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Which Vaccine? The Cost of Religious Freedom in Vaccination Policy

Which Vaccine? The Cost of Religious Freedom in Vaccination Policy Bioethical Inquiry (2021) 18:609–619 https://doi.org/10.1007/s11673-021-10148-6 ORIGINAL RESEARCH Which Vaccine? The Cost of Religious Freedom in Vaccination Policy Alberto Giubilini  · Julian Savulescu · Dominic Wilkinson  Received: 27 January 2021 / Accepted: 11 June 2021 / Published online: 23 December 2021 © The Author(s) 2021 Abstract We discuss whether and under what con- limited availability, considering the significant differ - ditions people should be allowed to choose which ences in costs and effectiveness profile of the vaccines COVID-19 vaccine to receive on the basis of personal available, people should only be allowed to choose the ethical views. The problem arises primarily with regard preferred vaccine if: 1) this does not risk compromis- to some religious groups’ concerns about the connec- ing vaccination strategies; and 2) they internalize any tion between certain COVID-19 vaccines and abortion. additional cost that their choice might entail. The State Vaccines currently approved in Western countries make should only subsidize the vaccine that is more cost- use of foetal cell lines obtained from aborted foetuses effective for any demographic group from the point of either at the testing stage (Pfizer/BioNTech and Mod - view of public health strategies. erna vaccines) or at the development stage (Oxford/ AstraZeneca vaccine). The Catholic Church’s position Keywords Vaccination ethics · COVID-19 · is that, if there are alternatives, Catholic people have a Pandemic ethics · Religious freedom moral obligation to request the vaccine whose link with abortion is more remote, which at present means that they should refuse the Oxford/AstraZeneca vaccine. We Introduction argue that any consideration regarding free choice of the vaccine should apply to religious and non-religious Various COVID-19 vaccines have been or are about to claims alike, in order to avoid religion-based discrimi- be approved for use in the population in many coun- nation. However, we also argue that, in a context of tries. More vaccines are expected to be approved in the future. These vaccines use different technologies and have been developed in different ways. For instance, A. Giubilini (*) · J. Savulescu · D. Wilkinson  both the vaccine developed by the pharmaceutical com- Oxford Uehiro Centre for Practical Ethics, University pany Pfizer together with the research centre BioNTech of Oxford, Oxford, UK e-mail: alberto.giubilini@philosophy.ox.ac.uk (henceforth, the Pfizer/BioNTech vaccine) and the one developed by the pharmaceutical company Moderna J. Savulescu  use a novel mRNA technology. The vaccine devel- Visiting Professorial Fellow in Biomedical Ethics, oped by the University of Oxford and produced by the Murdoch Childrens Research Institute, Melbourne, VIC, Australia pharmaceutical company AstraZeneca (henceforth, the Oxford/AstraZeneca vaccine) and the one produced by J. Savulescu  Distinguished Visiting International Professorship in Law, University of Melbourne, Melbourne, VIC, Australia Vol.: (0123456789) 1 3 610 Bioethical Inquiry (2021) 18:609–619 Johnson&Johnson use an adenovirus technique . Like more remote than in the case of vaccines that use fetal many other vaccines already widely used (e.g. against cell lines at the development stage. rubella, chickenpox, hepatitis A, and shingles), some of In a recent Note, the Congregation for the Doctrine the current and likely of the future vaccines, including of the Faith has stated that it can be morally permis- the Oxford/AstraZeneca and the Johnson&Johnson vac- sible to use COVID-19 vaccines linked to abortion, cines, have been developed by using cells that were rep- given that the link to the abortion is remote and the licated from HEK-293 cell lines obtained from foetuses use of the vaccine does not imply an endorsement of after elective abortions. The abortions took place in the abortion. In theological language, using such vac- early 1970s, but as with most cell lines derived from cines is a form of “passive material cooperation.” aborted foetuses for research purposes in those years, lit- According to the Note, tle is known about the foetuses and the women who had … all vaccinations recognized as clinically safe the abortions (Wadman 2020a). and effective can be used in good conscience Both types of vaccines raise ethical issues around with the certain knowledge that the use of such most appropriate vaccination policies, for example, vaccines does not constitute formal cooperation about which groups to target first (Giubilini, Savulescu, with the abortion from which the cells used in Wilkinson 2020) and what level of coercion, if any, there production of the vaccines derive. (Congrega- should be (e.g. mandatory vaccination or some other tion for the Doctrine of the Faith 2020, ¶3) measure). One ethical concern has been raised by rep- resentatives of certain religious groups who do not wish However, the Note also says that this applies only to receive COVID-19 vaccines that are linked to abor- “when ethically irreproachable COVID-19 vaccines tions (Wadman 2020b). The Catholic Archbishop of are not available” (¶2). This is precisely why, now Sydney Anthony Fisher, for instance, wrote that “those that many different vaccines are available, the prob - who are troubled by [the COVID-19 vaccine] will either lem might become more relevant (Congregation for have to acquiesce to the social pressure to use the vac- the Doctrine of the Faith 2020; Pontifical Academy cine on themselves and their dependents, or conscien- for Life 2006 and 2017). tiously object to it” (Fisher 2020). Some of those who Thus, for instance, the U.S. Conference of Catho- have previously defended a right to conscientious objec- lic Bishops urges that “to distance oneself as much as tion to vaccination in the name of religious freedom or possible from the immoral act of another party such freedom of conscience (e.g. Navin and Largent 2017) as abortion […], [t]he AstraZeneca vaccine should be have applied their arguments to the future COVID-19 avoided if there are alternatives available” and “the rea- vaccines (Navin and Redinger 2020). According to these sons to accept the new COVID-19 vaccines from Pfizer views, individual freedom, including religious freedom, and Moderna are sufficiently serious to justify their use, should be guaranteed as long as it does not pose signifi - despite their remote connection to morally compromised cant threats to the collective. Unlike some other vaccines, cell lines” (USCCB 2020, 5). In fact, the Pope himself in the case of COVID-19 there are alternatives to a vac- received the Pfizer/BioNTech vaccine on January 12, cine that uses fetal cell lines at the development stage — 2021, and has emphasized the moral obligation for Cath- at the moment, in many countries, these alternatives are olics to get vaccinated against COVID-19 when eligible the Pfizer/BioNTech and the Moderna vaccines. While (Sly 2021). these vaccines have not been developed with the use of Other vaccines currently being developed, such as fetal cell lines, they have used those fetal cell lines at the those by GlaxoSmithKline and Sanofi Pasteur, would testing phase. However, the connection with abortion is not make any use of fetal cell lines either at the devel- opment or at the testing phase, as far as we know at the moment. So, if they are approved, certain people would believe they have a moral obligation to use them In this article we focus on these four vaccines for the simple and refuse the others. reason that at the moment they are the most widely used, or most likely to be widely used, in the foreseeable future in most Should countries that are providing COVID-19 Western countries, and they exemplify well the ethical and vaccines to their populations take account of these religious concerns here discussed. The same points we make concerns and allow people to choose alternatives that here could be applied to any current or future approved vaccine they do not find ethically problematic? which shares the same problematic features. Vol:. (1234567890) 1 3 Bioethical Inquiry (2021) 18:609–619 611 This ethical issue will become more relevant as soon per cent effective at preventing high viral loads from as we have large enough availability of different vaccines the Delta variant (Powels et  al. 2021) Importantly, and more people will have access to at least one of them. these vaccines have shown high effectiveness on old Religious freedom, as part of a broader freedom of age groups. Thus, many countries are distributing conscience, is an important value in liberal societies. them according to a largely age-based priority order However, we often need to strike a balance between it (adjusted to include some frontline workers among and other important values that secular societies consider the high priority groups) to ensure that the most vul- at least as important, if not more important, especially in nerable will be the first to be immunized. This applied certain contexts like public health. These include fair and to the first dose of the vaccine and now applies to the effective allocation of scarce public health resources and third so-called “booster dose,” which some consider protection of public health and collective well-being. necessary in light of the quickly waning immunity In this paper we argue that requests to receive conferred by the first two doses. The Oxford/Astra- COVID-19 vaccines not linked to abortion on the Zeneca also proved to be very safe but showed lower basis of claims to religious freedom (and freedom of effectiveness, though with mixed results. Clinical tri- conscience more broadly) should be accommodated als showed around 70 per cent effectiveness across only on the following conditions: all age groups but with some interesting variation on the basis of dosage, with 90 per cent effectiveness if – There is sufficient availability of the alterna- administered through a half dose followed by a full tive vaccines such that the choice does not pre- dose and 62 per cent effectiveness if administered vent other people in a target group (whichever it through two full doses. It is unclear at the moment is) from getting the best vaccine for that group whether the more effective dosage would work (whichever it is). In other words, giving objectors equally well across different age groups, as it was an alternative vaccine should not undermine what- only observed in a group younger than 55 (Ramasamy ever public health strategy is in place. et  al. 2020; Voysey 2020; Knoll and Wonodi 2021). – The person requesting the alternative vaccine Against the Delta variant, the Oxford/AstraZeneca pays for any significant additional cost of such a vaccine is estimated to be 61 per cent effective against vaccine, so that the objection does not impose high viral load (Pouwels et al. 2021)—that is against additional costs on the community. severely symptomatic cases that are more likely to – The same option is offered to people who object result in hospitalizations and deaths. Clinical trials to vaccines for other moral reasons, whether related suggest that the Johnson&Johnson vaccine is 66 per to some other religious view or secular view. cent effective at preventing symptomatic infections. Like the Oxford/AstraZeneca, the Johnson&Johnson In practice, satisfying all these conditions at the vaccine has very high effectiveness at preventing same time might turn out to be very difficult. severe cases and hospitalizations (FDA 2021). However, it is also important to point out that all these vaccines’ effectiveness at preventing infection and trans- Relative Advantages and Disadvantages mission against the Delta variant is likely to be signifi- of Current COVID‑19 Vaccines cantly lower, though there is a lot of uncertainty around this aspect. According to a study by Imperial College, The COVID-19 vaccines we currently have and will London, double-vaccinated people have between 50 per likely have in the future differ from each other in several cent and 60 per cent reduced risk of infection (Elliot ways, which are relevant from a public health and an eth- et al. 2021). However, if they do get infected, CDC data ical perspective. We describe here some of these differ - indicate that with the Delta variant the viral load of vac- ences, which are also summarized in Table 1 above. cinated people is roughly the same as that of infected The Pfizer/BioNTech and Moderna vaccines have unvaccinated people (Brown et al. 2021). shown very promising results in terms of safety and All these different characteristics might in the effectiveness, at least at preventing serious symptoms future justify different vaccination policies with and deaths. The estimate is that, after 90  days from regard to the different types of vaccines. For example, the second dose, the Pfizer/BioNTech vaccine is 78 when availability increases and the most vulnerable Vol.: (0123456789) 1 3 612 Bioethical Inquiry (2021) 18:609–619 Table 1 Comparison of different advantages of current COVID-19 vaccines Cost Confidence Confidence Easy Use for Use for Advantage in overall in high storage and protection of collective effectiveness effectiveness distribution selected immunity Vaccine at preventing on vulnerable groups in the strategyin the infections groups short term longer term in (preventing most countries severe cases) Pfizer/BioNTech low very highx Moderna low very high x Oxford/AstraZeneca xLower high x x Johnson&Johnson x lower highx x have been vaccinated, one option for mass vaccina- the United Kingdom, this means that GP practices tion might be to distribute the Oxford/AstraZeneca and pharmacies, where vaccinations are normally or the Johnson&Johnson vaccine (or other similar administered, have limited capacity to store and pro- ones that will be approved) among younger popula- vide these vaccines. Both aspects would make it very tion groups and the Moderna and Pfizer/BioNTech difficult and often practically impossible to use such ones (or other similar) among older groups, given the vaccines in low-income countries or to rely com- latter’s higher effectiveness in older age group (who pletely on them even in high-income countries. Even need the vaccine the most) but also their larger cost. if it is true that countries like Israel or the United Indeed, one important difference between vac - States have successfully mass-vaccinated using the cines is in their cost. The Pfizer/BioNTech and Mod - Pfizer/BioNTech vaccine, many countries would erna vaccines are quite expensive (£29.26 for the two either not be able to afford such costs or, quite rea - doses of the Pfizer/BioNTech one, and £37.5 − £55.52 sonably, prefer to rely significantly on less expensive for the two doses of the Moderna one), and their dis- vaccines for mass vaccination. This will be even more tribution is made difficult by the fact that they need likely given that Pfizer is now increasing the cost of to be stored at very low temperatures (-70C for the its vaccine significantly, to US $23 per dose in the Pfizer one, and -20C for the Moderna one, though new contracts being signed with the European Union after thawing the Moderna one can be preserved at (Reuters 2021). When it comes to mass vaccination, normal fridge temperature for thirty days) (Brown many countries—especially low and middle income 2020)—although some countries are enhancing their ones—will want or need to rely to a significant extent storage and distribution capacities . In a country like on cheaper and easier to distribute vaccines such as the Oxford/AstraZeneca one, the Johnson&Johnson one, or any future vaccine that shares their features. See e.g. Australian Department of Health. 2021. Wider stor- The Oxford/AstraZeneca vaccine does not need very age and transportation conditions for the Pfizer COVID-19 low storage temperature and, very importantly, is vaccine now approved, April 8. https:// www. tga. gov. au/ media- much cheaper (approximately £4.50 if the vaccine is r elea se/ wider- s t or a g e- and- tr ans por t a tion- condi tions- pf izer- used with the half/full dose regime). The same could covid- 19- vacci ne- now- appro ved. Accessed October 20, 2021. Vol:. (1234567890) 1 3 Bioethical Inquiry (2021) 18:609–619 613 be said for Johnson&Johnson’s vaccine, which costs As we shall see, the problem becomes even more around US $10 per dose, but that only requires one marked if we consider that the kind of freedom advo- dose, making it not only economically but also prac- cated cannot be applied only to specific religious tically more feasible. These cheaper vaccines might views, which would be an unjustified form of reli- well be the only way out of the emergency for low- gious privilege. In secular societies, the same kind of and middle-income countries and an essential part of freedom, if granted to one specific religious views, the way out for high-income countries as well. should consistently be applied to other views around Thus, all in all, the Oxford/AstraZeneca vaccine vaccines, whether religious or secular. The risk of and the Johnson&Johnson vaccines have advantages compromising vaccination strategies would then be over the Pfizer/BioNTech and Moderna vaccines in higher. terms of potential for large scale distribution, espe- cially in low and middle-income countries, and for vaccination strategies aimed at immunizing large por- Vaccination Strategies and Religious Freedom tions of the population. Vaccination strategies will need to take these advantages into account. For exam- An ethical conflict arises if an individual is eligible to ple, when it comes to mass vaccination in the long receive a publicly funded vaccine to which they have term, especially if vaccines will be required on a reg- moral objections (for example, a conservative Catho- ular basis to prevent immunity from waning, a coun- lic person who is eligible to receive the Oxford/Astra- try might be able to offer the cheap Oxford/AstraZen- Zeneca vaccine). Should the State pay for the more eca or Johnson&Johnson vaccine completely free of expensive alternative? charge but only partially subsidize for certain groups It is useful to consider the same ethical problem an expensive vaccine like the Pfizer/BioNTech or when it arises in the context of individual clinical Moderna ones. Or a country might choose strategies decisions and then compare it with the case of public that rely more heavily or exclusively on cheaper vac- health decisions. cines because of financial constraints. One principle that publicly funded healthcare sys- Once we consider all these factors, it becomes tems might draw on is the following: clear that giving people a completely free choice The Optimal Treatment Principle: For a given of the vaccine might not be without public health condition, publicly-funded healthcare systems and economic costs. Religious freedom in this should provide only the most effective treatment case could stand in the way of important public that is both available and affordable. (Wilkinson health goals or the public goods we want to achieve and Savulescu 2018, 290) through vaccination policies in the most cost-effec- tive way. According to this principle, public healthcare sys- Of course, other factors might determine what at tems should not provide suboptimal treatment. A any one time is optimal vaccine roll out. An obvious treatment can be said to be suboptimal for an indi- one is the risk profile. At the time of writing, some vidual when it has one or more of the following, com- countries (including the United States, the United pared to available alternatives: reduced magnitude Kingdom, and European Union countries) have either of benefit; reduced probability of benefit; reduced suspended or limited the use of the Oxford/Astra- duration of benefit; increased magnitude of harm; Zeneca and the Johnson&Johnson’s vaccine after a increased probability of harm; reduced cost-effective- link was found with very rare cases of blood clots. ness; or, reduced evidence about actual costs and risk/ Whether the risk assessment in these cases has been benefit ratio (Wilkinson and Savulescu 2018). appropriate is an issue that would deserve a separate The Optimal Treatment Principle can be justi- discussion. However, since, as a matter of fact, even fied on the basis of considerations of beneficence, minuscule risks of vaccines are affecting vaccination non-maleficence, and a reasonable conception of strategies, it would also be relevant to consider how justice. Acting in the patient’s best interest requires the free choice of the vaccine would affect vaccina- maximizing the health benefit of the scarce health tion strategies in terms of fair distribution of vaccine resources we are using for them. Making the most risks. of a limited resource is also a matter of justice both Vol.: (0123456789) 1 3 614 Bioethical Inquiry (2021) 18:609–619 from a contractualist and a utilitarian perspective. best use of finite resources so as to free up as many Giving limited health resources to those who could of them as possible for others who need them. This benefit the most from them and in such a way that requirement also implies an ethical duty to minimize would minimize further costs on the collective seems future healthcare expenditures that the failure to pro- something that everyone would accept from “behind vide the optimal treatment would entail. a veil of ignorance” (for instance, ignorance with Balancing principles implies that there is a limit regard to one’s own future religious views) and that to the cost we should be prepared to pay to respect would maximize both the individual and collective autonomy (including religious freedom). Once the good. There can be reasonable disagreement around cost becomes too large in terms of sacrifice of other what counts as “benefitting the most,” as some peo - important values, autonomy may permissibly be ple might reasonably think that the benefit is defined limited—though of course people disagree on what by reduced chances of dying from a certain condi- counts as “too large.” Thus, in the medical context, tion, by life of years saved, by the expected quality if a suboptimal treatment results in requests for addi- of the remaining life, and possibly other aspects. But tional healthcare resources that the optimal treat- most would agree that these are the kinds of consid- ment would likely have prevented or contained, it is erations that should drive allocation of scarce medical reasonable to expect those requesting the suboptimal resources. treatment to cover such costs, at least when they are A missing ethical principle here is, of course, beyond a certain limit. This strikes a reasonable bal- autonomy, which is often considered the most impor- ance between autonomy and fair allocation of scarce tant principle in contemporary biomedical ethics. resources (Wilkinson and Savulescu 2018). It is normally considered acceptable for competent Similar considerations can be made with regard to patients to refuse treatments or to request suboptimal public health interventions, although the definition of treatments compared to an available alternative. The a suboptimal intervention in this area is slightly dif- choice might be based on judgements about whether ferent. Analogously to the case of individual clinical they would medically benefit from the intervention or intervention, a public health policy is suboptimal if it whether the side effects of treatments are worth their reduces magnitude, probability, or duration of benefit benefits. However, it might also be based on ethical for the collective or increases magnitude or probabil- or religious views. One of the textbook examples is ity of harm for the collective, or is less cost-effective that of the Jehovah’s Witness person who is entitled or has reduced evidence about costs and harm/benefit to refuse blood transfusions for themselves even when ratio, or any combination of these factors. However, they might be life-saving. A principle of religious public health interventions typically need to strike a freedom in medical ethics can be defended on the different type of balance between individual and col - basis of a more general principle of autonomy. lective interest than individual medical interventions. In this paper we focus on religious freedom In the case of individual medical interventions, because it is the specific principle that is being the intervention is optimal if the best outcome for the invoked with regard to the link between vaccines individual is achieved while minimizing the negative and fetal cell lines (e.g. Navin and Redinger 2020). impact on the collective (most notably through unfair However, as we are going to mention below, nothing use of scarce resources). A public health interven- in what we say here suggests that our considerations tion is optimal if the best outcome for the collective is are limited to religious opposition to certain vaccines. achieved while minimizing financial or other types of What is really at stake here is a more general prin- costs for the collective and for single individuals. ciple of autonomy, or of freedom of conscience, of It is the same problem that, absent vaccines, arises which religious freedom is a particular instantiation. with regard to other pandemic measures. A public However, autonomy is not an absolute princi- health intervention like a lockdown, for example, ple and needs to be balanced against other consid- is suboptimal if the costs it imposes on individu- erations, most notably fairness in allocation of scarce als (for instance, physical or mental health impact of healthcare resources. Fairness requires that treatments social isolation) are too large and not worth the col- provided are not only effective but at least to a cer - lective benefit. Identifying what kind of intervention tain degree cost-effective, since we want to make the is suboptimal in public health when individual and Vol:. (1234567890) 1 3 Bioethical Inquiry (2021) 18:609–619 615 collective interests are in tension in such an extreme If the different COVID-19 vaccines available were way can be difficult. However, the individual cost of roughly equally expensive, equally accessible, and vaccination is very small (assuming vaccines’ rela- equally effective on the same population groups, then tive safety) and the intervention is actually beneficial people who are eligible to receive a COVID-19 vac- (assuming vaccines’ high effectiveness). Thus, it is cine should be left free to decide which one to receive very unlikely that burdens of vaccination on individu- on the basis of personal moral or religious views als would make vaccination policies suboptimal, in without any additional cost. This is because auton- the way in which lockdown policies might be. omy and religious freedom matter. Other things being Thus, protecting the religious freedom and, more equal, individual autonomy, and therefore religious generally, the autonomy of those who have moral freedom, should be respected. objections to a vaccine should not pose significant However, the problem arises when other things costs in terms of hindering public health goals and in are not equal. Respect for autonomy and religious terms of costs for healthcare systems. Public health freedom in vaccination policies can pose costs on strategies are a context where autonomy and religious the collective or on particular individuals. These are freedom are of secondary importance compared to the either significant financial costs (e.g. because certain public health considerations that ground such strate- vaccines are more expensive) or costs in terms of gies. Religious freedom cannot be expected to have negative impact on public health strategies (e.g. by in public health policy the same special place that it slowing down the delivery of the right vaccine to the is normally bestowed in contexts where promoting right groups of people). In a moment when time is of freedom and pluralism is a primary goal (such as poli- essence in order to preserve lives, any delay implied cies on freedom of speech or freedom of association). by policies intended to accommodate objections to After all, this idea has been extensively applied in the specific vaccines might translate into more lives lost. case of recent pandemic measures, where individual We would need to make sure that such cost is liberties have been largely sacrificed to protect the borne by those who claim such freedom, rather than most vulnerable to COVID-19 and healthcare systems, on others. This is because the aforementioned public including restrictions on religious freedoms (such as health ethics constraints apply, including fairness con- on attendance at Mass or other religious ceremonies). straints. Fairness might require objectors to internal- It is true that religious freedom has been pro- ize the costs even if the number of people requesting tected in the United States more than in the Euro- alternative suboptimal vaccines is small and therefore pean Union, for example in the case of the Supreme their impact on public health strategies is minimal. Court blocking some limitations on religious services (One obvious objection is that we might be able to introduced by some U.S. states during this pandemic. accommodate a small number of claims to free choice However, not all of them have been blocked. And, without significant collective cost. We will address more generally, the priority of religious freedom over this at the end of the article.) If there was a funda- public health concerns started to be questioned in the mental right a stake, or even a “human right”, the cost United States even before the pandemic. For exam- of respecting that right should arguably be borne (to a ple, New York eliminated religious exemptions to the significant extent at least) by the collective, to make MMR vaccine requirement for school enrolment in sure differences in wealth do not affect the extent to 2019 to tackle the problem of frequent measles out- which individuals enjoy their basic rights. However, break, and at the moment five states allow no non- the point we are making here is precisely that being medical exemption to school vaccination mandates allowed to choose one’s ethically preferred vaccine on the basis of religious or personal beliefs (NCSL should not be seen as a fundamental individual right. 2021). Given that COVID-19 is posing a larger risk to At the moment, the vaccines not linked to abortion public health than measles (at least judging from the are significantly more expensive than those linked response to it), it would not be too surprising if the to abortion, as we saw above. A healthcare system prioritization of public health over religious freedom should only subsidize the cheapest and most effec- would become central in COVID-19 vaccination poli- tive option in order to fulfil its obligation to protect cies as well. public health, making the most efficient use of scarce What does this mean in practice? resources. Vol.: (0123456789) 1 3 616 Bioethical Inquiry (2021) 18:609–619 Allowing choice of the vaccine but making it con- their caring responsibilities. Or someone might feel ditional upon individuals paying any cost difference more responsible if they suffered injuries from the would represent a reasonable accommodation of reli- vaccine which they intentionally decided to take, as gious freedom. It might be an acceptable compromise opposed to getting sick naturally and unintentionally if there is enough availability of different vaccines. by getting infected from COVID-19—after all, this However, this may not be possible if vaccine availa- kind of omission bias has been observed in other bility is extremely limited, such that providing choice vaccination decisions (DiBonaventura and Chap- of vaccines deprives other people of the most appro- man 2008; Ritov and Baron 1992; Asch et al. 1994). priate vaccine (or of a vaccine at all). For example, The fact that it is considered a bias does not detract if there is insufficient mRNA vaccine to provide to from the respect owed to it qua personal belief, any higher risk groups, it may not be appropriate to allow more than the non-evidence base of religious beliefs lower risk patients to choose that option. In such does. From the point of view of public ethics, the cases, it may not be appropriate to accommodate reli- two stand or fall together. gious freedom, given the importance in public health Granted, not all of these secular views might have ethics during a pandemic of securing most protection the same status as religious views. It could be sug- for the vulnerable. When there is highly limited sup- gested that religious views are typically part of com- ply, patients should only be offered the vaccine that prehensive worldviews, while secular beliefs around, is most indicated for their group (or, if vaccination is say, the risk assessment on mRNA vaccines are more made mandatory, they should be subject to whatever often specific concerns not related to broader world - requirement is in place for that vaccine). views. This might be taken to make a difference to the respect owed to each of these views when it comes to public policy. Even accepting this (not implausi- Religious and Secular Objections Should be ble) view, it is still the case that many secular beliefs Treated Equally around vaccines can be part of comprehensive world- views, for example about the importance of natural Religious beliefs in liberal secular societies should lifestyles, the legitimate use of animals in research, not be privileged compared to secular moral beliefs. and so on. Thus, even if our point does not apply to This reflects the more general point that if religious all secular beliefs about vaccines, it does apply to values are accommodated in healthcare choices, other many of them. non-religious requests must be treated in the same If we allow religious objectors to access the way in order to avoid religion-based discrimination mRNA vaccine, we should allow many others to (Savulescu 1988). Refusal to vaccinate or refusal to access it for personal reasons. And if accessing more receive certain types of vaccines can be motivated by expensive alternatives requires internalizing the cost different types of beliefs, either factual (e.g. beliefs of the choice, this should apply to religious and non- about risks of the vaccine) or ethical (e.g. beliefs in religious requests alike. natural lifestyles and natural medications). Refusal However, this approach would also increase the based on risk perception can also reflect a type of eth - risk of jeopardizing overall public health vaccina- ical assessment. tion strategies because more people would claim such For example, someone might prefer an mRNA liberty. vaccine to an adenovirus vaccine because they If those who refuse a specific vaccine for any rea- believe (possibly erroneously) that it is safer or son are too many and they risk compromising public more effective. It is true that risk assessment is health strategies, then it may be justified not to offer based on factual information, but whether risks are vaccine choice. This should apply to both religious worth taking for any individual is a value choice and non-religious requests. and often a moral choice. For instance, someone If those who refuse a certain COVID-19 vacci- with dependents might think that it would be irre- nations for any reason would not compromise pub- sponsible for them to opt for the unknown risks of lic health strategies, then there would be no need to long-term side effects of the mRNA vaccine com - restrict vaccination choice for anyone, regardless of pared to the risks of an adenovirus vaccine, given whether the objection is religious in nature. However, Vol:. (1234567890) 1 3 Bioethical Inquiry (2021) 18:609–619 617 once again, this would likely entail some costs if the backfiring is larger than the risk of too-liberal policies morally preferred vaccine is more expensive. For the backfiring. reasons explained above, those making this choice A second objection is that we might be able to should internalize such costs. accommodate at least a small number of claims to Requiring people to internalize the cost of their free choice of the vaccine without compromising choice is a mild limitation of individual liberty public health strategies or posing significant costs on because not everyone might afford or might be will- the collective. If we can do that, surely, we should, ing to pay the cost. If we adopt it, then the same as we would achieve the same collective benefit with kind of limitation should apply to religious and non- less liberty infringements. This might be a better religious objections alike. The degree of liberty that way of balancing fairness, collective good, and indi- people enjoy in liberal, secular societies should not vidual freedom. However, we would need to consider depend on whether people hold certain types of reli- whether the mechanism used to identify those allowed gious views. to object is in itself fair. For instance, a first come/first served basis for granting free choice of the vaccine is unlikely to be a fair system. Those who come first Meeting Two Objections are likely to be either those who have priority access to the vaccine or easier access to healthcare services. One potential concern is that not offering the choice The fairer system might be a lottery among all those of a vaccine (particularly where there are ethical or who will be vaccinated in the short and long term and religious reasons that are important to people) might who would want the free choice. A lottery might be backfire by reducing people’s willingness to vacci- quite difficult to implement and to consistently keep nate. It might lead to negative publicity around vac- in place over time. It is also worth mentioning that it cination and risk worse overall public health. If our is not a solution normally adopted in other contexts worry is that giving a suboptimal vaccine might com- where a small number of outliers would not “make a promise public health strategies, surely a suboptimal difference.” For instance, we do not have a lottery to vaccine is still better than no vaccine at all. This con- allow a small number of individuals to decide what sideration is more relevant in a context where vacci- their taxes should and should not fund, even if we can nation is not mandatory, and therefore vaccine refusal certainly afford a certain number of such individuals. may lead to a failure to achieve adequate levels of This suggests that either a lottery solution is not very collective immunity. (Whether vaccine mandates easily implementable or that we think that it would would instead be effective is beyond the scope of this still be unfair towards those who do make their fair article). contribution. One possibility is that the unfairness in This is a reasonable concern. However, we also question lies not so much in the procedure to deter- need to consider the possibility, raised in the previous mine whom to exempt but in the idea that we should section, that providing choice of vaccine will under- have exemptions in the first place. mine strategies of vaccine distribution. If we make We are however happy to concede that the lottery the choice available to anyone irrespective of their model is an option worth considering if we agree it is moral or religious views (and there is a restricted fair and accommodates individual liberties at no sig- supply of vaccines), then this risk is real. Thus, vac- nificant collective cost. cination strategies could be compromised either way. We should not simply assume that a higher collective uptake with a large proportion of suboptimal indi- Conclusion vidual vaccinations would be better than a lower col- lective uptake where all those who do get vaccinated Distributing COVID-19 vaccines in the most effective receive the best vaccine for them. way is the most urgent goal and the primary responsibil- These issues largely come down to empiri- ity of governments in designing vaccination strategies. cal considerations and expectations about people’s There is also a strong ethical requirement to make the behaviour, more than to ethical considerations. It distribution cost-effective, at least as long as availabil- is hard to tell whether the risk of restrictive policies ity is limited (but probably also after this phase). These Vol.: (0123456789) 1 3 618 Bioethical Inquiry (2021) 18:609–619 Open Access This article is licensed under a Creative Com- requirements imply that vaccination strategies should be mons Attribution 4.0 International License, which permits guided primarily by considerations around public health use, sharing, adaptation, distribution and reproduction in any and effective use of limited resources. medium or format, as long as you give appropriate credit to the Different vaccines’ characteristics might require original author(s) and the source, provide a link to the Crea- tive Commons licence, and indicate if changes were made. The that different vaccines be distributed in different ways images or other third party material in this article are included and to different groups in the pursuit of such goals. in the article’s Creative Commons licence, unless indicated Whether vaccines have been obtained with the use otherwise in a credit line to the material. If material is not of aborted foetuses is not a consideration that is rel- included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds evant to the pursuit of such strategies, and protecting the permitted use, you will need to obtain permission directly religious freedom is not a priority of public health from the copyright holder. To view a copy of this licence, visit interventions (to say that it is not a “priority” does not http:// creat iveco mmons. org/ licen ses/ by/4. 0/. mean that it is not important). However, as long as public health interventions are carried out in liberal societies, individual freedoms References should be given some consideration, in a way that does not significantly affect public health priorities. Asch, D., J. Baron, J.C. Hershey, et al. 1994. Omission bias and pertussis vaccination. Medical Decision Making 14(2): Thus, if there is sufficient availability of different 118–123. vaccines and giving people the choice of which vac- Brown, E. 2020. The race for the Covid-19 vaccine—how do cine to receive on the basis personal religious beliefs Pfizer, Moderna, and Oxford compare? GM, November does not compromise public health goals, then peo- 2020. https:// www. gmjou rnal. co. uk/ the- race- for- the- covid- 19- vacci ne- how- do- pf izer- moder na- and- oxfor d- ple should be allowed to choose which vaccines to compa re. Accessed September 16, 2021. receive. However, they should pay for any additional Brown, C. M., J. Vostok, H. Johnson, et  al. 2021. Outbreak cost of this choice. This should extend to non-reli- of SARS-CoV-2 infections, including COVID-19 vac- gious requests for vaccine alternatives. cine breakthrough infections, associated with large pub- lic gatherings—Barnstable County, Massachusetts, July Limited availability of the vaccine might still make 2021.  Morbidity and Mortality Weekly Report  70(31): a small number of exemptions affordable. If so, we might want to consider the very unusual solution of Di Bonaventura, M., and G.B. Chapman. 2008. Do decision a lottery to determine who will enjoy the privilege of biases predict bad decisions? Omission bias, naturalness bias, and influenza vaccination. Medical Decision Making the free choice, but we would need more discussion 28(4): 532–539. to determine whether this would be fair. Elliot, P., D. Haw, H. Wang, et  al. 2021. REACT-1 round 13 If we do not want to consider the lottery solu- final report: Exponential growth, high prevalence of tion and if there is no sufficient availability to allow SARS-CoV-2 and vaccine effectiveness associated with Delta variant in England during May to July 2021. med this qualified form of religious freedom, then people Rxiv  2021.09.02.21262979.  doi: https:// doi. org/ 10. 1101/ should be subject to whichever vaccination require- 2021. 09. 02. 21262 979. ment is in place or have access only to whichever vac- Fisher, A. 2020. Let’s not create an ethical dilemma. The Cath- cine is targeted to their group. olic Weekly, August 24. www. catho licwe ekly. com. au/ archb ishop- fisher- op- lets- not- create- an- ethic al- dilem ma/. Accessed September 16, 2021. Giubilini, A., J. Savulescu, and D. Wilkinson. 2020. COVID- Funding This research was funded in whole, or in part, by 19 vaccine: Vaccinate the young to protect the old? Jour- the UKRI [Grant number AH/V006819/] and the Wellcome nal of Law and the Biosciences 7(1): lsaa050. Trust [grant numbers WT203132 and WT104848]. Knoll, M.D. and C. Wonodi. 2021. Oxford-AstraZeneca For the purpose of open access, the author has applied COVID-19 vaccine efficacy. The Lancet 397: 72−74. a CC BY public copyright licence to any Author Accepted NCSL (National Conference of State Legislatures). 2021. Manuscript version arising from this submission.  Julian States with religious and philosophical exemptions from Savulescu  also received support from the UKRI/ AHRC Eth- school immunization requirements. https:// www. ncsl. org/ ics Accelerator (AH/V013947/1) and the Australian Research r e se a r c h/ he al t h/ s c ho ol- i mmun i zat i o n- exem p t ion- s t at e- Council (DP190101547). Through his involvement with the laws. aspx. Accessed October 20, 2021 Murdoch Children’s Research Institute, JS received fund- Navin, M., and M. Largent 2017. Improving nonmedical vac- ing through from the Victorian State Government through the cine exemption policies: Three case studies. Public Health Operational Infrastructure Support (OIS) Program” Ethics 10(3): 225−235. Vol:. (1234567890) 1 3 Bioethical Inquiry (2021) 18:609–619 619 Navin, M., and M. Redinger. 2020. Everyone should support Savulescu, J. 1998. The cost of refusing treatment and equality abortion-free vaccines. Bioethics.net, September 15. of outcome. Journal of Medical Ethics 24: 231−236. http:// www. bioet hics. net/ 2020/ 09/ every one- should- suppo Sly, E. 2021. Pope Francis calls opposition to Covid vaccine rt- abort ion- free- vacci nes/. Accessed September 23, 2021. “suicidal denial” and says he will get jab. The Independ- Offices of the Congregation for the Doctrine of the Faith. 2020. ent, January 12. www.independent.co.uk/news/world/ Note on the morality of using some anti-COVID vaccines, europe/pope-francis-vaccine-coronavirus-b1785051.html. December 21. https:// press. vatic an. va/ conte nt/ salas tampa/ Accessed September 16, 2021. USCCB (United States Conference of Catholic Bishops). 2020. i t / b o l l e t t i n o / p u b b l i c o / 2 0 2 0 / 1 2 / 2 1 / 0 6 8 1 / 0 1 5 9 1 . h t m l. Moral considerations regarding the new covid-19 vac- Accessed September 23, 2021. cines. https://www.usccb.org/moral-considerations-covid- Pontifical Academy for Life. 2006. Moral reflections on vac- vaccines. Accessed October 20, 2021 cines prepared from cells derived from aborted human Voysey, M., S.A.C. Clemens, S.A. Madhi, et  al. 2021. fetuses. The National Catholic Bioethics Quarterly 6(3): Safety and efficacy of the ChAdOx1 nCoV-19 vaccine 541−537. (AZD1222) against SARS-CoV-2: An interim analysis of Pontifical Academy for Life. 2017. Note on Italian vaccine four randomised controlled trials in Brazil, South Africa, issue. July 31. http:// www. acade myfor life. va/ conte nt/ and the UK [published correction appears in Lancet. 2021 pav/ en/ the- acade my/ activ ity- acade my/ note- vacci ni. html. Jan 9;397(10269):98]. Lancet 397(10269): 99−111. Accessed September 16, 2021. Wadman, M. 2020a. Vaccines that use human fetal cells draw Pouwels, K.B., E. Pritchard, P.C. Matthews,  et al.  2021. fire. Science 368(6496):1170–1171. Effect of Delta variant on viral burden and vaccine Wadman, M. 2020b. Abortion opponents protest COVID-19 effectiveness against new SARS-CoV-2 infections in vaccines’ use of fetal cells. Science, June 5. https://www. the UK.  Nature Medicine.doi.https:// doi. org/ 10. 1038/ sciencemag.org/news/2020/06/abortion-opponents-pro- s41591- 021- 01548-7. test-covid-19-vaccines-use-fetal-cells. Accessed Septem- Ritov, I., and J. Baron. 1992. Reluctance to vaccinate. Omis- ber 23, 2021. sion bias and ambiguity. Journal of Behavioural Decision Wilkinson, D., and J. Savulescu 2018. Cost-equivalence and Making 3: 263–277. pluralism in publicly-funded health-care systems. Health Reuters. 2021. Bulgarian PM reveals price for EU’s new vac- Care Analysis 26(4): 287−309. cine contract with Pfizer. Reuters.com, April 12. https:// www.reuters.com/article/us-eu-bulgaria-pfizer-prices/ bulgarian-pm-reveals-price-for-eus-new-vaccine-contract- Publisher’s Note Springer Nature remains neutral with regard with-pfizer-idUSKBN2BZ1JP. Accessed September 16, to jurisdictional claims in published maps and institutional affiliations. Vol.: (0123456789) 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Bioethical Inquiry Pubmed Central

Which Vaccine? The Cost of Religious Freedom in Vaccination Policy

Journal of Bioethical Inquiry , Volume 18 (4) – Dec 23, 2021

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10.1007/s11673-021-10148-6
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Abstract

Bioethical Inquiry (2021) 18:609–619 https://doi.org/10.1007/s11673-021-10148-6 ORIGINAL RESEARCH Which Vaccine? The Cost of Religious Freedom in Vaccination Policy Alberto Giubilini  · Julian Savulescu · Dominic Wilkinson  Received: 27 January 2021 / Accepted: 11 June 2021 / Published online: 23 December 2021 © The Author(s) 2021 Abstract We discuss whether and under what con- limited availability, considering the significant differ - ditions people should be allowed to choose which ences in costs and effectiveness profile of the vaccines COVID-19 vaccine to receive on the basis of personal available, people should only be allowed to choose the ethical views. The problem arises primarily with regard preferred vaccine if: 1) this does not risk compromis- to some religious groups’ concerns about the connec- ing vaccination strategies; and 2) they internalize any tion between certain COVID-19 vaccines and abortion. additional cost that their choice might entail. The State Vaccines currently approved in Western countries make should only subsidize the vaccine that is more cost- use of foetal cell lines obtained from aborted foetuses effective for any demographic group from the point of either at the testing stage (Pfizer/BioNTech and Mod - view of public health strategies. erna vaccines) or at the development stage (Oxford/ AstraZeneca vaccine). The Catholic Church’s position Keywords Vaccination ethics · COVID-19 · is that, if there are alternatives, Catholic people have a Pandemic ethics · Religious freedom moral obligation to request the vaccine whose link with abortion is more remote, which at present means that they should refuse the Oxford/AstraZeneca vaccine. We Introduction argue that any consideration regarding free choice of the vaccine should apply to religious and non-religious Various COVID-19 vaccines have been or are about to claims alike, in order to avoid religion-based discrimi- be approved for use in the population in many coun- nation. However, we also argue that, in a context of tries. More vaccines are expected to be approved in the future. These vaccines use different technologies and have been developed in different ways. For instance, A. Giubilini (*) · J. Savulescu · D. Wilkinson  both the vaccine developed by the pharmaceutical com- Oxford Uehiro Centre for Practical Ethics, University pany Pfizer together with the research centre BioNTech of Oxford, Oxford, UK e-mail: alberto.giubilini@philosophy.ox.ac.uk (henceforth, the Pfizer/BioNTech vaccine) and the one developed by the pharmaceutical company Moderna J. Savulescu  use a novel mRNA technology. The vaccine devel- Visiting Professorial Fellow in Biomedical Ethics, oped by the University of Oxford and produced by the Murdoch Childrens Research Institute, Melbourne, VIC, Australia pharmaceutical company AstraZeneca (henceforth, the Oxford/AstraZeneca vaccine) and the one produced by J. Savulescu  Distinguished Visiting International Professorship in Law, University of Melbourne, Melbourne, VIC, Australia Vol.: (0123456789) 1 3 610 Bioethical Inquiry (2021) 18:609–619 Johnson&Johnson use an adenovirus technique . Like more remote than in the case of vaccines that use fetal many other vaccines already widely used (e.g. against cell lines at the development stage. rubella, chickenpox, hepatitis A, and shingles), some of In a recent Note, the Congregation for the Doctrine the current and likely of the future vaccines, including of the Faith has stated that it can be morally permis- the Oxford/AstraZeneca and the Johnson&Johnson vac- sible to use COVID-19 vaccines linked to abortion, cines, have been developed by using cells that were rep- given that the link to the abortion is remote and the licated from HEK-293 cell lines obtained from foetuses use of the vaccine does not imply an endorsement of after elective abortions. The abortions took place in the abortion. In theological language, using such vac- early 1970s, but as with most cell lines derived from cines is a form of “passive material cooperation.” aborted foetuses for research purposes in those years, lit- According to the Note, tle is known about the foetuses and the women who had … all vaccinations recognized as clinically safe the abortions (Wadman 2020a). and effective can be used in good conscience Both types of vaccines raise ethical issues around with the certain knowledge that the use of such most appropriate vaccination policies, for example, vaccines does not constitute formal cooperation about which groups to target first (Giubilini, Savulescu, with the abortion from which the cells used in Wilkinson 2020) and what level of coercion, if any, there production of the vaccines derive. (Congrega- should be (e.g. mandatory vaccination or some other tion for the Doctrine of the Faith 2020, ¶3) measure). One ethical concern has been raised by rep- resentatives of certain religious groups who do not wish However, the Note also says that this applies only to receive COVID-19 vaccines that are linked to abor- “when ethically irreproachable COVID-19 vaccines tions (Wadman 2020b). The Catholic Archbishop of are not available” (¶2). This is precisely why, now Sydney Anthony Fisher, for instance, wrote that “those that many different vaccines are available, the prob - who are troubled by [the COVID-19 vaccine] will either lem might become more relevant (Congregation for have to acquiesce to the social pressure to use the vac- the Doctrine of the Faith 2020; Pontifical Academy cine on themselves and their dependents, or conscien- for Life 2006 and 2017). tiously object to it” (Fisher 2020). Some of those who Thus, for instance, the U.S. Conference of Catho- have previously defended a right to conscientious objec- lic Bishops urges that “to distance oneself as much as tion to vaccination in the name of religious freedom or possible from the immoral act of another party such freedom of conscience (e.g. Navin and Largent 2017) as abortion […], [t]he AstraZeneca vaccine should be have applied their arguments to the future COVID-19 avoided if there are alternatives available” and “the rea- vaccines (Navin and Redinger 2020). According to these sons to accept the new COVID-19 vaccines from Pfizer views, individual freedom, including religious freedom, and Moderna are sufficiently serious to justify their use, should be guaranteed as long as it does not pose signifi - despite their remote connection to morally compromised cant threats to the collective. Unlike some other vaccines, cell lines” (USCCB 2020, 5). In fact, the Pope himself in the case of COVID-19 there are alternatives to a vac- received the Pfizer/BioNTech vaccine on January 12, cine that uses fetal cell lines at the development stage — 2021, and has emphasized the moral obligation for Cath- at the moment, in many countries, these alternatives are olics to get vaccinated against COVID-19 when eligible the Pfizer/BioNTech and the Moderna vaccines. While (Sly 2021). these vaccines have not been developed with the use of Other vaccines currently being developed, such as fetal cell lines, they have used those fetal cell lines at the those by GlaxoSmithKline and Sanofi Pasteur, would testing phase. However, the connection with abortion is not make any use of fetal cell lines either at the devel- opment or at the testing phase, as far as we know at the moment. So, if they are approved, certain people would believe they have a moral obligation to use them In this article we focus on these four vaccines for the simple and refuse the others. reason that at the moment they are the most widely used, or most likely to be widely used, in the foreseeable future in most Should countries that are providing COVID-19 Western countries, and they exemplify well the ethical and vaccines to their populations take account of these religious concerns here discussed. The same points we make concerns and allow people to choose alternatives that here could be applied to any current or future approved vaccine they do not find ethically problematic? which shares the same problematic features. Vol:. (1234567890) 1 3 Bioethical Inquiry (2021) 18:609–619 611 This ethical issue will become more relevant as soon per cent effective at preventing high viral loads from as we have large enough availability of different vaccines the Delta variant (Powels et  al. 2021) Importantly, and more people will have access to at least one of them. these vaccines have shown high effectiveness on old Religious freedom, as part of a broader freedom of age groups. Thus, many countries are distributing conscience, is an important value in liberal societies. them according to a largely age-based priority order However, we often need to strike a balance between it (adjusted to include some frontline workers among and other important values that secular societies consider the high priority groups) to ensure that the most vul- at least as important, if not more important, especially in nerable will be the first to be immunized. This applied certain contexts like public health. These include fair and to the first dose of the vaccine and now applies to the effective allocation of scarce public health resources and third so-called “booster dose,” which some consider protection of public health and collective well-being. necessary in light of the quickly waning immunity In this paper we argue that requests to receive conferred by the first two doses. The Oxford/Astra- COVID-19 vaccines not linked to abortion on the Zeneca also proved to be very safe but showed lower basis of claims to religious freedom (and freedom of effectiveness, though with mixed results. Clinical tri- conscience more broadly) should be accommodated als showed around 70 per cent effectiveness across only on the following conditions: all age groups but with some interesting variation on the basis of dosage, with 90 per cent effectiveness if – There is sufficient availability of the alterna- administered through a half dose followed by a full tive vaccines such that the choice does not pre- dose and 62 per cent effectiveness if administered vent other people in a target group (whichever it through two full doses. It is unclear at the moment is) from getting the best vaccine for that group whether the more effective dosage would work (whichever it is). In other words, giving objectors equally well across different age groups, as it was an alternative vaccine should not undermine what- only observed in a group younger than 55 (Ramasamy ever public health strategy is in place. et  al. 2020; Voysey 2020; Knoll and Wonodi 2021). – The person requesting the alternative vaccine Against the Delta variant, the Oxford/AstraZeneca pays for any significant additional cost of such a vaccine is estimated to be 61 per cent effective against vaccine, so that the objection does not impose high viral load (Pouwels et al. 2021)—that is against additional costs on the community. severely symptomatic cases that are more likely to – The same option is offered to people who object result in hospitalizations and deaths. Clinical trials to vaccines for other moral reasons, whether related suggest that the Johnson&Johnson vaccine is 66 per to some other religious view or secular view. cent effective at preventing symptomatic infections. Like the Oxford/AstraZeneca, the Johnson&Johnson In practice, satisfying all these conditions at the vaccine has very high effectiveness at preventing same time might turn out to be very difficult. severe cases and hospitalizations (FDA 2021). However, it is also important to point out that all these vaccines’ effectiveness at preventing infection and trans- Relative Advantages and Disadvantages mission against the Delta variant is likely to be signifi- of Current COVID‑19 Vaccines cantly lower, though there is a lot of uncertainty around this aspect. According to a study by Imperial College, The COVID-19 vaccines we currently have and will London, double-vaccinated people have between 50 per likely have in the future differ from each other in several cent and 60 per cent reduced risk of infection (Elliot ways, which are relevant from a public health and an eth- et al. 2021). However, if they do get infected, CDC data ical perspective. We describe here some of these differ - indicate that with the Delta variant the viral load of vac- ences, which are also summarized in Table 1 above. cinated people is roughly the same as that of infected The Pfizer/BioNTech and Moderna vaccines have unvaccinated people (Brown et al. 2021). shown very promising results in terms of safety and All these different characteristics might in the effectiveness, at least at preventing serious symptoms future justify different vaccination policies with and deaths. The estimate is that, after 90  days from regard to the different types of vaccines. For example, the second dose, the Pfizer/BioNTech vaccine is 78 when availability increases and the most vulnerable Vol.: (0123456789) 1 3 612 Bioethical Inquiry (2021) 18:609–619 Table 1 Comparison of different advantages of current COVID-19 vaccines Cost Confidence Confidence Easy Use for Use for Advantage in overall in high storage and protection of collective effectiveness effectiveness distribution selected immunity Vaccine at preventing on vulnerable groups in the strategyin the infections groups short term longer term in (preventing most countries severe cases) Pfizer/BioNTech low very highx Moderna low very high x Oxford/AstraZeneca xLower high x x Johnson&Johnson x lower highx x have been vaccinated, one option for mass vaccina- the United Kingdom, this means that GP practices tion might be to distribute the Oxford/AstraZeneca and pharmacies, where vaccinations are normally or the Johnson&Johnson vaccine (or other similar administered, have limited capacity to store and pro- ones that will be approved) among younger popula- vide these vaccines. Both aspects would make it very tion groups and the Moderna and Pfizer/BioNTech difficult and often practically impossible to use such ones (or other similar) among older groups, given the vaccines in low-income countries or to rely com- latter’s higher effectiveness in older age group (who pletely on them even in high-income countries. Even need the vaccine the most) but also their larger cost. if it is true that countries like Israel or the United Indeed, one important difference between vac - States have successfully mass-vaccinated using the cines is in their cost. The Pfizer/BioNTech and Mod - Pfizer/BioNTech vaccine, many countries would erna vaccines are quite expensive (£29.26 for the two either not be able to afford such costs or, quite rea - doses of the Pfizer/BioNTech one, and £37.5 − £55.52 sonably, prefer to rely significantly on less expensive for the two doses of the Moderna one), and their dis- vaccines for mass vaccination. This will be even more tribution is made difficult by the fact that they need likely given that Pfizer is now increasing the cost of to be stored at very low temperatures (-70C for the its vaccine significantly, to US $23 per dose in the Pfizer one, and -20C for the Moderna one, though new contracts being signed with the European Union after thawing the Moderna one can be preserved at (Reuters 2021). When it comes to mass vaccination, normal fridge temperature for thirty days) (Brown many countries—especially low and middle income 2020)—although some countries are enhancing their ones—will want or need to rely to a significant extent storage and distribution capacities . In a country like on cheaper and easier to distribute vaccines such as the Oxford/AstraZeneca one, the Johnson&Johnson one, or any future vaccine that shares their features. See e.g. Australian Department of Health. 2021. Wider stor- The Oxford/AstraZeneca vaccine does not need very age and transportation conditions for the Pfizer COVID-19 low storage temperature and, very importantly, is vaccine now approved, April 8. https:// www. tga. gov. au/ media- much cheaper (approximately £4.50 if the vaccine is r elea se/ wider- s t or a g e- and- tr ans por t a tion- condi tions- pf izer- used with the half/full dose regime). The same could covid- 19- vacci ne- now- appro ved. Accessed October 20, 2021. Vol:. (1234567890) 1 3 Bioethical Inquiry (2021) 18:609–619 613 be said for Johnson&Johnson’s vaccine, which costs As we shall see, the problem becomes even more around US $10 per dose, but that only requires one marked if we consider that the kind of freedom advo- dose, making it not only economically but also prac- cated cannot be applied only to specific religious tically more feasible. These cheaper vaccines might views, which would be an unjustified form of reli- well be the only way out of the emergency for low- gious privilege. In secular societies, the same kind of and middle-income countries and an essential part of freedom, if granted to one specific religious views, the way out for high-income countries as well. should consistently be applied to other views around Thus, all in all, the Oxford/AstraZeneca vaccine vaccines, whether religious or secular. The risk of and the Johnson&Johnson vaccines have advantages compromising vaccination strategies would then be over the Pfizer/BioNTech and Moderna vaccines in higher. terms of potential for large scale distribution, espe- cially in low and middle-income countries, and for vaccination strategies aimed at immunizing large por- Vaccination Strategies and Religious Freedom tions of the population. Vaccination strategies will need to take these advantages into account. For exam- An ethical conflict arises if an individual is eligible to ple, when it comes to mass vaccination in the long receive a publicly funded vaccine to which they have term, especially if vaccines will be required on a reg- moral objections (for example, a conservative Catho- ular basis to prevent immunity from waning, a coun- lic person who is eligible to receive the Oxford/Astra- try might be able to offer the cheap Oxford/AstraZen- Zeneca vaccine). Should the State pay for the more eca or Johnson&Johnson vaccine completely free of expensive alternative? charge but only partially subsidize for certain groups It is useful to consider the same ethical problem an expensive vaccine like the Pfizer/BioNTech or when it arises in the context of individual clinical Moderna ones. Or a country might choose strategies decisions and then compare it with the case of public that rely more heavily or exclusively on cheaper vac- health decisions. cines because of financial constraints. One principle that publicly funded healthcare sys- Once we consider all these factors, it becomes tems might draw on is the following: clear that giving people a completely free choice The Optimal Treatment Principle: For a given of the vaccine might not be without public health condition, publicly-funded healthcare systems and economic costs. Religious freedom in this should provide only the most effective treatment case could stand in the way of important public that is both available and affordable. (Wilkinson health goals or the public goods we want to achieve and Savulescu 2018, 290) through vaccination policies in the most cost-effec- tive way. According to this principle, public healthcare sys- Of course, other factors might determine what at tems should not provide suboptimal treatment. A any one time is optimal vaccine roll out. An obvious treatment can be said to be suboptimal for an indi- one is the risk profile. At the time of writing, some vidual when it has one or more of the following, com- countries (including the United States, the United pared to available alternatives: reduced magnitude Kingdom, and European Union countries) have either of benefit; reduced probability of benefit; reduced suspended or limited the use of the Oxford/Astra- duration of benefit; increased magnitude of harm; Zeneca and the Johnson&Johnson’s vaccine after a increased probability of harm; reduced cost-effective- link was found with very rare cases of blood clots. ness; or, reduced evidence about actual costs and risk/ Whether the risk assessment in these cases has been benefit ratio (Wilkinson and Savulescu 2018). appropriate is an issue that would deserve a separate The Optimal Treatment Principle can be justi- discussion. However, since, as a matter of fact, even fied on the basis of considerations of beneficence, minuscule risks of vaccines are affecting vaccination non-maleficence, and a reasonable conception of strategies, it would also be relevant to consider how justice. Acting in the patient’s best interest requires the free choice of the vaccine would affect vaccina- maximizing the health benefit of the scarce health tion strategies in terms of fair distribution of vaccine resources we are using for them. Making the most risks. of a limited resource is also a matter of justice both Vol.: (0123456789) 1 3 614 Bioethical Inquiry (2021) 18:609–619 from a contractualist and a utilitarian perspective. best use of finite resources so as to free up as many Giving limited health resources to those who could of them as possible for others who need them. This benefit the most from them and in such a way that requirement also implies an ethical duty to minimize would minimize further costs on the collective seems future healthcare expenditures that the failure to pro- something that everyone would accept from “behind vide the optimal treatment would entail. a veil of ignorance” (for instance, ignorance with Balancing principles implies that there is a limit regard to one’s own future religious views) and that to the cost we should be prepared to pay to respect would maximize both the individual and collective autonomy (including religious freedom). Once the good. There can be reasonable disagreement around cost becomes too large in terms of sacrifice of other what counts as “benefitting the most,” as some peo - important values, autonomy may permissibly be ple might reasonably think that the benefit is defined limited—though of course people disagree on what by reduced chances of dying from a certain condi- counts as “too large.” Thus, in the medical context, tion, by life of years saved, by the expected quality if a suboptimal treatment results in requests for addi- of the remaining life, and possibly other aspects. But tional healthcare resources that the optimal treat- most would agree that these are the kinds of consid- ment would likely have prevented or contained, it is erations that should drive allocation of scarce medical reasonable to expect those requesting the suboptimal resources. treatment to cover such costs, at least when they are A missing ethical principle here is, of course, beyond a certain limit. This strikes a reasonable bal- autonomy, which is often considered the most impor- ance between autonomy and fair allocation of scarce tant principle in contemporary biomedical ethics. resources (Wilkinson and Savulescu 2018). It is normally considered acceptable for competent Similar considerations can be made with regard to patients to refuse treatments or to request suboptimal public health interventions, although the definition of treatments compared to an available alternative. The a suboptimal intervention in this area is slightly dif- choice might be based on judgements about whether ferent. Analogously to the case of individual clinical they would medically benefit from the intervention or intervention, a public health policy is suboptimal if it whether the side effects of treatments are worth their reduces magnitude, probability, or duration of benefit benefits. However, it might also be based on ethical for the collective or increases magnitude or probabil- or religious views. One of the textbook examples is ity of harm for the collective, or is less cost-effective that of the Jehovah’s Witness person who is entitled or has reduced evidence about costs and harm/benefit to refuse blood transfusions for themselves even when ratio, or any combination of these factors. However, they might be life-saving. A principle of religious public health interventions typically need to strike a freedom in medical ethics can be defended on the different type of balance between individual and col - basis of a more general principle of autonomy. lective interest than individual medical interventions. In this paper we focus on religious freedom In the case of individual medical interventions, because it is the specific principle that is being the intervention is optimal if the best outcome for the invoked with regard to the link between vaccines individual is achieved while minimizing the negative and fetal cell lines (e.g. Navin and Redinger 2020). impact on the collective (most notably through unfair However, as we are going to mention below, nothing use of scarce resources). A public health interven- in what we say here suggests that our considerations tion is optimal if the best outcome for the collective is are limited to religious opposition to certain vaccines. achieved while minimizing financial or other types of What is really at stake here is a more general prin- costs for the collective and for single individuals. ciple of autonomy, or of freedom of conscience, of It is the same problem that, absent vaccines, arises which religious freedom is a particular instantiation. with regard to other pandemic measures. A public However, autonomy is not an absolute princi- health intervention like a lockdown, for example, ple and needs to be balanced against other consid- is suboptimal if the costs it imposes on individu- erations, most notably fairness in allocation of scarce als (for instance, physical or mental health impact of healthcare resources. Fairness requires that treatments social isolation) are too large and not worth the col- provided are not only effective but at least to a cer - lective benefit. Identifying what kind of intervention tain degree cost-effective, since we want to make the is suboptimal in public health when individual and Vol:. (1234567890) 1 3 Bioethical Inquiry (2021) 18:609–619 615 collective interests are in tension in such an extreme If the different COVID-19 vaccines available were way can be difficult. However, the individual cost of roughly equally expensive, equally accessible, and vaccination is very small (assuming vaccines’ rela- equally effective on the same population groups, then tive safety) and the intervention is actually beneficial people who are eligible to receive a COVID-19 vac- (assuming vaccines’ high effectiveness). Thus, it is cine should be left free to decide which one to receive very unlikely that burdens of vaccination on individu- on the basis of personal moral or religious views als would make vaccination policies suboptimal, in without any additional cost. This is because auton- the way in which lockdown policies might be. omy and religious freedom matter. Other things being Thus, protecting the religious freedom and, more equal, individual autonomy, and therefore religious generally, the autonomy of those who have moral freedom, should be respected. objections to a vaccine should not pose significant However, the problem arises when other things costs in terms of hindering public health goals and in are not equal. Respect for autonomy and religious terms of costs for healthcare systems. Public health freedom in vaccination policies can pose costs on strategies are a context where autonomy and religious the collective or on particular individuals. These are freedom are of secondary importance compared to the either significant financial costs (e.g. because certain public health considerations that ground such strate- vaccines are more expensive) or costs in terms of gies. Religious freedom cannot be expected to have negative impact on public health strategies (e.g. by in public health policy the same special place that it slowing down the delivery of the right vaccine to the is normally bestowed in contexts where promoting right groups of people). In a moment when time is of freedom and pluralism is a primary goal (such as poli- essence in order to preserve lives, any delay implied cies on freedom of speech or freedom of association). by policies intended to accommodate objections to After all, this idea has been extensively applied in the specific vaccines might translate into more lives lost. case of recent pandemic measures, where individual We would need to make sure that such cost is liberties have been largely sacrificed to protect the borne by those who claim such freedom, rather than most vulnerable to COVID-19 and healthcare systems, on others. This is because the aforementioned public including restrictions on religious freedoms (such as health ethics constraints apply, including fairness con- on attendance at Mass or other religious ceremonies). straints. Fairness might require objectors to internal- It is true that religious freedom has been pro- ize the costs even if the number of people requesting tected in the United States more than in the Euro- alternative suboptimal vaccines is small and therefore pean Union, for example in the case of the Supreme their impact on public health strategies is minimal. Court blocking some limitations on religious services (One obvious objection is that we might be able to introduced by some U.S. states during this pandemic. accommodate a small number of claims to free choice However, not all of them have been blocked. And, without significant collective cost. We will address more generally, the priority of religious freedom over this at the end of the article.) If there was a funda- public health concerns started to be questioned in the mental right a stake, or even a “human right”, the cost United States even before the pandemic. For exam- of respecting that right should arguably be borne (to a ple, New York eliminated religious exemptions to the significant extent at least) by the collective, to make MMR vaccine requirement for school enrolment in sure differences in wealth do not affect the extent to 2019 to tackle the problem of frequent measles out- which individuals enjoy their basic rights. However, break, and at the moment five states allow no non- the point we are making here is precisely that being medical exemption to school vaccination mandates allowed to choose one’s ethically preferred vaccine on the basis of religious or personal beliefs (NCSL should not be seen as a fundamental individual right. 2021). Given that COVID-19 is posing a larger risk to At the moment, the vaccines not linked to abortion public health than measles (at least judging from the are significantly more expensive than those linked response to it), it would not be too surprising if the to abortion, as we saw above. A healthcare system prioritization of public health over religious freedom should only subsidize the cheapest and most effec- would become central in COVID-19 vaccination poli- tive option in order to fulfil its obligation to protect cies as well. public health, making the most efficient use of scarce What does this mean in practice? resources. Vol.: (0123456789) 1 3 616 Bioethical Inquiry (2021) 18:609–619 Allowing choice of the vaccine but making it con- their caring responsibilities. Or someone might feel ditional upon individuals paying any cost difference more responsible if they suffered injuries from the would represent a reasonable accommodation of reli- vaccine which they intentionally decided to take, as gious freedom. It might be an acceptable compromise opposed to getting sick naturally and unintentionally if there is enough availability of different vaccines. by getting infected from COVID-19—after all, this However, this may not be possible if vaccine availa- kind of omission bias has been observed in other bility is extremely limited, such that providing choice vaccination decisions (DiBonaventura and Chap- of vaccines deprives other people of the most appro- man 2008; Ritov and Baron 1992; Asch et al. 1994). priate vaccine (or of a vaccine at all). For example, The fact that it is considered a bias does not detract if there is insufficient mRNA vaccine to provide to from the respect owed to it qua personal belief, any higher risk groups, it may not be appropriate to allow more than the non-evidence base of religious beliefs lower risk patients to choose that option. In such does. From the point of view of public ethics, the cases, it may not be appropriate to accommodate reli- two stand or fall together. gious freedom, given the importance in public health Granted, not all of these secular views might have ethics during a pandemic of securing most protection the same status as religious views. It could be sug- for the vulnerable. When there is highly limited sup- gested that religious views are typically part of com- ply, patients should only be offered the vaccine that prehensive worldviews, while secular beliefs around, is most indicated for their group (or, if vaccination is say, the risk assessment on mRNA vaccines are more made mandatory, they should be subject to whatever often specific concerns not related to broader world - requirement is in place for that vaccine). views. This might be taken to make a difference to the respect owed to each of these views when it comes to public policy. Even accepting this (not implausi- Religious and Secular Objections Should be ble) view, it is still the case that many secular beliefs Treated Equally around vaccines can be part of comprehensive world- views, for example about the importance of natural Religious beliefs in liberal secular societies should lifestyles, the legitimate use of animals in research, not be privileged compared to secular moral beliefs. and so on. Thus, even if our point does not apply to This reflects the more general point that if religious all secular beliefs about vaccines, it does apply to values are accommodated in healthcare choices, other many of them. non-religious requests must be treated in the same If we allow religious objectors to access the way in order to avoid religion-based discrimination mRNA vaccine, we should allow many others to (Savulescu 1988). Refusal to vaccinate or refusal to access it for personal reasons. And if accessing more receive certain types of vaccines can be motivated by expensive alternatives requires internalizing the cost different types of beliefs, either factual (e.g. beliefs of the choice, this should apply to religious and non- about risks of the vaccine) or ethical (e.g. beliefs in religious requests alike. natural lifestyles and natural medications). Refusal However, this approach would also increase the based on risk perception can also reflect a type of eth - risk of jeopardizing overall public health vaccina- ical assessment. tion strategies because more people would claim such For example, someone might prefer an mRNA liberty. vaccine to an adenovirus vaccine because they If those who refuse a specific vaccine for any rea- believe (possibly erroneously) that it is safer or son are too many and they risk compromising public more effective. It is true that risk assessment is health strategies, then it may be justified not to offer based on factual information, but whether risks are vaccine choice. This should apply to both religious worth taking for any individual is a value choice and non-religious requests. and often a moral choice. For instance, someone If those who refuse a certain COVID-19 vacci- with dependents might think that it would be irre- nations for any reason would not compromise pub- sponsible for them to opt for the unknown risks of lic health strategies, then there would be no need to long-term side effects of the mRNA vaccine com - restrict vaccination choice for anyone, regardless of pared to the risks of an adenovirus vaccine, given whether the objection is religious in nature. However, Vol:. (1234567890) 1 3 Bioethical Inquiry (2021) 18:609–619 617 once again, this would likely entail some costs if the backfiring is larger than the risk of too-liberal policies morally preferred vaccine is more expensive. For the backfiring. reasons explained above, those making this choice A second objection is that we might be able to should internalize such costs. accommodate at least a small number of claims to Requiring people to internalize the cost of their free choice of the vaccine without compromising choice is a mild limitation of individual liberty public health strategies or posing significant costs on because not everyone might afford or might be will- the collective. If we can do that, surely, we should, ing to pay the cost. If we adopt it, then the same as we would achieve the same collective benefit with kind of limitation should apply to religious and non- less liberty infringements. This might be a better religious objections alike. The degree of liberty that way of balancing fairness, collective good, and indi- people enjoy in liberal, secular societies should not vidual freedom. However, we would need to consider depend on whether people hold certain types of reli- whether the mechanism used to identify those allowed gious views. to object is in itself fair. For instance, a first come/first served basis for granting free choice of the vaccine is unlikely to be a fair system. Those who come first Meeting Two Objections are likely to be either those who have priority access to the vaccine or easier access to healthcare services. One potential concern is that not offering the choice The fairer system might be a lottery among all those of a vaccine (particularly where there are ethical or who will be vaccinated in the short and long term and religious reasons that are important to people) might who would want the free choice. A lottery might be backfire by reducing people’s willingness to vacci- quite difficult to implement and to consistently keep nate. It might lead to negative publicity around vac- in place over time. It is also worth mentioning that it cination and risk worse overall public health. If our is not a solution normally adopted in other contexts worry is that giving a suboptimal vaccine might com- where a small number of outliers would not “make a promise public health strategies, surely a suboptimal difference.” For instance, we do not have a lottery to vaccine is still better than no vaccine at all. This con- allow a small number of individuals to decide what sideration is more relevant in a context where vacci- their taxes should and should not fund, even if we can nation is not mandatory, and therefore vaccine refusal certainly afford a certain number of such individuals. may lead to a failure to achieve adequate levels of This suggests that either a lottery solution is not very collective immunity. (Whether vaccine mandates easily implementable or that we think that it would would instead be effective is beyond the scope of this still be unfair towards those who do make their fair article). contribution. One possibility is that the unfairness in This is a reasonable concern. However, we also question lies not so much in the procedure to deter- need to consider the possibility, raised in the previous mine whom to exempt but in the idea that we should section, that providing choice of vaccine will under- have exemptions in the first place. mine strategies of vaccine distribution. If we make We are however happy to concede that the lottery the choice available to anyone irrespective of their model is an option worth considering if we agree it is moral or religious views (and there is a restricted fair and accommodates individual liberties at no sig- supply of vaccines), then this risk is real. Thus, vac- nificant collective cost. cination strategies could be compromised either way. We should not simply assume that a higher collective uptake with a large proportion of suboptimal indi- Conclusion vidual vaccinations would be better than a lower col- lective uptake where all those who do get vaccinated Distributing COVID-19 vaccines in the most effective receive the best vaccine for them. way is the most urgent goal and the primary responsibil- These issues largely come down to empiri- ity of governments in designing vaccination strategies. cal considerations and expectations about people’s There is also a strong ethical requirement to make the behaviour, more than to ethical considerations. It distribution cost-effective, at least as long as availabil- is hard to tell whether the risk of restrictive policies ity is limited (but probably also after this phase). These Vol.: (0123456789) 1 3 618 Bioethical Inquiry (2021) 18:609–619 Open Access This article is licensed under a Creative Com- requirements imply that vaccination strategies should be mons Attribution 4.0 International License, which permits guided primarily by considerations around public health use, sharing, adaptation, distribution and reproduction in any and effective use of limited resources. medium or format, as long as you give appropriate credit to the Different vaccines’ characteristics might require original author(s) and the source, provide a link to the Crea- tive Commons licence, and indicate if changes were made. The that different vaccines be distributed in different ways images or other third party material in this article are included and to different groups in the pursuit of such goals. in the article’s Creative Commons licence, unless indicated Whether vaccines have been obtained with the use otherwise in a credit line to the material. If material is not of aborted foetuses is not a consideration that is rel- included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds evant to the pursuit of such strategies, and protecting the permitted use, you will need to obtain permission directly religious freedom is not a priority of public health from the copyright holder. To view a copy of this licence, visit interventions (to say that it is not a “priority” does not http:// creat iveco mmons. org/ licen ses/ by/4. 0/. mean that it is not important). However, as long as public health interventions are carried out in liberal societies, individual freedoms References should be given some consideration, in a way that does not significantly affect public health priorities. Asch, D., J. Baron, J.C. Hershey, et al. 1994. Omission bias and pertussis vaccination. 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Published: Dec 23, 2021

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