ‘[i]f the only available COVID-19 vac- According to the note, ‘all vaccinations recognized as cine were one connected to abortion, then COVID-19 clinically safe and effective can be used in good con- vaccine mandates would significantly constrain the reli- science with the certain knowledge that the use of such gious liberty of people who object to vaccines for reli- vaccines does not constitute formal cooperation with the gious reasons’—which would also violate a legal abortion from which the cells used in production of the requirement (in the USA) to ‘use the least restrictive vaccines derive’ (Congregation for the Doctrine of Faith, means to promote compelling government interests 2020). whenever the state’s activity impedes religious liberty’ However, the Congregation is also very clear that this (Navin and Redinger, 2020). Similar legal constraints consideration only applies if alternative, more ethical are in place in other countries, such as Canada. Thus, THE ETHICAL VACCINE 245 according to Navin and Redinger, mandating a vaccine We will first address the issues around research ethics. without conscience exemptions, when it is possible to We will argue that even accepting (for the sake of argu- fund an alternative vaccine that would not compromise ment) the premise that abortion is impermissible, it is religious liberty, might be illegal in the USA. As we shall not morally impermissible to conduct research on vac- see, if funding alternative vaccines means diverting cines linked to abortion. Indeed, we will argue that such resources from more promising lines of research, thus research is a moral imperative if there is a realistic pro- delaying vaccine development, then funding an alterna- spect of it resulting in more safe and effective vaccines tive vaccine is not the least restrictive means to promote more quickly than with alternative lines of research. government interests. A government’s primary interest We will then move on to discuss vaccination policies. is to have an effective vaccine as soon as possible (and as We will argue that if at some point vaccination mandates reasonable ethical and scientific standards allow). (for instance in the form of vaccine or immunity pass- The reasons offered by Navin and Redinger, and ports) turn out to be ethically justified and necessary to hinted at in the letters mentioned above, are not only achieve adequate vaccination coverage, there is no eth- ethical or legal in nature. There are also practical reasons: ical justification for conscience or religious exemptions a COVID-19 vaccine linked to abortion might increase to vaccination mandates. Contrary to what defenders of the rate of vaccine refusal. All in all, both ethical and conscience exemptions imply, it is likely that exemption pragmatic considerations translate into two claims. policies will impose costs on innocent third parties. First, that we should not prioritize COVID-19 vaccine There are also other ethical requirements that need to research linked to abortion. Second, that, if we do it and be fulfilled apart from not imposing costs or harms to the first approved vaccine will be one linked to abortion, others—most notably fairness in vaccination policies. people with moral or religious opposition to it should be Finally, we will briefly analyse claims about individual permitted to opt out in the name of freedom of religion morality: we will argue that it can be morally permis- and/or freedom of conscience. sible—even for people who consider abortion immoral It is important to point out that none of these religious or a ‘grave moral sin’—to use vaccines linked to abor- authorities is against the ethical obligation to get vacci- tions. Establishing this point as a matter of individual nated per se. All of them emphasize how important vac- morality is important for two reasons. First, it could cines are for the protection of the public good and the convince some to avoid claiming conscience exemp- most vulnerable members of society—which is why tions. Second, one condition set out by Navin and some think the Catholic social teaching implies a moral Largent for the justification of conscience exemptions duty to vaccinate (Carson and Flood, 2017). The em- is, as per quote above, that ‘objectors have reasons to phasis is rather on the request to divert resources into object’ (which we take to mean that they have reasons funding research on vaccines not linked to abortion, and that meet some minimum threshold of validity, includ- when this is not done, on leaving people free to follow ing that they are consistent with one’s own ethical prin- their conscience: vaccines in themselves are a good thing, ciples). If it turns out that objectors do not have such but a moral agent’s opposition to abortion weighs more reasons, then their argument for conscience exemptions heavily, they claim. does not apply. In this article, we argue that respect for religious views These considerations apply to the vaccines currently and freedom should not hinder vaccine development approved and to the vaccines that will be researched and and uptake—including the implementation of effective may be approved in the future as well. vaccination policies in a pandemic. This means that re- search on vaccines linked to abortion should be priori- tized if and when that maximizes the chances of having a Research Ethics: Prioritizing new vaccine sooner rather than later, which at the time of Religious Freedom over Potentially writing is the case with COVID-19 vaccine research. It also means that if mandatory vaccination will turn out to Life-Saving Research is Unethical be necessary and ethically justified (an issue we are not Some people believe that abortion is wrong and that it is going to take a stance on here), cost-free exemptions based on personal moral or religious views should not wrong to benefit from a serious wrongdoing like abor- tion. Is this a good enough reason to deprioritize re- be granted. We agree that more religiously acceptable alternatives should be pursued, other things being equal. search linked to practices perceived to be unethical in However, they should not be pursued at the cost of this way? human lives. The proposition here can be read in two ways. 246 GIUBILINI et al. First, given a fixed research budget, at least some of the and development and so to prevent avoidable deaths. funds should be directed towards what people opposed Given the gravity of the current situation, and the fact to abortion take to be ethical research. But this would de that large numbers of lives are at stake, this is equivalent facto mean reducing funding for research linked to to slowing down such research by diverting currently abortion. If research linked to abortion is very promis- allocated research budget to less promising lines of ing—for example, there are vaccine candidates linked to research. abortion at an already advanced stage of study—this In secular societies, what makes research ethical or strategy would seriously risk delaying the moment unethical should be established on grounds of public when we have an effective vaccine, thus ultimately result- reason, that is, on principles that can be justified without ing in more avoidable deaths. It is worth keeping in mind appealing to particular sectarian religious views—al- that even if alternative vaccines are being developed and though one has good reasons to try to satisfy the prefer- are very promising, we would still need more vaccines in ences of everyone, including those with religious beliefs, the pipeline in order to guarantee enough supply at least when it comes at little or no significant cost. Ethical in the short term. The criterion for allocating research principles regulating medical research—especially re- funding to different lines of research should be how like- search benefitting the whole population—cannot be ly they are to be successful, not whether they are or are merely religious in nature. Ethics typically sets bounda- not linked to abortion. The choice to use human foetal ries to what researchers can permissibly do, which often cell lines for vaccine research is explained by the fact that justifiably slows down research. Unethical research such research represents a distinct and promising avenue would often mean quicker research. Since, under current to quickly deliver the required vaccine safely. circumstances, time means life, it is important that the In addition to the considerations above, non-human ethical reasons for such boundaries be reasons that peo- cells are more likely to carry bacteria or viruses that could ple with diverse religious views and people with no reli- contaminate the resulting vaccine. For example, some gion alike can share—given that their lives and their polio vaccines developed in the 20th Century using cell health are at stake, too. In other words, they need to be lines derived from monkeys were found to contain a based on public reason, which ‘requires that our moral monkey virus that only by luck did turn out to be not or political principles be justifiable to, or reasonably ac- harmful for humans (CPP (College of Physicians of ceptable to, all those persons to whom the principles are Philadelphia) 2018). For all these reasons, it is not un- meant to apply’ (Quong, 2017). common for vaccine research and manufacturing to be As for non-religious arguments for the moral imper- linked to human foetal cell lines. Current vaccines missibility of abortion (e.g. those based on the potential against rubella, chickenpox, hepatitis A and shingles of a foetus to become a person, or on the future a foetus is were developed using cell-lines obtained from aborted being deprived of), these are the subject of reasonable foetuses. A non-human cell line might not produce safe disagreement. In any case, current codes of ethics, both and effective vaccines immediately, though it could do with regard to research and to clinical practice, do con- over the years. In the current pandemic, years is a length sider at least some instances of abortion ethically per- of time we cannot afford if we want to preserve human missible (e.g. AMA, 2016), and they allow for data or lives. Thus, funding alternative research just because it is tissues resulting from abortion to be used for research not linked to abortion risks diverting resources into re- purposes with the of the woman who had the abortion search that is less likely to be effective in the short term, (AMA, 2016, Opinion 7.3.4)). Moral uncertainty and and that would very likely cost lives. moral disagreement about abortion do not make re- Second, the request might be taken to mean that more search linked to abortion unethical by current research funds should be put into vaccine research and develop- ethics standards. ment, and this additional funding should be reserved for There are other possible ethical objections to using research that is not linked to abortions. Of course, it is foetal cell lines in vaccine research. Although we do desirable to fund different streams of research in order to not have precise information about the foetus from maximize the chances that at least some of those will which the tissues were harvested, it seems that the foetus, deliver a vaccine soon. But the criterion for increasing aborted in 1972 in the Netherlands, was ‘of unknown and allocating research funding should be the maximiza- family history’ (US FDA (Food and Drug tion of the chances of having the safest and most effective vaccine sooner rather than later. Increasing research Administration) 2001). It was not too uncommon at funding in order to satisfy some other criterion would that time to use foetal material from abortion without be a missed opportunity to accelerate vaccine research the consent of the woman (Wadman, 2018). THE ETHICAL VACCINE 247 So, opponents might claim, this research is doubly ‘[i[n the rare instances when ethically tainted data have been validated by rigorous scientific analysis, wrong: women did not consent and it uses tissue are the only data of such nature available, and obtained by immoral killing of the foetus. Even if the human lives would certainly be lost without the latter aspect might be the subject of reasonable disagree- knowledge obtained from the data, it may be per- ment, there likely is more widespread agreement on the missible to use or publish findings from unethical wrongness of the former—or at least the wrongness of experiments. Physicians who engage with data the former can more easily be established on the basis of from unethical experiments as authors, peer reviewers, or editors of medical publications public reason. should: However, even though by today’s standards that foetal tissue procurement was unethical, it remains to be estab- 1. Disclose that the data derive from studies that do not lished whether the causal connection with previous un- meet contemporary standards for the ethical conduct ethical practices makes current research unethical. of research. According to current standards and codes of research 2. Clearly describe and acknowledge the unethical na- ethics, such causal link does not suffice to make current ture of the experiment(s) from which the data are research unethical. derived. Where the benefits of current research are sufficiently 3. Provide ethically compelling reasons for which the valuable, benefitting from unethical past research is eth- data are being released or cited, such as the need to ically acceptable—and we would argue, ethically save human lives when no other relevant data are required. Let’s grant for the sake of argument that abor- available. tion is morally wrong and/or that deriving cell lines from 4. Pay respect to those who were the victims of the un- aborted foetuses for research purposes was unethical, for ethical experimentation’ example because women did not give valid consent. Now let’s compare this with infamous Nazi experiments Baruch Cohen (1990) has noted that one way to de- unanimously considered immoral. In the ‘immersion fend the use of such data would be to see the use as a way hypothermia project’, for instance, Nazi scientists of honouring the victims of such research. Their—invol- immersed non-consenting concentration camp prison- untary—sacrifices could at least be seen to contribute to ers in tanks of icy water until they died. These experi- the good of humanity. ments were grotesquely unethical. The purpose was to Understandably, this is not an interpretation that was research the most effective treatment for German victims shared by every holocaust survivor. However, as Stephen of immersion hypothermia, for instance fighter pilots Post (1991) notes, some holocaust survivors held this shot down over the English Channel (Berger, 1990). view, provided there was a ‘clear and significant benefit’ Some data resulting from this research have been used to humanity. and cited in subsequent research and dozens of scientific One could argue that a similar line of reasoning could papers (Moe, 1984). be applied to foetal material derived from aborted foe- We agree that such data ought to be handled with care tuses by those who think that abortions constitute a ser- to avoid the risk of ‘being contaminated by the moral ious moral wrong. Refusing to use the results of such taint’ (Higgins et al., 2020)—for example by acknowl- research could well be seen as showing disrespect to edging the harm caused to the victims of such experi- the aborted foetuses whose genetic material was used ments whenever unethical research is cited (Moe, 1984, to undertake research the results of which are offering Higgins et al., 2020). However, current research guide- a clear and significant benefit to humanity. lines do permit the use of such data for research pur- Because time means life, if research on COVID-19 poses, including their reference in scientific papers, if would be slowed down by the requirement not to be significant benefit can result from such research; if the linked to abortion, there are indeed ethically compelling unethical nature of the original research is properly reasons for conducting such research even assuming that acknowledged; and if compelling ethical reasons can be obtaining the cell lines in the first place was unethical. provided for its use. For example, Opinion 7.2.2. of the The burden of providing an argument to the contrary is Code of Ethics of the American Medical Association on those who claim that current research ‘tainted’ by that (AMA, 2016) states, with regard to past unethical experi- causal link is unethical. ments such as Nazi experiments during World War II or As a way of analogy, consider the case of research the US Public Health Service Tuskegee Syphilis Study, involving the destruction of human embryos for the pur- that pose of embryonic stem cell procurement. After the 248 GIUBILINI et al. discovery that induced pluripotent stem cells could be groups, level of protection conferred, vaccine availabil- derived from human skin, there was some call for the ity) which are unknown at the moment. However, if it abolition of research involving human embryonic stem turns out that mandatory vaccination will at some point cells. However, although pluripotent stem cells derived be necessary or ethically justified, then there should be from adult cells have great potential, it is uncertain no conscience exemptions to mandates, whether for whether they can actually replace embryonic stem cells moral or religious reasons. Indeed, an ethical assessment for all research and therapeutic purposes. If there is at of (i) whether future COVID-19 vaccination policies least some reasonable chance of benefit in the continu- should be mandatory and (ii) for whom they should be ation of research using embryonic stem cells, then this mandatory should not be based on some people’s moral research ought to continue: there are no ethical reasons or religious opposition to the vaccine or on a principle of against it that can be established on the basis of public freedom of conscience and of religion. reason, and lives could be saved thanks to such research. Before we argue why there should no exemption for Research that is not unethical on the basis of careful, conscientious objection, we should clarify what we mean rational assessment on secular grounds should only be by ‘no exemption’. What we mean is no exemption to the stopped or prevented because of certain people’s or cost imposed for not being vaccinated. We do not mean groups’ moral opposition if it is futile, that is, if there that people must be forcibly vaccinated. Mandatory vac- is no actual benefit that can plausibly be derived from it cination already exists with costs including fines (Italy), and that would outweigh people’s opposition to it. But, refusal of admission to school (USA), withdrawal of under the current circumstances, neither embryo re- childcare benefits or child care (Australia). What we search nor COVID-19 vaccine research linked to abor- mean is that if you object, for whatever reason, you tion are futile. should pay the relevant cost, e.g. fine, withdrawal of After all, chasing a regenerative medical cure or a vac- childcare benefit, etc. What constitutes an appropriate cine for COVID-19 is like a horse race. We should let all form of coercion (or cost) is a separate issue and it horses run because we should not scratch a potential should be proportionate (Savulescu, 2020). winner. Because time is lives, all plausible candidates Why should we not exempt conscientious objectors to must be tested on the basis of their chances to deliver vaccination? The comparison we made above with em- the desired outcome sooner rather than later, unless bryonic stem cell research is once again useful. there are convergent ethical reasons to eliminate a can- Vaccination is different from regenerative medicine didate (Devolder and Savulescu, 2006). based on embryonic stem cells in an important respect. In the case of regenerative medicine, a patient refusing to use treatments based on embryonic stem cell research Vaccination Policy: Prioritizing does not harm anyone else directly and, more generally, there is no significant public good at stake. In a public Religious Freedom over Public health system, there might be a case for requiring an Health is Unethical individual to cover the costs for the healthcare system of them refusing a more effective treatment (Savulescu, Another claim being made in the name of religious free- 1998), but there is no compelling reason for overriding dom and freedom of conscience is that, if COVID-19 vaccination policies are mandatory, there should be con- their autonomous decision about refusing certain treat- science exemptions for those who object to the vaccine ments on personal moral grounds. However, in the case of vaccination, refusal to vaccinate both risks one’s own because of its connection to abortion. Now, whether COVID-19 vaccination should be health and the health of others directly, and it represents made mandatory, and in that case for which people or a failure to contribute to an important public good (herd immunity against serious infectious diseases). Because groups, is an issue that would require a separate discus- sion. We want future COVID-19 vaccination policies to each person is potentially a lethal threat to others, there is be maximally effective at preventing the largest numbers a requirement to ‘lay down your guns’ and reduce your of lives lost prematurely and to strike the right balance threat to others (Flanigan, 2014). There is no valid reli- gious duty or right to harm or to pose a serious risk of between pursuing the collective interest and minimizing the risks for individuals, while exerting the lowest degree harm to innocent other people. Just as terrorists should of coercion possible. Whether this will require manda- not kill innocent people in the name of God, conscien- tory vaccination will depend on a number of factors tious objectors should not pass on lethal viruses that (safety profile of the vaccine, effectiveness in different could kill vulnerable people in the name of God. THE ETHICAL VACCINE 249 Because the reasons not to allow conscientious When we talk about harm prevention through vaccin- exemptions to vaccination are based on considerations ation, we are talking about responsibility that is not only of harm prevention (both directly, by not exposing individual, but also collective. Protecting people from others to the virus, and indirectly, by contributing to infectious diseases requires collective effort—for in- herd immunity), the only valid alternative to vaccination stance, realizing herd immunity requires a large portion would be extreme self-isolation. In this way, one would of the population to be vaccinated. The harm or risk of literally present no threat to others and would contribute harm imposed on vulnerable people by absence of herd to the collective effort of eradicating or containing the immunity—when herd immunity could be achieved disease. However, religious leaders, and more generally through vaccination—is collectively produced. those who claim a right to conscientious objection in the Now, collective responsibility is a complex notion, context of healthcare and public health, expect exemp- both conceptually (Giubilini and Levy, 2018) and ethic- tions to be cost-free, for example by claiming that objec- ally. One ethical problem is that often individual contri- tors should continue to receive state benefits and welfare. butions to the fulfilment of collective responsibilities For example, Australian Catholic Archbishop Antony and prevention of collective harm ‘does not make a dif- Fisher complained that ‘if the COVID-19 vaccine is ference’. Derek Parfit used now famous thought experi- linked to “no jab, no pay” rules, Catholic families could ments to illustrate the problem. In one of these, for lose access to family payments if they refuse to vaccinate instance, a large number of people could contribute a their children’. pint of water to a collective cart that can be brought to It is also important to recognize that rigorous self- the desert, where the water can be distributed among an isolation may reduce the direct threat to others, but it equally large number of thirsty people. In the ‘harmless cannot contribute to herd immunity or to mitigating the torturer’ case, a large number of people give each a very wider harms of pandemic measures such as lockdowns. mild electric shock to a person; the shock from each Indeed, by delaying herd immunity, it increases the like- individual torturer is negligible, but collectively the lihood of such harms occurring. shocks cause severe pain to the victim (Parfit, 1984). In Conscientious objectors could say that there is an ob- both cases, Parfit claims that individuals do have a moral vious difference between conscientious objection to vac- obligation to contribute to harm prevention (either cination and terrorism: terrorists will almost certainly through action or inaction, respectively), even if the re- kill innocent people; objectors are only imposing a sponsibility to prevent harm or to help out is collective very small risk of death on any individual. In a way, and each individual would not ‘make a difference’. the argument goes, we impose small risks on others every Some of us have translated this principle into a prin- time we sneeze or drive a car, and failure to be vaccinated ciple of collective easy rescue in the case of vaccination, is not much worse than these behaviours. which grounds both a collective responsibility to realize However, this response fails. herd immunity when the cost required to individuals is First, the risk posed by those who object to vaccination small, and an individual responsibility to contribute to is not just that of infecting some other individual. Such that good by appealing to fairness in the distribution of infected individuals could go on and infect others (espe- the burdens (Giubilini et al., 2018, 2020). Thus, those cially with diseases like COVID-19, where infected peo- who request not to be vaccinated on the basis of personal ple are often asymptomatic and therefore not aware of moral or religious reasons are in fact requesting to be being spreaders). The risk is therefore not as small as it exempted from making their fair contribution to collect- might initially seem. ive harm prevention, and ultimately to an important Second, we do take reasonable measures—that is, global public good from which they will themselves measures that are not too costly for an individual—to benefit significantly. Controlling the spread of minimize risks on others posed by the aforementioned COVID-19 through a vaccine would protect everyone behaviours. We do have speed limits and other road not only against the risks of COVID-19, but also against rules, and the social norm of covering our mouth with the economic damage, education costs, and risks for our elbow when sneezing is now quite widespread. physical and mental health that pandemic management During this pandemic, we are often required to use measures are creating. If we allow a principle of freedom face covering. Assuming vaccines are safe for any tar- of conscience to outweigh fairness in this context, we geted group or group for which they are approved, vac- cination is just a similarly reasonable and low-cost undermine one of the core principles regulating collect- preventive measure. And we do impose costs when those ive efforts and public goods in liberal societies. We rules are broken, such as speeding fines. should prioritize fairness over religious freedom, given 250 GIUBILINI et al. that fairness has very significant intrinsic and instru- others. However, the problem is that not everyone can mental value. mount an effective immune response, not everyone can That fairness has intrinsic value is a point that would be vaccinated because of medical reasons, and immunity need a philosophical discussion to be established. For the often wanes over time. If mandatory vaccination were purpose of the this article, suffice it to say that the point is warranted, it is an open question whether herd immun- suggested by the prominence fairness is given in many ity could be achieved if personal or religious exemptions other public policies. Taxation policies are an obvious were allowed. example: we want taxation policies to be not only effect- Some have argued that there is no point in imposing ive at generating enough revenue to provide important the costs or risks of vaccination on few people who goods, but also to be fair. In principle, we can achieve the would want to refuse the vaccine, when we can be con- former without the latter. And yet, we want taxation fident that there is enough protection at the collective policies to be effective and fair. level. In that case, freeriding would not be a problem But the value of fairness is not only intrinsic. It is also (Dawson, 2007). However, even accepting this point, instrumental: we value fairness because fair policies are we should not forget that religious or moral opposition more likely to be successful by motivating people to to abortion is only one among the many possible and at comply. In other words, fairness would address the so- least equally (un)reasonable moral beliefs one can appeal called ‘problem of assurance’: people are more moti- to in order to refuse vaccination: people might be vated to contribute to public goods if they have enough opposed to the use of animals or animal products in reassurance that others would do the same . In the case of research, might be committed to natural lifestyles, might vaccination, fairness requires equal distribution of the refuse what they perceive to be authoritarian invasions of burdens involved in the realization of herd immunity. It their bodily integrity, might be opposed to the capitalist is not unfair to exempt people from requirements if these system behind for-profit pharmaceutical companies, are too burdensome or risky on objective grounds—that and so on. All of these beliefs, and many others, could is, grounds that can be assessed and reasonably estab- be considered a matter of conscience in the same way as lished through public reason. If someone is at serious religious opposition to abortion. risk of significant side effects from vaccination (say, be- Moreover, herd immunity is a very unstable condition cause of allergies), it is not unfair to exempt this person and vaccination coverage is subject to constant change. from vaccination requirements, because the sacrifice Any measure that makes it more likely that vaccination required of them to contribute to the public good would uptake will drop creates risks for vulnerable members of be too large. the community—when vaccination uptake drops below Such risks can be assessed through public reason and herd immunity, it is too late and these people are already on objective grounds (for instance, medical grounds). exposed to risks. We should prevent rather than remedy But claiming that personal moral or religious beliefs rep- such situations. It is not acceptable to put people’s health resent equally strong reasons for exemptions implies and lives at significant risk because of convictions that assuming a relativistic perspective, where religious views cannot be defended by appeal to public reason. about abortion or complicity are as worthy of protection A compromise that some of us have proposed is that as harm prevention, fairness or the public good. Public of requiring those who request non-medical exemptions policies in liberal democratic societies cannot be based to provide alternative services that are roughly as bur- on such ethical relativism (Blackford and Schuklenk, densome and as valuable to society as the contribution 2021). Preserving the public good, obligations towards they request the exemption from Giubilini et al. (2017). other people (and most notably the obligation not to This would offer more reassurance that their request is pose other people at easily preventable risk of harm), sincere and not motivated by the intention to freeride. fairness requirements are all considerations that take pri- However, it is often difficult to establish what could ority over freedom of conscience when it comes to pro- make up for failure to vaccinate against infectious dis- tecting people’s lives. Allowing conscience objectors to eases. In this specific circumstance, where a pandemic is free-ride on others’ contributions to important public killing hundreds of thousands of people and paralyzing goods in the name of freedom of conscience would re- the world’s economy, it is hard to find suitable alterna- quire giving freedom of religion or of conscience a moral tive contributions—except perhaps extreme self- weight that is difficult to justify (Leiter, 2014). isolation. Defenders of religious exemptions might respond that Respect for religious freedom or freedom of con- those at risk can themselves be vaccinated, so that the science more broadly can be part of what public reason conscientious objectors would not pose any risk to requires, to the extent that it is a principle that all THE ETHICAL VACCINE 251 reasonable people—religious and non-religious alike— linked to abortion in terms of their own doctrine. So far, we have assumed that the principle at stake is one can accept. However, priorities need to be considered to determine what public reason requires in any specific of freedom to follow one’s religious views. However, religious doctrines that oppose abortion typically do context. What constitutes a reasonable compromise is not always what lies half-way between two opposite stan- not condemn tout court the use of vaccines linked to abortion. The argument from religious freedom might ces. Sometimes compromise itself is unreasonable, and the more extreme the circumstances, the more likely this in this case rest on shaky foundations. For example, the Roman Catholic social doctrine in is. In the case of public health policies in situations of general supports a moral duty to vaccinate in order to emergency like the current pandemic, protecting people contribute to social goods and to prevent harm (Carson from COVID-19 is the priority even when it comes at and Flood, 2017). Also, it supports the use of vaccines some cost in terms of liberty. After all, we have accepted linked to abortion if they are necessary to protect vul- incredibly harmful restrictions of liberty through indis- nerable individuals and there is no suitable alternative. criminate long lockdowns, quite regardless of whether As we mentioned above, also the official note of the the moral or political or religious beliefs of restricted Congregation for the Doctrine of Faith explicitly says individuals were consistent with accepting this kind of that when alternative vaccines are not available, it is confinement. Consider, for example, the situation of a morally permissible for Catholics to use COVID-19 vac- hard-core libertarian subject to lockdown restrictions. cines linked to abortion given the current grave risk the Whether lockdown has been unreasonable or effective disease poses (Congregation for the Doctrine of Faith, is up for debate, of course, but the fact that most have 2020). accepted it suggests that in emergency situations pre- That document makes explicitly reference and relies venting grave harm may legitimately take priority, and on the views on the matter previously expressed by the reasonable policies are those that prioritize preventing Pontifical Academy for Life, which was established by the grave harm (whether or not this applies to lockdown). Pope specifically to study and promote the value of Unfortunately, in conditions of scarce resources and human life consistently with the Catholic doctrine. In when we have to run against time in order to preserve lives, 2017, the Academy published a short addendum (PAL, it is reasonable to compromise a certain degree of freedom, 2017) to one of their previous documents on vaccination including freedom of conscience and religious freedom, if (PAL, 2006). In this addendum, they state that using that increases the chances of preserving more lives. vaccines linked to abortion is in certain cases not only Of course, if we had a situation of herd immunity morally permissible but also morally mandatory. As they against COVID-19 or if those refusing vaccination were put it, ‘the moral obligation to guarantee the vaccination only the ones living isolated from the rest of society (as is coverage necessary for the safety of others is no less ur- the case for example for certain ultraorthodox groups gent, especially the safety of more vulnerable subjects traditionally opposed to vaccines), then there would be such as pregnant women and those affected by immuno- strong reasons to respect their freedom of choice with deficiency who cannot be vaccinated against these dis- regard to vaccination, as their decisions would not affect eases’ (PAL, 2017). Moreover, they ‘exclude that there is others. However, we are not in that situation (yet). a morally relevant cooperation between those who use In the same way, when we have ample availability of these vaccines today and the practice of voluntary abor- different vaccines, then the reasons for offering the tion’ and they clarify that ‘all clinically recommended choice of which vaccine on the basis of personal moral vaccinations can be used with a clear conscience and beliefs will be very strong (with an open question as to that the use of such vaccines does not signify some sort whether people choosing more expensive vaccines for of cooperation with voluntary abortion’ (PAL, 2017). reasons of conscience should be required to pay (part Now this is not the only pronouncement by the of) the additional cost—a question we are happy to leave Academy. It is an addendum to a longer original pro- open). However, again, we are far from that situation in nouncement. In the original document, the Academy most countries. did express a concern about cooperation in wrongdoing of people producing the vaccines, distributing them, Individual Morality and the using them, and also promoting their use (as in the case of many states imposing mandatory vaccinations). Irrationality of Objection They had originally asserted that all these parties are Finally, it is interesting to explore on what grounds complicit in wrongdoing, although to different degrees Catholics or other religious people object to vaccines and in different ways. The degree of cooperation in 252 GIUBILINI et al. wrongdoing of those using vaccines linked to abortion freedom is a solid ground for requests of vaccine exemp- was judged to be very low, yet it required abstaining from tions at least by Roman Catholics. Even assuming that the use of such vaccines unless they were necessary in religious freedom should be given significant moral order to protect the health of children and, indirectly, of weight in the formulation of vaccination policies, the the whole population. principle does not seem to warrant a right at least for According to the same original document, people Catholics to be exempted from vaccination require- using these vaccines were involved in a form of ‘very ments on the basis of their religion. remote mediate [i.e. indirect] material cooperation, What this demonstrates is that religious interpret- and thus very mild, in the performance of the original ation is flexible. Catholicism is only one denomination act of abortion’ (PAL, 2006). The remoteness of cooper- of Christianity. But what it shows is that religious leaders ation in the Catholic doctrine can refer to either or both a can reinterpret their prohibitions. We call on them to temporal and a physical relation to the abortion. In this put life first, as many already proclaim to do. case, for instance, remoteness consists in the fact that the abortions were performed about fifty years ago. Material Conclusion cooperation denotes that an individual does not share and does not approve of the decision to perform the Even if one accepted the premise that abortion is uneth- abortion, hence is not as complicit as someone who ical and/or that using aborted foetuses to derive cell lines would encourage or approve of such act. The document for research purposes is unethical, using those cell lines also notes that this form of cooperation is passive. To say now for research purposes is not unethical and it is ac- that the cooperation is passive, rather than active, indi- tually ethically required. cates that the person using the vaccine only has a duty to Even assuming current research to develop a COVID- denounce the fact that the vaccine was linked to an im- 19 vaccine using cell lines from aborted foetuses is un- moral act such as an abortion. Had they been actively ethical, it is not unethical to benefit from such research complicit, they would have been in the position of doing by using this vaccine. Using the vaccine would not only something to prevent the abortion from happening. protect those who are vaccinated but also protect other In sum, the original document explained that the co- people around them and contribute to the public good of operation in wrongdoing of people using such vaccines herd immunity and disease eradication, which will pre- was remote and not as morally problematic as that of vent a significant number of deaths. people performing the abortion, or using the foetal cells It is important to stress that making vaccination man- for research. Yet, the document stated that, generally, datory does not imply that people would be forced to be one should refuse to be complicit to even such a remote vaccinated. Coercion can come in the form of withhold- degree, and therefore refuse to get vaccinated. Moreover, ing of benefits, fines or restriction of school entry. The the document continued, they had a moral duty to ask costs of mandatory vaccination must be proportionate for alternative vaccines developed without the use of (Savulescu, 2021), but there should not be religious aborted foetal tissues. exceptions to incurring these costs. However, even in that older original document the Finally, general religious prohibitions are sometimes Pontifical Academy for Life allowed for exceptions to applied flexibly in specific cases, and COVID-19 vaccine the general prohibition. Passive indirect material co- research policy is one of those cases, given the large bene- operation does not require one not to cooperate when fit that such vaccine can produce—we call on religious there are good reasons to do so. According to the same leaders to fully support and use the most effective, safe document, ‘it is right to abstain from using these vac- vaccine in COVID-19, and to support the most rapid cines if it can be done without causing children, and means of developing it. indirectly the population as a whole, to undergo signifi- We should prioritize lives, fairness and responsibility cant risks to their health. However, if the latter are over religious freedom. Delaying such research and vac- exposed to considerable dangers to their health, vaccines cine uptake in the name of religious freedom is unethical with moral problems pertaining to them may also be because it risks causing more unnecessary deaths, and it used on a temporary basis. The moral reason is that the duty to avoid passive material cooperation is not is irresponsible because it stands in the way of fulfilling individual and collective responsibilities in containing obligatory if there is grave inconvenience’ (PAL, 2006). 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The ‘Ethical’ COVID-19 Vaccine is the One that Preserves Lives: Religious and Moral Beliefs on the COVID-19 Vaccine

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PUBLIC HEALTH ETHICS VOLUME 14 ISSUE 3 2021 242–255 242 • • • The ‘Ethical’ COVID-19 Vaccine is the One that Preserves Lives: Religious and Moral Beliefs on the COVID-19 Vaccine Alberto Giubilini *, Oxford Uehiro Centre for Practical Ethics, University of Oxford Francesca Minerva, Department of Philosophy, University of Milan Udo Schuklenk, Queen’s University Julian Savulescu, Oxford Uehiro Centre for Practical Ethics, University of Oxford; Visiting Professorial Fellow in Biomedical Ethics, Murdoch Childrens Research Institute; Distinguished Visiting International Professorship in Law, University of Melbourne *Corresponding author: Alberto Giubilini, Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK. Email: alberto.giubilini@philosophy.ox.ac.uk Although the COVID-19 pandemic is a serious public health and economic emergency, and although effective vaccines are the best weapon we have against it, there are groups and individuals who oppose certain kinds of vaccines because of personal moral or religious reasons. The most widely discussed case has been that of certain religious groups that oppose research on COVID-19 vaccines that use cell lines linked to abortions and that object to receiving those vaccine because of their moral opposition to abortion. However, moral opposition to COVID-19 vaccine research can be based on other considerations, both secular and religious. We argue that religious or personal moral objections to vaccine research are unethical and irresponsible, and in an important sense often irrational. They are unethical because of the risk of causing serious harm to other people for no valid reason; irresponsible because they run counter to individual and collective responsibilities to contribute to important public health goals; and in the case of certain kinds of religious opposition, they might be irrational because they are internally inconsistent. All in all, our argument translates into the rather uncontroversial claim that we should prioritize people’s lives over religious freedom in vaccine research and vaccination roll out. October 2020, COVID-19 has reportedly killed directly Introduction over 1 million people all over the world in slightly less The COVID-19 pandemic should not have been an un- than a year (Musil, 2020). To prevent or contain such outbreaks today, it is ne- expected event, since pandemics or large epidemics peri- odically occurred throughout human history (Garrett, cessary to not only develop safe and effective vaccines but to also do it as quickly as possible and to make them 1994). Indeed, new pandemics are likely to occur again and to be more virulent than this one. The ‘Spanish Flu’ accessible to as many people as possible. This requires pursuing more lines of research at the same time, given pandemic in 1918 killed at least 50 million people and infected 500 million people worldwide. The ‘Black that inevitably many of them will be unsuccessful or would require longer than others to be completed. It is Death’ plague ‘devastated the Western world from 1347 to 1351, killing 25–50% of Europe’s population also important to have different types of vaccines in order to maximize the chances of conferring protection and causing or accelerating marked political, economic, social and cultural changes’ (Gottfried, 1983) Around 75 against new variants of the virus and of conferring ad- equate protection to different population groups. The million people perished at the time (Sandle, 2013). By doi:10.1093/phe/phab018 Advance Access publication on 19 July 2021 V C The Author(s) 2021. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. THE ETHICAL VACCINE 243 longer we go without adequate vaccine supply, the more Canada and Australia. They have condemned research people will die of COVID-19 (or other viruses that might on the COVID-19 vaccine that uses cell lines obtained appear in the future) or of the consequences of pandemic from tissues harvested from aborted foetuses. management measures [such as declaring cancer care (Henceforth, we will refer to such vaccines as ‘vaccines non-urgent, resulting in a spike of people presenting at linked to abortion’.) hospitals with advanced cancer (Ogilvie, 2020)]. Why are human foetal cell lines being used in re- However, the urgency of developing vaccines does not search? One major approach to developing a new vaccine mean that research, development, distribution and vac- for corona virus is to use viral vectors, such as adeno- cination policies may bypass ethical and scientific stand- virus. Johnson and Johnson in the USA and the ards (London and Kimmelman, 2020). ‘As quickly as University of Oxford (partnered with the pharmaceut- possible’ means as quickly as reasonable ethical and sci- ical company AstraZeneca) have used adenovirus entific standards allow. approaches. These require the use of cell lines such as What constitutes an ethical vaccine research and pol- the HEK (human embryonic kidney) 293 cell-line, which icy has recently been the subject of some controversy is derived from tissues of a foetus aborted in 1972 involving religious authorities and scholars defending (Wadman, 2020b). religious freedom, particularly those from the HEK293 cell lines enable the deletion of genes so that Christian tradition. Religious objections are not the the adenovirus vector does not replicate in the vaccinee’s only type of moral objections to certain vaccines. The cells (He et al., 1998; Thomas and Smart, 2005). Thus, arguments we are going to provide in this paper apply to the virus contains the gene which stimulates production a number of religious and non-religious positions on of COVID-19 proteins, which elicit immunity, without vaccine research alike. Actually, as we shall see, the fact overwhelming cells with the virus, which can happen that there are many possible kinds of moral objections to with natural infection. In other words, HEK293 cell lines certain kinds of vaccine research is itself a further reason make vaccine development efficient, because they con- in support of our line of argument, as it makes respect for tain the genetic material necessary to produce the desired freedom of conscience with regard to vaccine choice even more difficult to justify. However, we are going to adenoviruses and that cannot be obtained through ani- focus primarily on religious objections to vaccine re- mal cell lines, and safe, because the resulting adenovirus search that uses foetal cell lines because it has been would not contain the genes that would replicate the more prominent in the debate and because it could po- virus and infect the cells of the vaccinees. tentially influence the vaccination choice of a very large The Pfizer/BioNTech vaccine does not use foetal cell number of people. lines in the development of the vaccine, although it did Ethical considerations, when sound, can legitimately use it to test the vaccine. For those who object to research slow down vaccine development and uptake. Because linked to abortion, it might not be ‘ethically uncontro- slowing down vaccine development and uptake likely versial’, as some have called it (e.g. Sherley and Prentice, results in avoidable deaths, it is important to assess 2020), but to many, it is less controversial than, for ex- whether these ethical considerations are legitimate and ample, the Oxford/AstraZeneca vaccine. It might be what ethical weight they should be given, if any. At the objected that this makes it unnecessary to use vaccines moment, it is difficult to estimate or predict how many using an adenovirus. But this would be a mistake. We people have refused or will refuse a certain vaccine be- need as many different vaccines as possible. Besides, cause of these kinds of personal ethical concerns. The there are serious drawbacks with an mRNA vaccine. It rate may be very different in different countries or cul- must be stored at70 C(94 F) and it can’t be removed tural contexts. But the number is potentially very high at from the fridge more than four times. This severely least in certain contexts, given the number of ethical limits its distribution, especially considering that it issues that vaccine development raises and the number must be administered in two doses. Many countries of followers of certain religions. have already invested and signed agreements for the pro- In particular, two types of concerns have been raised: duction of adenovirus vaccines. For quite some time, about vaccine research itself and about future vaccin- there will be vaccine shortages and because in a pandem- ation policies. ic time is lives, changing vaccine may cost significant With regard to the first, a lot of publicity, including by numbers of lives. The more vaccines are approved, the highly respected scientific journals (Wadman, 2020a), more availability we will have in the shorter term, and has been given to views expressed by some Catholic, Anglican and Greek Orthodox authorities in the USA, the more lives will be preserved. 244 GIUBILINI et al. So how should we evaluate ethical opposition to the vaccines are not available, ‘(e.g. in countries where vac- cines without ethical problems are not made available to use of vaccines which use aborted foetal material in their production? physicians and patients, or where their distribution is The Congregation for the Doctrine of Faith, which is more difficult due to special storage and transport con- taken by the Roman Catholic Church as source of au- ditions, or when various types of vaccines are distributed thoritative teaching, has stated that use of already exist- in the same country but health authorities do not allow ing COVID-19 vaccines derived from tissues harvested citizens to choose the vaccine with which to be inocu- from foetuses after elective abortions can be morally per- lated)’ (Congregation for the Doctrine of Faith, 2020). Besides, freedom of conscience and religious freedom missible (Congregation for the Doctrine of Faith, 2020). However, this consideration is not taken to apply to are not conditional upon adherence to some official doc- trine. Part of the notion of religious freedom is the free- novel research on vaccines. In a letter addressed to the US Food and Drug Administration, and signed by a dom to choose which religious authorities to follow and number of American Bishops, Archbishops, the the dictates of one’s own conscience (thus, for instance, a President of the Catholic Medical Association and a Catholic in Australia might want to follow the recom- group representing socially conservative paediatricians, mendation of the local Archbishop rather than of the Roman authority). the signatories. The issue of conscientious objection to vaccination— ‘strongly urge [the] federal government to ensure that is, the refusal to comply with certain vaccination that fundamental moral principles are followed in requirements because of personal moral or religious the development of such vaccines, most import- views (as opposed to refusal motivated by concerns antly, the principle that human life is sacred and should never be exploited, [and] urgently and re- around safety or effectiveness of vaccines)—has been spectfully implore [the US Government] to not discussed in recent years (e.g. Clarke et al., 2017; only ensure that Americans will have access to a Giubilini et al., 2017; Navin and Largent, 2017; COVID vaccine that is free of ethical concerns, Giubilini, 2019). Some of those who have previously but to encourage and incentivize pharmaceutical defended such a right in the name of religious freedom companies to use only ethical cell lines or proc- or freedom of conscience (e.g. Navin and Largent, 2017) esses for producing vaccines’. have endorsed the stance of these religious leaders with A second concern is that governments should ensure regard to the future COVID-19 vaccine (Navin and that people are left with alternatives to what they con- Redinger, 2020). The general principle regulating con- sider an unethical vaccine. If the state cannot or does not scientious objection to vaccination, according to Mark want to guarantee that an alternative vaccine is available Navin and Mark Largent, is taken to be the following: by allocating research funding accordingly, then, they ‘it is morally justifiable to offer exemptions to argue, a moral conflict can arise between the duty to people who object to general laws for reasons of get vaccinated and the duty not to use unethical vaccines. religious conviction, secular conscience or per- For instance, according to the Catholic Archbishop of sonal integrity. In particular, there are good rea- Sydney Anthony Fisher, ‘those who are troubled by [the sons to exempt people from general laws when COVID-19 vaccine] will either have to acquiesce to the objectors have reasons to object, when imposing the law on objectors would subject them to social pressure to use the vaccine on themselves and their unique burdens and when exemptions policies dependents, or conscientiously object to it’. do not impose costs on third parties’ (Navin It is worth stressing that the Congregation for the and Largent, 2017). Doctrine of Faith has issued a specific document stating the moral permissibility for Catholics to use COVID-19 Along the same lines, Navin and Redinger have re- vaccines linked to abortion in the current situation. cently argued that ‘[i]f the only available COVID-19 vac- According to the note, ‘all vaccinations recognized as cine were one connected to abortion, then COVID-19 clinically safe and effective can be used in good con- vaccine mandates would significantly constrain the reli- science with the certain knowledge that the use of such gious liberty of people who object to vaccines for reli- vaccines does not constitute formal cooperation with the gious reasons’—which would also violate a legal abortion from which the cells used in production of the requirement (in the USA) to ‘use the least restrictive vaccines derive’ (Congregation for the Doctrine of Faith, means to promote compelling government interests 2020). whenever the state’s activity impedes religious liberty’ However, the Congregation is also very clear that this (Navin and Redinger, 2020). Similar legal constraints consideration only applies if alternative, more ethical are in place in other countries, such as Canada. Thus, THE ETHICAL VACCINE 245 according to Navin and Redinger, mandating a vaccine We will first address the issues around research ethics. without conscience exemptions, when it is possible to We will argue that even accepting (for the sake of argu- fund an alternative vaccine that would not compromise ment) the premise that abortion is impermissible, it is religious liberty, might be illegal in the USA. As we shall not morally impermissible to conduct research on vac- see, if funding alternative vaccines means diverting cines linked to abortion. Indeed, we will argue that such resources from more promising lines of research, thus research is a moral imperative if there is a realistic pro- delaying vaccine development, then funding an alterna- spect of it resulting in more safe and effective vaccines tive vaccine is not the least restrictive means to promote more quickly than with alternative lines of research. government interests. A government’s primary interest We will then move on to discuss vaccination policies. is to have an effective vaccine as soon as possible (and as We will argue that if at some point vaccination mandates reasonable ethical and scientific standards allow). (for instance in the form of vaccine or immunity pass- The reasons offered by Navin and Redinger, and ports) turn out to be ethically justified and necessary to hinted at in the letters mentioned above, are not only achieve adequate vaccination coverage, there is no eth- ethical or legal in nature. There are also practical reasons: ical justification for conscience or religious exemptions a COVID-19 vaccine linked to abortion might increase to vaccination mandates. Contrary to what defenders of the rate of vaccine refusal. All in all, both ethical and conscience exemptions imply, it is likely that exemption pragmatic considerations translate into two claims. policies will impose costs on innocent third parties. First, that we should not prioritize COVID-19 vaccine There are also other ethical requirements that need to research linked to abortion. Second, that, if we do it and be fulfilled apart from not imposing costs or harms to the first approved vaccine will be one linked to abortion, others—most notably fairness in vaccination policies. people with moral or religious opposition to it should be Finally, we will briefly analyse claims about individual permitted to opt out in the name of freedom of religion morality: we will argue that it can be morally permis- and/or freedom of conscience. sible—even for people who consider abortion immoral It is important to point out that none of these religious or a ‘grave moral sin’—to use vaccines linked to abor- authorities is against the ethical obligation to get vacci- tions. Establishing this point as a matter of individual nated per se. All of them emphasize how important vac- morality is important for two reasons. First, it could cines are for the protection of the public good and the convince some to avoid claiming conscience exemp- most vulnerable members of society—which is why tions. Second, one condition set out by Navin and some think the Catholic social teaching implies a moral Largent for the justification of conscience exemptions duty to vaccinate (Carson and Flood, 2017). The em- is, as per quote above, that ‘objectors have reasons to phasis is rather on the request to divert resources into object’ (which we take to mean that they have reasons funding research on vaccines not linked to abortion, and that meet some minimum threshold of validity, includ- when this is not done, on leaving people free to follow ing that they are consistent with one’s own ethical prin- their conscience: vaccines in themselves are a good thing, ciples). If it turns out that objectors do not have such but a moral agent’s opposition to abortion weighs more reasons, then their argument for conscience exemptions heavily, they claim. does not apply. In this article, we argue that respect for religious views These considerations apply to the vaccines currently and freedom should not hinder vaccine development approved and to the vaccines that will be researched and and uptake—including the implementation of effective may be approved in the future as well. vaccination policies in a pandemic. This means that re- search on vaccines linked to abortion should be priori- tized if and when that maximizes the chances of having a Research Ethics: Prioritizing new vaccine sooner rather than later, which at the time of Religious Freedom over Potentially writing is the case with COVID-19 vaccine research. It also means that if mandatory vaccination will turn out to Life-Saving Research is Unethical be necessary and ethically justified (an issue we are not Some people believe that abortion is wrong and that it is going to take a stance on here), cost-free exemptions based on personal moral or religious views should not wrong to benefit from a serious wrongdoing like abor- tion. Is this a good enough reason to deprioritize re- be granted. We agree that more religiously acceptable alternatives should be pursued, other things being equal. search linked to practices perceived to be unethical in However, they should not be pursued at the cost of this way? human lives. The proposition here can be read in two ways. 246 GIUBILINI et al. First, given a fixed research budget, at least some of the and development and so to prevent avoidable deaths. funds should be directed towards what people opposed Given the gravity of the current situation, and the fact to abortion take to be ethical research. But this would de that large numbers of lives are at stake, this is equivalent facto mean reducing funding for research linked to to slowing down such research by diverting currently abortion. If research linked to abortion is very promis- allocated research budget to less promising lines of ing—for example, there are vaccine candidates linked to research. abortion at an already advanced stage of study—this In secular societies, what makes research ethical or strategy would seriously risk delaying the moment unethical should be established on grounds of public when we have an effective vaccine, thus ultimately result- reason, that is, on principles that can be justified without ing in more avoidable deaths. It is worth keeping in mind appealing to particular sectarian religious views—al- that even if alternative vaccines are being developed and though one has good reasons to try to satisfy the prefer- are very promising, we would still need more vaccines in ences of everyone, including those with religious beliefs, the pipeline in order to guarantee enough supply at least when it comes at little or no significant cost. Ethical in the short term. The criterion for allocating research principles regulating medical research—especially re- funding to different lines of research should be how like- search benefitting the whole population—cannot be ly they are to be successful, not whether they are or are merely religious in nature. Ethics typically sets bounda- not linked to abortion. The choice to use human foetal ries to what researchers can permissibly do, which often cell lines for vaccine research is explained by the fact that justifiably slows down research. Unethical research such research represents a distinct and promising avenue would often mean quicker research. Since, under current to quickly deliver the required vaccine safely. circumstances, time means life, it is important that the In addition to the considerations above, non-human ethical reasons for such boundaries be reasons that peo- cells are more likely to carry bacteria or viruses that could ple with diverse religious views and people with no reli- contaminate the resulting vaccine. For example, some gion alike can share—given that their lives and their polio vaccines developed in the 20th Century using cell health are at stake, too. In other words, they need to be lines derived from monkeys were found to contain a based on public reason, which ‘requires that our moral monkey virus that only by luck did turn out to be not or political principles be justifiable to, or reasonably ac- harmful for humans (CPP (College of Physicians of ceptable to, all those persons to whom the principles are Philadelphia) 2018). For all these reasons, it is not un- meant to apply’ (Quong, 2017). common for vaccine research and manufacturing to be As for non-religious arguments for the moral imper- linked to human foetal cell lines. Current vaccines missibility of abortion (e.g. those based on the potential against rubella, chickenpox, hepatitis A and shingles of a foetus to become a person, or on the future a foetus is were developed using cell-lines obtained from aborted being deprived of), these are the subject of reasonable foetuses. A non-human cell line might not produce safe disagreement. In any case, current codes of ethics, both and effective vaccines immediately, though it could do with regard to research and to clinical practice, do con- over the years. In the current pandemic, years is a length sider at least some instances of abortion ethically per- of time we cannot afford if we want to preserve human missible (e.g. AMA, 2016), and they allow for data or lives. Thus, funding alternative research just because it is tissues resulting from abortion to be used for research not linked to abortion risks diverting resources into re- purposes with the of the woman who had the abortion search that is less likely to be effective in the short term, (AMA, 2016, Opinion 7.3.4)). Moral uncertainty and and that would very likely cost lives. moral disagreement about abortion do not make re- Second, the request might be taken to mean that more search linked to abortion unethical by current research funds should be put into vaccine research and develop- ethics standards. ment, and this additional funding should be reserved for There are other possible ethical objections to using research that is not linked to abortions. Of course, it is foetal cell lines in vaccine research. Although we do desirable to fund different streams of research in order to not have precise information about the foetus from maximize the chances that at least some of those will which the tissues were harvested, it seems that the foetus, deliver a vaccine soon. But the criterion for increasing aborted in 1972 in the Netherlands, was ‘of unknown and allocating research funding should be the maximiza- family history’ (US FDA (Food and Drug tion of the chances of having the safest and most effective vaccine sooner rather than later. Increasing research Administration) 2001). It was not too uncommon at funding in order to satisfy some other criterion would that time to use foetal material from abortion without be a missed opportunity to accelerate vaccine research the consent of the woman (Wadman, 2018). THE ETHICAL VACCINE 247 So, opponents might claim, this research is doubly ‘[i[n the rare instances when ethically tainted data have been validated by rigorous scientific analysis, wrong: women did not consent and it uses tissue are the only data of such nature available, and obtained by immoral killing of the foetus. Even if the human lives would certainly be lost without the latter aspect might be the subject of reasonable disagree- knowledge obtained from the data, it may be per- ment, there likely is more widespread agreement on the missible to use or publish findings from unethical wrongness of the former—or at least the wrongness of experiments. Physicians who engage with data the former can more easily be established on the basis of from unethical experiments as authors, peer reviewers, or editors of medical publications public reason. should: However, even though by today’s standards that foetal tissue procurement was unethical, it remains to be estab- 1. Disclose that the data derive from studies that do not lished whether the causal connection with previous un- meet contemporary standards for the ethical conduct ethical practices makes current research unethical. of research. According to current standards and codes of research 2. Clearly describe and acknowledge the unethical na- ethics, such causal link does not suffice to make current ture of the experiment(s) from which the data are research unethical. derived. Where the benefits of current research are sufficiently 3. Provide ethically compelling reasons for which the valuable, benefitting from unethical past research is eth- data are being released or cited, such as the need to ically acceptable—and we would argue, ethically save human lives when no other relevant data are required. Let’s grant for the sake of argument that abor- available. tion is morally wrong and/or that deriving cell lines from 4. Pay respect to those who were the victims of the un- aborted foetuses for research purposes was unethical, for ethical experimentation’ example because women did not give valid consent. Now let’s compare this with infamous Nazi experiments Baruch Cohen (1990) has noted that one way to de- unanimously considered immoral. In the ‘immersion fend the use of such data would be to see the use as a way hypothermia project’, for instance, Nazi scientists of honouring the victims of such research. Their—invol- immersed non-consenting concentration camp prison- untary—sacrifices could at least be seen to contribute to ers in tanks of icy water until they died. These experi- the good of humanity. ments were grotesquely unethical. The purpose was to Understandably, this is not an interpretation that was research the most effective treatment for German victims shared by every holocaust survivor. However, as Stephen of immersion hypothermia, for instance fighter pilots Post (1991) notes, some holocaust survivors held this shot down over the English Channel (Berger, 1990). view, provided there was a ‘clear and significant benefit’ Some data resulting from this research have been used to humanity. and cited in subsequent research and dozens of scientific One could argue that a similar line of reasoning could papers (Moe, 1984). be applied to foetal material derived from aborted foe- We agree that such data ought to be handled with care tuses by those who think that abortions constitute a ser- to avoid the risk of ‘being contaminated by the moral ious moral wrong. Refusing to use the results of such taint’ (Higgins et al., 2020)—for example by acknowl- research could well be seen as showing disrespect to edging the harm caused to the victims of such experi- the aborted foetuses whose genetic material was used ments whenever unethical research is cited (Moe, 1984, to undertake research the results of which are offering Higgins et al., 2020). However, current research guide- a clear and significant benefit to humanity. lines do permit the use of such data for research pur- Because time means life, if research on COVID-19 poses, including their reference in scientific papers, if would be slowed down by the requirement not to be significant benefit can result from such research; if the linked to abortion, there are indeed ethically compelling unethical nature of the original research is properly reasons for conducting such research even assuming that acknowledged; and if compelling ethical reasons can be obtaining the cell lines in the first place was unethical. provided for its use. For example, Opinion 7.2.2. of the The burden of providing an argument to the contrary is Code of Ethics of the American Medical Association on those who claim that current research ‘tainted’ by that (AMA, 2016) states, with regard to past unethical experi- causal link is unethical. ments such as Nazi experiments during World War II or As a way of analogy, consider the case of research the US Public Health Service Tuskegee Syphilis Study, involving the destruction of human embryos for the pur- that pose of embryonic stem cell procurement. After the 248 GIUBILINI et al. discovery that induced pluripotent stem cells could be groups, level of protection conferred, vaccine availabil- derived from human skin, there was some call for the ity) which are unknown at the moment. However, if it abolition of research involving human embryonic stem turns out that mandatory vaccination will at some point cells. However, although pluripotent stem cells derived be necessary or ethically justified, then there should be from adult cells have great potential, it is uncertain no conscience exemptions to mandates, whether for whether they can actually replace embryonic stem cells moral or religious reasons. Indeed, an ethical assessment for all research and therapeutic purposes. If there is at of (i) whether future COVID-19 vaccination policies least some reasonable chance of benefit in the continu- should be mandatory and (ii) for whom they should be ation of research using embryonic stem cells, then this mandatory should not be based on some people’s moral research ought to continue: there are no ethical reasons or religious opposition to the vaccine or on a principle of against it that can be established on the basis of public freedom of conscience and of religion. reason, and lives could be saved thanks to such research. Before we argue why there should no exemption for Research that is not unethical on the basis of careful, conscientious objection, we should clarify what we mean rational assessment on secular grounds should only be by ‘no exemption’. What we mean is no exemption to the stopped or prevented because of certain people’s or cost imposed for not being vaccinated. We do not mean groups’ moral opposition if it is futile, that is, if there that people must be forcibly vaccinated. Mandatory vac- is no actual benefit that can plausibly be derived from it cination already exists with costs including fines (Italy), and that would outweigh people’s opposition to it. But, refusal of admission to school (USA), withdrawal of under the current circumstances, neither embryo re- childcare benefits or child care (Australia). What we search nor COVID-19 vaccine research linked to abor- mean is that if you object, for whatever reason, you tion are futile. should pay the relevant cost, e.g. fine, withdrawal of After all, chasing a regenerative medical cure or a vac- childcare benefit, etc. What constitutes an appropriate cine for COVID-19 is like a horse race. We should let all form of coercion (or cost) is a separate issue and it horses run because we should not scratch a potential should be proportionate (Savulescu, 2020). winner. Because time is lives, all plausible candidates Why should we not exempt conscientious objectors to must be tested on the basis of their chances to deliver vaccination? The comparison we made above with em- the desired outcome sooner rather than later, unless bryonic stem cell research is once again useful. there are convergent ethical reasons to eliminate a can- Vaccination is different from regenerative medicine didate (Devolder and Savulescu, 2006). based on embryonic stem cells in an important respect. In the case of regenerative medicine, a patient refusing to use treatments based on embryonic stem cell research Vaccination Policy: Prioritizing does not harm anyone else directly and, more generally, there is no significant public good at stake. In a public Religious Freedom over Public health system, there might be a case for requiring an Health is Unethical individual to cover the costs for the healthcare system of them refusing a more effective treatment (Savulescu, Another claim being made in the name of religious free- 1998), but there is no compelling reason for overriding dom and freedom of conscience is that, if COVID-19 vaccination policies are mandatory, there should be con- their autonomous decision about refusing certain treat- science exemptions for those who object to the vaccine ments on personal moral grounds. However, in the case of vaccination, refusal to vaccinate both risks one’s own because of its connection to abortion. Now, whether COVID-19 vaccination should be health and the health of others directly, and it represents made mandatory, and in that case for which people or a failure to contribute to an important public good (herd immunity against serious infectious diseases). Because groups, is an issue that would require a separate discus- sion. We want future COVID-19 vaccination policies to each person is potentially a lethal threat to others, there is be maximally effective at preventing the largest numbers a requirement to ‘lay down your guns’ and reduce your of lives lost prematurely and to strike the right balance threat to others (Flanigan, 2014). There is no valid reli- gious duty or right to harm or to pose a serious risk of between pursuing the collective interest and minimizing the risks for individuals, while exerting the lowest degree harm to innocent other people. Just as terrorists should of coercion possible. Whether this will require manda- not kill innocent people in the name of God, conscien- tory vaccination will depend on a number of factors tious objectors should not pass on lethal viruses that (safety profile of the vaccine, effectiveness in different could kill vulnerable people in the name of God. THE ETHICAL VACCINE 249 Because the reasons not to allow conscientious When we talk about harm prevention through vaccin- exemptions to vaccination are based on considerations ation, we are talking about responsibility that is not only of harm prevention (both directly, by not exposing individual, but also collective. Protecting people from others to the virus, and indirectly, by contributing to infectious diseases requires collective effort—for in- herd immunity), the only valid alternative to vaccination stance, realizing herd immunity requires a large portion would be extreme self-isolation. In this way, one would of the population to be vaccinated. The harm or risk of literally present no threat to others and would contribute harm imposed on vulnerable people by absence of herd to the collective effort of eradicating or containing the immunity—when herd immunity could be achieved disease. However, religious leaders, and more generally through vaccination—is collectively produced. those who claim a right to conscientious objection in the Now, collective responsibility is a complex notion, context of healthcare and public health, expect exemp- both conceptually (Giubilini and Levy, 2018) and ethic- tions to be cost-free, for example by claiming that objec- ally. One ethical problem is that often individual contri- tors should continue to receive state benefits and welfare. butions to the fulfilment of collective responsibilities For example, Australian Catholic Archbishop Antony and prevention of collective harm ‘does not make a dif- Fisher complained that ‘if the COVID-19 vaccine is ference’. Derek Parfit used now famous thought experi- linked to “no jab, no pay” rules, Catholic families could ments to illustrate the problem. In one of these, for lose access to family payments if they refuse to vaccinate instance, a large number of people could contribute a their children’. pint of water to a collective cart that can be brought to It is also important to recognize that rigorous self- the desert, where the water can be distributed among an isolation may reduce the direct threat to others, but it equally large number of thirsty people. In the ‘harmless cannot contribute to herd immunity or to mitigating the torturer’ case, a large number of people give each a very wider harms of pandemic measures such as lockdowns. mild electric shock to a person; the shock from each Indeed, by delaying herd immunity, it increases the like- individual torturer is negligible, but collectively the lihood of such harms occurring. shocks cause severe pain to the victim (Parfit, 1984). In Conscientious objectors could say that there is an ob- both cases, Parfit claims that individuals do have a moral vious difference between conscientious objection to vac- obligation to contribute to harm prevention (either cination and terrorism: terrorists will almost certainly through action or inaction, respectively), even if the re- kill innocent people; objectors are only imposing a sponsibility to prevent harm or to help out is collective very small risk of death on any individual. In a way, and each individual would not ‘make a difference’. the argument goes, we impose small risks on others every Some of us have translated this principle into a prin- time we sneeze or drive a car, and failure to be vaccinated ciple of collective easy rescue in the case of vaccination, is not much worse than these behaviours. which grounds both a collective responsibility to realize However, this response fails. herd immunity when the cost required to individuals is First, the risk posed by those who object to vaccination small, and an individual responsibility to contribute to is not just that of infecting some other individual. Such that good by appealing to fairness in the distribution of infected individuals could go on and infect others (espe- the burdens (Giubilini et al., 2018, 2020). Thus, those cially with diseases like COVID-19, where infected peo- who request not to be vaccinated on the basis of personal ple are often asymptomatic and therefore not aware of moral or religious reasons are in fact requesting to be being spreaders). The risk is therefore not as small as it exempted from making their fair contribution to collect- might initially seem. ive harm prevention, and ultimately to an important Second, we do take reasonable measures—that is, global public good from which they will themselves measures that are not too costly for an individual—to benefit significantly. Controlling the spread of minimize risks on others posed by the aforementioned COVID-19 through a vaccine would protect everyone behaviours. We do have speed limits and other road not only against the risks of COVID-19, but also against rules, and the social norm of covering our mouth with the economic damage, education costs, and risks for our elbow when sneezing is now quite widespread. physical and mental health that pandemic management During this pandemic, we are often required to use measures are creating. If we allow a principle of freedom face covering. Assuming vaccines are safe for any tar- of conscience to outweigh fairness in this context, we geted group or group for which they are approved, vac- cination is just a similarly reasonable and low-cost undermine one of the core principles regulating collect- preventive measure. And we do impose costs when those ive efforts and public goods in liberal societies. We rules are broken, such as speeding fines. should prioritize fairness over religious freedom, given 250 GIUBILINI et al. that fairness has very significant intrinsic and instru- others. However, the problem is that not everyone can mental value. mount an effective immune response, not everyone can That fairness has intrinsic value is a point that would be vaccinated because of medical reasons, and immunity need a philosophical discussion to be established. For the often wanes over time. If mandatory vaccination were purpose of the this article, suffice it to say that the point is warranted, it is an open question whether herd immun- suggested by the prominence fairness is given in many ity could be achieved if personal or religious exemptions other public policies. Taxation policies are an obvious were allowed. example: we want taxation policies to be not only effect- Some have argued that there is no point in imposing ive at generating enough revenue to provide important the costs or risks of vaccination on few people who goods, but also to be fair. In principle, we can achieve the would want to refuse the vaccine, when we can be con- former without the latter. And yet, we want taxation fident that there is enough protection at the collective policies to be effective and fair. level. In that case, freeriding would not be a problem But the value of fairness is not only intrinsic. It is also (Dawson, 2007). However, even accepting this point, instrumental: we value fairness because fair policies are we should not forget that religious or moral opposition more likely to be successful by motivating people to to abortion is only one among the many possible and at comply. In other words, fairness would address the so- least equally (un)reasonable moral beliefs one can appeal called ‘problem of assurance’: people are more moti- to in order to refuse vaccination: people might be vated to contribute to public goods if they have enough opposed to the use of animals or animal products in reassurance that others would do the same . In the case of research, might be committed to natural lifestyles, might vaccination, fairness requires equal distribution of the refuse what they perceive to be authoritarian invasions of burdens involved in the realization of herd immunity. It their bodily integrity, might be opposed to the capitalist is not unfair to exempt people from requirements if these system behind for-profit pharmaceutical companies, are too burdensome or risky on objective grounds—that and so on. All of these beliefs, and many others, could is, grounds that can be assessed and reasonably estab- be considered a matter of conscience in the same way as lished through public reason. If someone is at serious religious opposition to abortion. risk of significant side effects from vaccination (say, be- Moreover, herd immunity is a very unstable condition cause of allergies), it is not unfair to exempt this person and vaccination coverage is subject to constant change. from vaccination requirements, because the sacrifice Any measure that makes it more likely that vaccination required of them to contribute to the public good would uptake will drop creates risks for vulnerable members of be too large. the community—when vaccination uptake drops below Such risks can be assessed through public reason and herd immunity, it is too late and these people are already on objective grounds (for instance, medical grounds). exposed to risks. We should prevent rather than remedy But claiming that personal moral or religious beliefs rep- such situations. It is not acceptable to put people’s health resent equally strong reasons for exemptions implies and lives at significant risk because of convictions that assuming a relativistic perspective, where religious views cannot be defended by appeal to public reason. about abortion or complicity are as worthy of protection A compromise that some of us have proposed is that as harm prevention, fairness or the public good. Public of requiring those who request non-medical exemptions policies in liberal democratic societies cannot be based to provide alternative services that are roughly as bur- on such ethical relativism (Blackford and Schuklenk, densome and as valuable to society as the contribution 2021). Preserving the public good, obligations towards they request the exemption from Giubilini et al. (2017). other people (and most notably the obligation not to This would offer more reassurance that their request is pose other people at easily preventable risk of harm), sincere and not motivated by the intention to freeride. fairness requirements are all considerations that take pri- However, it is often difficult to establish what could ority over freedom of conscience when it comes to pro- make up for failure to vaccinate against infectious dis- tecting people’s lives. Allowing conscience objectors to eases. In this specific circumstance, where a pandemic is free-ride on others’ contributions to important public killing hundreds of thousands of people and paralyzing goods in the name of freedom of conscience would re- the world’s economy, it is hard to find suitable alterna- quire giving freedom of religion or of conscience a moral tive contributions—except perhaps extreme self- weight that is difficult to justify (Leiter, 2014). isolation. Defenders of religious exemptions might respond that Respect for religious freedom or freedom of con- those at risk can themselves be vaccinated, so that the science more broadly can be part of what public reason conscientious objectors would not pose any risk to requires, to the extent that it is a principle that all THE ETHICAL VACCINE 251 reasonable people—religious and non-religious alike— linked to abortion in terms of their own doctrine. So far, we have assumed that the principle at stake is one can accept. However, priorities need to be considered to determine what public reason requires in any specific of freedom to follow one’s religious views. However, religious doctrines that oppose abortion typically do context. What constitutes a reasonable compromise is not always what lies half-way between two opposite stan- not condemn tout court the use of vaccines linked to abortion. The argument from religious freedom might ces. Sometimes compromise itself is unreasonable, and the more extreme the circumstances, the more likely this in this case rest on shaky foundations. For example, the Roman Catholic social doctrine in is. In the case of public health policies in situations of general supports a moral duty to vaccinate in order to emergency like the current pandemic, protecting people contribute to social goods and to prevent harm (Carson from COVID-19 is the priority even when it comes at and Flood, 2017). Also, it supports the use of vaccines some cost in terms of liberty. After all, we have accepted linked to abortion if they are necessary to protect vul- incredibly harmful restrictions of liberty through indis- nerable individuals and there is no suitable alternative. criminate long lockdowns, quite regardless of whether As we mentioned above, also the official note of the the moral or political or religious beliefs of restricted Congregation for the Doctrine of Faith explicitly says individuals were consistent with accepting this kind of that when alternative vaccines are not available, it is confinement. Consider, for example, the situation of a morally permissible for Catholics to use COVID-19 vac- hard-core libertarian subject to lockdown restrictions. cines linked to abortion given the current grave risk the Whether lockdown has been unreasonable or effective disease poses (Congregation for the Doctrine of Faith, is up for debate, of course, but the fact that most have 2020). accepted it suggests that in emergency situations pre- That document makes explicitly reference and relies venting grave harm may legitimately take priority, and on the views on the matter previously expressed by the reasonable policies are those that prioritize preventing Pontifical Academy for Life, which was established by the grave harm (whether or not this applies to lockdown). Pope specifically to study and promote the value of Unfortunately, in conditions of scarce resources and human life consistently with the Catholic doctrine. In when we have to run against time in order to preserve lives, 2017, the Academy published a short addendum (PAL, it is reasonable to compromise a certain degree of freedom, 2017) to one of their previous documents on vaccination including freedom of conscience and religious freedom, if (PAL, 2006). In this addendum, they state that using that increases the chances of preserving more lives. vaccines linked to abortion is in certain cases not only Of course, if we had a situation of herd immunity morally permissible but also morally mandatory. As they against COVID-19 or if those refusing vaccination were put it, ‘the moral obligation to guarantee the vaccination only the ones living isolated from the rest of society (as is coverage necessary for the safety of others is no less ur- the case for example for certain ultraorthodox groups gent, especially the safety of more vulnerable subjects traditionally opposed to vaccines), then there would be such as pregnant women and those affected by immuno- strong reasons to respect their freedom of choice with deficiency who cannot be vaccinated against these dis- regard to vaccination, as their decisions would not affect eases’ (PAL, 2017). Moreover, they ‘exclude that there is others. However, we are not in that situation (yet). a morally relevant cooperation between those who use In the same way, when we have ample availability of these vaccines today and the practice of voluntary abor- different vaccines, then the reasons for offering the tion’ and they clarify that ‘all clinically recommended choice of which vaccine on the basis of personal moral vaccinations can be used with a clear conscience and beliefs will be very strong (with an open question as to that the use of such vaccines does not signify some sort whether people choosing more expensive vaccines for of cooperation with voluntary abortion’ (PAL, 2017). reasons of conscience should be required to pay (part Now this is not the only pronouncement by the of) the additional cost—a question we are happy to leave Academy. It is an addendum to a longer original pro- open). However, again, we are far from that situation in nouncement. In the original document, the Academy most countries. did express a concern about cooperation in wrongdoing of people producing the vaccines, distributing them, Individual Morality and the using them, and also promoting their use (as in the case of many states imposing mandatory vaccinations). Irrationality of Objection They had originally asserted that all these parties are Finally, it is interesting to explore on what grounds complicit in wrongdoing, although to different degrees Catholics or other religious people object to vaccines and in different ways. The degree of cooperation in 252 GIUBILINI et al. wrongdoing of those using vaccines linked to abortion freedom is a solid ground for requests of vaccine exemp- was judged to be very low, yet it required abstaining from tions at least by Roman Catholics. Even assuming that the use of such vaccines unless they were necessary in religious freedom should be given significant moral order to protect the health of children and, indirectly, of weight in the formulation of vaccination policies, the the whole population. principle does not seem to warrant a right at least for According to the same original document, people Catholics to be exempted from vaccination require- using these vaccines were involved in a form of ‘very ments on the basis of their religion. remote mediate [i.e. indirect] material cooperation, What this demonstrates is that religious interpret- and thus very mild, in the performance of the original ation is flexible. Catholicism is only one denomination act of abortion’ (PAL, 2006). The remoteness of cooper- of Christianity. But what it shows is that religious leaders ation in the Catholic doctrine can refer to either or both a can reinterpret their prohibitions. We call on them to temporal and a physical relation to the abortion. In this put life first, as many already proclaim to do. case, for instance, remoteness consists in the fact that the abortions were performed about fifty years ago. Material Conclusion cooperation denotes that an individual does not share and does not approve of the decision to perform the Even if one accepted the premise that abortion is uneth- abortion, hence is not as complicit as someone who ical and/or that using aborted foetuses to derive cell lines would encourage or approve of such act. The document for research purposes is unethical, using those cell lines also notes that this form of cooperation is passive. To say now for research purposes is not unethical and it is ac- that the cooperation is passive, rather than active, indi- tually ethically required. cates that the person using the vaccine only has a duty to Even assuming current research to develop a COVID- denounce the fact that the vaccine was linked to an im- 19 vaccine using cell lines from aborted foetuses is un- moral act such as an abortion. Had they been actively ethical, it is not unethical to benefit from such research complicit, they would have been in the position of doing by using this vaccine. Using the vaccine would not only something to prevent the abortion from happening. protect those who are vaccinated but also protect other In sum, the original document explained that the co- people around them and contribute to the public good of operation in wrongdoing of people using such vaccines herd immunity and disease eradication, which will pre- was remote and not as morally problematic as that of vent a significant number of deaths. people performing the abortion, or using the foetal cells It is important to stress that making vaccination man- for research. Yet, the document stated that, generally, datory does not imply that people would be forced to be one should refuse to be complicit to even such a remote vaccinated. Coercion can come in the form of withhold- degree, and therefore refuse to get vaccinated. Moreover, ing of benefits, fines or restriction of school entry. The the document continued, they had a moral duty to ask costs of mandatory vaccination must be proportionate for alternative vaccines developed without the use of (Savulescu, 2021), but there should not be religious aborted foetal tissues. exceptions to incurring these costs. However, even in that older original document the Finally, general religious prohibitions are sometimes Pontifical Academy for Life allowed for exceptions to applied flexibly in specific cases, and COVID-19 vaccine the general prohibition. Passive indirect material co- research policy is one of those cases, given the large bene- operation does not require one not to cooperate when fit that such vaccine can produce—we call on religious there are good reasons to do so. According to the same leaders to fully support and use the most effective, safe document, ‘it is right to abstain from using these vac- vaccine in COVID-19, and to support the most rapid cines if it can be done without causing children, and means of developing it. indirectly the population as a whole, to undergo signifi- We should prioritize lives, fairness and responsibility cant risks to their health. However, if the latter are over religious freedom. Delaying such research and vac- exposed to considerable dangers to their health, vaccines cine uptake in the name of religious freedom is unethical with moral problems pertaining to them may also be because it risks causing more unnecessary deaths, and it used on a temporary basis. The moral reason is that the duty to avoid passive material cooperation is not is irresponsible because it stands in the way of fulfilling individual and collective responsibilities in containing obligatory if there is grave inconvenience’ (PAL, 2006). 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Published: Jul 19, 2021

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