This open access book discusses individual, collective, and institutional responsibilities with regard to vaccination from the perspective of philosophy and public health ethics. It addresses the issue of what it means for a collective to be morally responsible for the realisation of herd immunity and what the implications of collective responsibility are for individual and institutional responsibilities. The first chapter introduces some key concepts in the vaccination debate, such as ‘herd immunity’, ‘public goods’, and ‘vaccine refusal’; and explains why failure (...) to vaccinate raises certain ethical issues. The second chapter analyses, from a philosophical perspective, the relationship between individual, collective, and institutional responsibilities with regard to the realisation of herd immunity. The third chapter is about the principle of least restrictive alternative in public health ethics and its implications for vaccination policies. Finally, the fourth chapter presents an ethical argument for unqualified compulsory vaccination, i.e. for compulsory vaccination that does not allow for any conscientious objection. The book will appeal to philosophers interested in public health ethics and the general public interested in the philosophical underpinning of different arguments about our moral obligations with regard to vaccination. (shrink)

Abortion is largely accepted even for reasons that do not have anything to do with the fetus' health. By showing that (1) both fetuses and newborns do not have the same moral status as actual persons, (2) the fact that both are potential persons is morally irrelevant and (3) adoption is not always in the best interest of actual people, the authors argue that what we call ‘after-birth abortion’ (killing a newborn) should be permissible in all the cases where abortion (...) is, including cases where the newborn is not disabled. (shrink)

We describe a form of moral artificial intelligence that could be used to improve human moral decision-making. We call it the “artificial moral advisor”. The AMA would implement a quasi-relativistic version of the “ideal observer” famously described by Roderick Firth. We describe similarities and differences between the AMA and Firth’s ideal observer. Like Firth’s ideal observer, the AMA is disinterested, dispassionate, and consistent in its judgments. Unlike Firth’s observer, the AMA is non-absolutist, because it would take into account the human (...) agent’s own principles and values. We argue that the AMA would respect and indeed enhance individuals’ moral autonomy, help individuals achieve wide and a narrow reflective equilibrium, make up for the limitations of human moral psychology in a way that takes conservatives’ objections to human bioenhancement seriously, and implement the positive functions of intuitions and emotions in human morality without their downsides, such as biases and prejudices. (shrink)

We argue that individuals who have access to vaccines and for whom vaccination is not medically contraindicated have a moral obligation to contribute to the realisation of herd immunity by being vaccinated. Contrary to what some have claimed, we argue that this individual moral obligation exists in spite of the fact that each individual vaccination does not significantly affect vaccination coverage rates and therefore does not significantly contribute to herd immunity. Establishing the existence of a moral obligation to be vaccinated (...) despite the negligible contribution each vaccination can make to the realisation of herd immunity is important because such moral obligation would strengthen the justification for coercive vaccination policies. We show that two types of arguments—namely a utilitarian argument based on Parfit’s Principle of Group Beneficence and a contractualist argument—can ground an individual moral obligation to be vaccinated, in spite of the imperceptible contribution that any single vaccination makes to vaccine coverage rates. We add a further argument for a moral obligation to be vaccinated that does not require embracing problematic comprehensive moral theories such as utilitarianism or contractualism. The argument is based on a “duty of easy rescue” applied to collectives, which grounds a collective moral obligation to realise herd immunity, and on a principle of fairness in the distribution of the burdens that must be borne to realise herd immunity. (shrink)

Conscientious objection in health care is a form of compromise whereby health care practitioners can refuse to take part in safe, legal, and beneficial medical procedures to which they have a moral opposition (for instance abortion). Arguments in defense of conscientious objection in medicine are usually based on the value of respect for the moral integrity of practitioners. I will show that philosophical arguments in defense of conscientious objection based on respect for such moral integrity are extremely weak and, if (...) taken seriously, lead to consequences that we would not (and should not) accept. I then propose that the best philosophical argument that defenders of conscientious objection in medicine can consistently deploy is one that appeals to (some form of) either moral relativism or subjectivism. I suggest that, unless either moral relativism or subjectivism is a valid theory—which is exactly what many defenders of conscientious objection (as well as many others) do not think—the role of moral integrity and conscientious objection in health care should be significantly downplayed and left out of the range of ethically relevant considerations. (shrink)

I argue that there are significant moral reasons in addition to harm prevention for making vaccination against certain common infectious diseases compulsory. My argument is based on an analogy between vaccine refusal and tax evasion. First, I discuss some of the arguments for compulsory vaccination that are based on considerations of the risk of harm that the non‐vaccinated would pose on others; I will suggest that the strength of such arguments is contingent upon circumstances and that in order to provide (...) the strongest defence possible of compulsory vaccination, such arguments need to be supplemented by additional arguments. I will then offer my additional argument for compulsory vaccination: I will argue that in both cases of vaccine refusal and of tax evasion individuals fail to make their fair contribution to important social and public goods, regardless of whether each individual contribution ‘makes a difference’. While fairness considerations have sometimes been used to support a moral duty to vaccinate, they have not been appealed to in order to argue for a legal duty to vaccinate. I will suggest that this is due, among other things, to a misapplication of the principle of the least restrictive alternative in public health. Finally, I will address nine possible objections to my argument. (shrink)

Controlled Human Infection Model (CHIM) research involves the infection of otherwise healthy participants with disease often for the sake of vaccine development. The COVID-19 pandemic has emphasised the urgency of enhancing CHIM research capability and the importance of having clear ethical guidance for their conduct. The payment of CHIM participants is a controversial issue involving stakeholders across ethics, medicine and policymaking with allegations circulating suggesting exploitation, coercion and other violations of ethical principles. There are multiple approaches to payment: reimbursement, wage (...) payment and unlimited payment. We introduce a new Payment for Risk Model, which involves paying for time, pain and inconvenience and for risk associated with participation. We give philosophical arguments based on utility, fairness and avoidance of exploitation to support this. We also examine a cross-section of the UK public and CHIM experts. We found that CHIM participants are currently paid variable amounts. A representative sample of the UK public believes CHIM participants should be paid approximately triple the UK minimum wage and should be paid for the risk they endure throughout participation. CHIM experts believe CHIM participants should be paid more than double the UK minimum wage but are divided on the payment for risk. The Payment for Risk Model allows risk and pain to be accounted for in payment and could be used to determine ethically justifiable payment for CHIM participants.Although many research guidelines warn against paying large amounts or paying for risk, our empirical findings provide empirical support to the growing number of ethical arguments challenging this status quo. We close by suggesting two ways (value of statistical life or consistency with risk in other employment) by which payment for risk could be calculated. (shrink)

We address the issue of whether, why and under what conditions, quarantine and isolation are morally justified, with a particular focus on measures implemented in the developing world. We argue that the benefits of quarantine and isolation justify some level of coercion or compulsion by the state, but that the state should be able to provide the strongest justification possible for implementing such measures. While a constrained form of consequentialism might provide a justification for such public health interventions, we argue (...) that a stronger justification is provided by a principle of State Enforced Easy Rescue: a state may permissibly compel individuals to engage in activities that entail a small cost to them but a large benefit to others, because individuals have a moral duty of easy rescue to engage in those activities. The principle of State Enforced Easy Rescue gives rise to an Obligation Enforcement Requirement: the state should create the conditions such that submitting to coercive or compulsive measures becomes a fundamental moral duty of individuals, i.e. a duty of easy rescue. When the state can create such conditions, it has the strongest justification possible for implementing coercive or compulsive measures, because individuals have a moral duty to temporarily relinquish the rights that such measures would infringe. Our argument has significant implications for how public health emergencies in the developing world should be tackled. Where isolation and quarantine measures are necessary, states or the international community have a moral obligation to provide certain benefits to those quarantined or isolated. (shrink)

We argue that, from the point of view public health ethics, vaccination is significantly analogous to seat belt use in motor vehicles and that coercive vaccination policies are ethically justified for the same reasons why coercive seat belt laws are ethically justified. We start by taking seriously the small risk of vaccines’ side effects and the fact that such risks might need to be coercively imposed on individuals. If millions of individuals are vaccinated, even a very small risk of serious (...) side effects implies that, statistically, at some point side effects will occur. Imposing such risks raises issues about individual freedom to decide what risks to take on oneself or on one’s children and about attribution of responsibility in case of adverse side effects. Seat belt requirements raise many of the same ethical issues as vaccination requirements, and seat belt laws initially encountered some opposition from the public that is very similar to some of the current opposition to vaccine mandates. The analogy suggests that the risks of vaccines do not constitute strong enough reasons against coercive vaccination policies and that the same reasons that justify compulsory seat belt use—a measure now widely accepted and endorsed—also justify coercive vaccination policies. (shrink)

The rapid development of vaccines against COVID‐19 represents a huge achievement, and offers hope of ending the global pandemic. At least three COVID‐19 vaccines have been approved or are about to be approved for distribution in many countries. However, with very limited initial availability, only a minority of the population will be able to receive vaccines this winter. Urgent decisions will have to be made about who should receive priority for access. Current policy in the UK appears to take the (...) view that those who are most vulnerable to COVID‐19 should get the vaccine first. While this is intuitively attractive, we argue that there are other possible values and criteria that need to be considered. These include both intrinsic and instrumental values. The former are numbers of lives saved, years of life saved, quality of the lives saved, quality‐adjusted life‐years (QALYs), and possibly others including age. Instrumental values include protecting healthcare systems and other broader societal interests, which might require prioritizing key worker status and having dependants. The challenge from an ethical point of view is to strike the right balance among these values. It also depends on effectiveness of different vaccines on different population groups and on modelling around cost‐effectiveness of different strategies. It is a mistake to simply assume that prioritizing the most vulnerable is the best strategy. Although that could end up being the best approach, whether it is or not requires careful ethical and empirical analysis. (shrink)

Vaccine refusal occurs for a variety of reasons. In this article we examine vaccine refusals that are made on conscientious grounds; that is, for religious, moral, or philosophical reasons. We focus on two questions: first, whether people should be entitled to conscientiously object to vaccination against contagious diseases ; second, if so, to what constraints or requirements should conscientious objection to vaccination be subject. To address these questions, we consider an analogy between CO to vaccination and CO to military service. (...) We argue that conscientious objectors to vaccination should make an appropriate contribution to society in lieu of being vaccinated. The contribution to be made will depend on the severity of the relevant disease, its morbidity, and also the likelihood that vaccine refusal will lead to harm. In particular, the contribution required will depend on whether the rate of CO in a given population threatens herd immunity to the disease in question: for severe or highly contagious diseases, if the population rate of CO becomes high enough to threaten herd immunity, the requirements for CO could become so onerous that CO, though in principle permissible, would be de facto impermissible. (shrink)

An international legal agreement governing the global antimicrobial commons would represent the strongest commitment mechanism for achieving collective action on antimicrobial resistance (AMR). Since AMR has important similarities to climate change—both are common pool resource challenges that require massive, long-term political commitments—the first article in this special issue draws lessons from various climate agreements that could be applicable for developing a grand bargain on AMR. We consider the similarities and differences between the Paris Climate Agreement and current governance structures for (...) AMR, and identify the merits and challenges associated with different international forums for developing a long-term international agreement on AMR. To be effective, fair, and feasible, an enduring legal agreement on AMR will require a combination of universal, differentiated, and individualized requirements, nationally determined contributions that are regularly reviewed and ratcheted up in level of ambition, a regular independent scientific stocktake to support evidence informed policymaking, and a concrete global goal to rally support. (shrink)

I argue that appeals to conscience do not constitute reasons for granting healthcare professionals exemptions from providing services they consider immoral. My argument is based on a comparison between a type of objection that many people think should be granted, i.e. to abortion, and one that most people think should not be granted, i.e. to antibiotics. I argue that there is no principled reason in favour of conscientious objection qua conscientious that allows to treat these two cases differently. Therefore, I (...) conclude that there is no principled reason for granting conscientious objection qua conscientious in healthcare. What matters for the purpose of justifying exemptions is not whether an objection is ‘conscientious’, but whether it is based on the principles and values informing the profession. I provide examples of acceptable forms of objection in healthcare. (shrink)

Ethical debate surrounding human enhancement, especially by biotechnological means, has burgeoned since the turn of the century. Issues discussed include whether specific types of enhancement are permissible or even obligatory, whether they are likely to produce a net good for individuals and for society, and whether there is something intrinsically wrong in playing God with human nature. We characterize the main camps on the issue, identifying three main positions: permissive, restrictive and conservative positions. We present the major sub-debates and lines (...) of argument from each camp. The review also gives a flavor of the general approach of key writers in the literature such as Julian Savulescu, Nick Bostrom, Michael Sandel, and Leon Kass. (shrink)

Strategies to increase influenza vaccination rates have typically targeted healthcare professionals and individuals in various high-risk groups such as the elderly. We argue that they should focus on increasing vaccination rates in children. Because children suffer higher influenza incidence rates than any other demographic group, and are major drivers of seasonal influenza epidemics, we argue that influenza vaccination strategies that serve to increase uptake rates in children are likely to be more effective in reducing influenza-related morbidity and mortality than those (...) targeting HCPs or the elderly. This is true even though influenza-related morbidity and mortality amongst children are low, except in the very young. Further, we argue that there are no decisive reasons to suppose that children-focused strategies are less ethically acceptable than elderly or HCP-focused strategies. (shrink)

Seven COVID-19 vaccines are now being distributed and administered around the world (figure correct at the time of submission), with more on the horizon. It is widely accepted that healthcare workers should have high priority. However, questions have been raised about what we ought to do if members of priority groups refuse vaccination. Using the case of influenza vaccination as a comparison, we know that coercive approaches to vaccination uptake effectively increase vaccination rates among healthcare workers and reduce patient morbidity (...) if properly implemented. Using the principle of least restrictive alternative, we have developed an intervention ladder for COVID-19 vaccination policies among healthcare workers. We argue that healthcare workers refusing vaccination without a medical reason should be temporarily redeployed and, if their refusal persists after the redeployment period, eventually suspended, in order to reduce the risk to their colleagues and patients. This ‘conditional’ policy is a compromise between entirely voluntary or entirely mandatory policies for healthcare workers, and is consistent with healthcare workers’ established professional, legal and ethical obligations to their patients and to society at large. (shrink)

Cameron et al ’s1 ethical considerations about the ‘Dualism of Values’ in pandemic response emphasise the need to strike a fair balance between the interests of the less vulnerable to COVID-19 and the interests of the more vulnerable. Those considerations are at the basis of ethical defences of focused protection strategies.2 One example is the proposal put forward in the Great Barrington Declaration. It presented focused protection strategies as more ethical alternatives to lockdowns which would prevent lockdowns’ ‘irreparable damage, with (...) the underprivileged disproportionately harmed’.3 Here we want to suggest that a version of Cameron et al ’s analysis can be applied to the case of vaccines to support a focused protection vaccination strategy. At this stage, we should limit vaccination to the vulnerable and not target children in COVID-19 vaccination strategies. We argue that, given the current state of knowledge about COVID-19, immunity and vaccines, it would be wrong to pose the costs and risks of vaccines on children for three reasons. First, they are unlikely to benefit from COVID-19 vaccination …. (shrink)

In this review article we describe the current scope, methods, and contents of medical ethics education in medical schools in Western English speaking countries (mainly the United Kingdom, the United States, and Australia). We assess the strengths and weaknesses of current medical ethics curricula, and students’ levels of satisfaction with different teaching approaches and their reported difficulties in learning medical ethics concepts and applying them in clinical practice. We identify three main challenges for medical ethics education: counteracting the bad effects (...) of the “hidden curriculum,” teaching students how to apply ethical knowledge and critical thinking to real cases in clinical practice, and shaping future doctors’ right character through ethics education. We suggest ways in which these challenges could be addressed. On the basis of this analysis, we propose practical guidelines for designing, implementing, teaching, and assessing a medical ethics program within a four-year medical course. (shrink)

I argue that much philosophical discussion of moral disgust suffers from two ambiguities: first, it is not clear whether arguments for the moral authority of disgust apply to disgust as a consequence of moral evaluations or instead to disgust as a moralizing emotion; second, it is not clear whether the word ‘moral’ is used in a normative or in a descriptive sense. This lack of clarity generates confusion between ‘fittingness’ and ‘appropriateness’ of disgust. I formulate three conditions that arguments for (...) the moral authority of disgust need—but typically fail—to satisfy, in order to avoid (1) circularity, (2) the naturalistic fallacy, and (3) redundancy. These conditions are, respectively, (1) the identification of the direction of the causal relation between disgust and moral evaluation, (2) a demonstration that disgust is ‘fitting’ to morally relevant properties, and (3) a demonstration that disgust is ‘appropriate’ when elicited by these morally relevant properties. I will also suggest that, regardless of whether an argument for the moral authority of disgust can be made, it would be better to avoid the rather obscure term ‘moral disgust’. (shrink)

We provide ethical criteria to establish when vaccine mandates for healthcare workers are ethically justifiable. The relevant criteria are the utility of the vaccine for healthcare workers, the utility for patients (both in terms of prevention of transmission of infection and reduction in staff shortage), and the existence of less restrictive alternatives that can achieve comparable benefits. Healthcare workers have professional obligations to promote the interests of patients that entail exposure to greater risks or infringement of autonomy than ordinary members (...) of the public. Thus, we argue that when vaccine mandates are justified on the basis of these criteria, they are not unfairly discriminatory and the level of coercion they involve is ethically acceptable—and indeed comparable to that already accepted in healthcare employment contracts. Such mandates might be justified even when general population mandates are not. Our conclusion is that, given current evidence, those ethical criteria justify mandates for influenza vaccination, but not COVID-19 vaccination, for healthcare workers. We extend our arguments to other vaccines. (shrink)

Conflict of interests in medicine are typically taken to be financial in nature: it is often assumed that a COI occurs when a healthcare practitioner’s financial interest conflicts with patients’ interests, public health interests, or professional obligations more generally. Even when non-financial COIs are acknowledged, ethical concerns are almost exclusively reserved for financial COIs. However, the notion of “interests” cannot be reduced to its financial component. Individuals in general, and medical professionals in particular, have different types of interests, many of (...) which are non-financial in nature but can still conflict with professional obligations. The debate about healthcare delivery has largely overlooked this broader notion of interests. Here, we will focus on health practitioners’ moral or religious values as particular types of personal interests involved in healthcare delivery that can generate COIs and on conscientious objection in healthcare as the expression of a particular type of COI. We argue that, in the healthcare context, the COIs generated by interests of conscience can be as ethically problematic, and therefore should be treated in the same way, as financial COIs. (shrink)

To the extent that antibiotic resistance (ABR) is accelerated by antibiotic consumption and that it represents a serious public health emergency, it is imperative to drastically reduce antibiotic consumption, particularly in high‐income countries. I present the problem of ABR as an instance of the collective action problem known as ‘tragedy of the commons’. I propose that there is a strong ethical justification for taxing certain uses of antibiotics, namely when antibiotics are required to treat minor and self‐limiting infections, such as (...) respiratory tract infections, in otherwise healthy individuals. Taxation would allow a reduction in consumption (given certain behavioural economics assumptions) and/or ensure that individuals internalize or compensate for their contribution to the erosion of the common good of antibiotic effectiveness. I suggest that revenue from the tax could be used to fund conservation and innovation strategies. Taxation might be a coercive policy, especially for certain individuals, but the ethical case for coercive policies is very strong when the good to be preserved is important enough and when they force individuals to do something they have a moral obligation to do anyway. I argue that, in the case of mild and self‐limiting infections, individuals have a moral duty of easy rescue and a moral duty of fairness to make their contribution to the preservation of the common good of antibiotic effectiveness by foregoing antibiotics. I also suggest that taxing antibiotics in such cases is an all things considered ethically justified policy even if it would introduce inequalities in access to healthcare. (shrink)

The range of opportunities people enjoy in life largely depends on social, biological, and genetic factors for which individuals are not responsible. Philosophical debates about equality of opportunities have focussed mainly on addressing social determinants of inequalities. However, the introduction of human bioenhancement should make us reconsider what our commitment to equality entails. We propose a way of improving morally relevant equality that is centred on what we consider a fair distribution of bioenhancements. In the first part, we identify three (...) main positions in the debate on bioenhancement and equality, and we show how each of them fails to meet the demands of a serious commitment to equality. In the second part, we formulate a new proposal that we think better promotes equality of opportunities: people from disadvantaged socio-economic backgrounds should be given access to bioenhancements while people from privileged socio-economic background should be prohibited from using them. We argue that those who are concerned about the inequality implications of bioenhancement should embrace this solution, rather than reject bioenhancement. (shrink)

Public health policies often require individuals to make personal sacrifices for the sake of protecting other individuals or the community at large. Such requirements can be more or less demanding for individuals. This paper examines the implications of demandingness for public health ethics and policy. It focuses on three possible public health policies that pose requirements that are differently demanding: vaccination policies, policy to contain antimicrobial resistance, and quarantine and isolation policies. Assuming the validity of the ‘demandingness objection’ in ethics, (...) we argue that states should try to pose requirements that individuals would have an independent moral obligation to fulfil, and therefore that are not too demanding. In such cases, coercive measures are ethically justified, especially if the interventions also entail some benefits to the individuals; this is, for example, the case of vaccination policies. When public health policies need to require individuals to do something that is too demanding to constitute an independent moral obligation, states have an obligation to either provide incentives to give individuals non-moral reasons to fulfil a certain requirement – as in the case of policies that limit antibiotic prescriptions – or to compensate individuals for being forced to do something that is too demanding to constitute an independent moral obligation – as in the case of quarantine and isolation policies. (shrink)

We humans can enhance some of our mental and physical abilities above the normal upper limits for our species with the use of particular drug therapies and medical procedures. We will be able to enhance many more of our abilities in more ways in the near future. Some commentators have welcomed the prospect of wide use of human enhancement technologies, while others have viewed it with alarm, and have made clear that they find human enhancement morally objectionable. The Ethics of (...) Human Enhancement examines whether the reactions can be supported by articulated philosophical reasoning, or perhaps explained in terms of psychological influences on moral reasoning. An international team of ethicists refresh the debate with new ideas and arguments, making connections with scientific research and with related issues in moral philosophy. (shrink)

An international team of ethicists refresh the debate about human enhancement by examining whether resistance to the use of technology to enhance our mental and physical capabilities can be supported by articulated philosophical reasoning, or explained away, e.g. in terms of psychological influences on moral reasoning.

Antimicrobial resistance (AMR) is an urgent threat to global public health and development. Mitigating this threat requires substantial short-term action on key AMR priorities. While international legal agreements are the strongest mechanism for ensuring collaboration among countries, negotiating new international agreements can be a slow process. In the second article in this special issue, we consider whether harnessing existing international legal agreements offers an opportunity to increase collective action on AMR goals in the short-term. We highlight ten AMR priorities and (...) several strategies for achieving these goals using existing “legal hooks” that draw on elements of international environmental, trade and health laws governing related matters that could be used as they exist or revised to include AMR. We also consider the institutional mandates of international authorities to highlight areas where additional steps could be taken on AMR without constitutional changes. Overall, we identify 37 possible mechanisms to strengthen AMR governance using the International Health Regulations, the Agreement on the Application of Sanitary and Phytosanitary Measures, the Agreement on Trade-Related Aspects of Intellectual Property Rights, the Agreement on Technical Barriers to Trade, the International Convention on the Harmonized Commodity Description and Coding System, and the Basel, Rotterdam, and Stockholm conventions. Although we identify many shorter-term opportunities for addressing AMR using existing legal hooks, none of these options are capable of comprehensively addressing all global governance challenges related to AMR, such that they should be pursued simultaneously with longer-term approaches including a dedicated international legal agreement on AMR. (shrink)

Antibiotic use in animal farming is one of the main drivers of antibiotic resistance both in animals and in humans. In this paper we propose that one feasible and fair way to address this problem is to tax animal products obtained with the use of antibiotics. We argue that such tax is supported both by deontological arguments, which are based on the duty individuals have to compensate society for the antibiotic resistance to which they are contributing through consumption of animal (...) products obtained with the use of antibiotics; and a cost-benefit analysis of taxing such animal products and of using revenue from the tax to fund alternatives to use of antibiotics in animal farming. Finally, we argue that such a tax would be fair because individuals who consume animal products obtained with the use of antibiotics can be held morally responsible, i.e. blameworthy, for their contribution to antibiotic resistance, in spite of the fact that each individual contribution is imperceptible. (shrink)

Antimicrobial resistance (AMR) is a global public health disaster driven largely by antibiotic use in human health care. Doctors considering whether to prescribe antibiotics face an ethical conflict between upholding individual patient health and advancing public health aims. Existing literature mainly examines whether patients awaiting consultations desire or expect to receive antibiotic prescriptions, but does not report views of the wider public regarding conditions under which doctors should prescribe antibiotics. It also does not explore the ethical significance of public views (...) or their sensitivity to awareness of AMR risks or the standpoint (self-interested or impartial) taken by participants. Methods: An online survey was conducted with a sample of the U.S. public (n = 158). Participants were asked to indicate what relative priority should be given to individual patients and society-at-large from various standpoints and in various contexts, including antibiotic prescription. Results: Of the participants, 50.3% thought that doctors should generally prioritize individual patients over society, whereas 32.0% prioritized society over individual patients. When asked in the context of AMR, 39.2% prioritized individuals whereas 45.5% prioritized society. Participants were significantly less willing to prioritize society over individuals when they themselves were the patient, both in general (p = .001) and in relation to AMR specifically (p = .006). Conclusions: Participants’ attitudes were more oriented to society and sensitive to collective responsibility when informed about the social costs of antibiotic use and when considered from a third-person rather than first-person perspective. That is, as participants came closer to taking the perspective of an informed and impartial “ideal observer,” their support for prioritizing society increased. Our findings suggest that, insofar as antibiotic policies and practices should be informed by attitudes that are impartial and well-informed, there is significant support for prioritizing society. (shrink)

We argue that we should provide extra payment not only for extra time worked but also for the extra risks healthcare workers (and those working in healthcare settings) incur while caring for COVID‐19 patients—and more generally when caring for patients poses them at significantly higher risks than normal. We argue that the extra payment is warranted regardless of whether healthcare workers have a professional obligation to provide such risky healthcare. Payment for risk would meet four essential ethical requirements. First, assuming (...) healthcare workers do not have a professional obligation to take on themselves the risks, payments in the form of incentives would preserve autonomy in deciding what risks to take on oneself. Second, even assuming that healthcare workers do have a professional obligation to take on themselves the risks, payments for risk would create fair working conditions by avoiding exploitation. Third, payments for risk would make it more likely that public healthcare systems can discharge their institutional responsibility to provide healthcare in circumstances where healthcare workers may otherwise (perhaps legitimately) opt out. Fourth, payments for risk would guarantee an efficient healthcare system in pandemic situations. Finally, we address two likely objections that some might raise against our proposal, particularly with regard to incentives, namely that such payments or incentives can themselves be coercive and that they represent a form of undue inducement. (shrink)

I argue that appeals to conscience do not constitute reasons for granting healthcare professionals exemptions from providing services they consider immoral (e.g. abortion). My argument is based on a comparison between a type of objection that many people think should be granted, i.e. to abortion, and one that most people think should not be granted, i.e. to antibiotics. I argue that there is no principled reason in favour of conscientious objection qua conscientious that allows to treat these two cases differently. (...) Therefore, I conclude that there is no principled reason for granting conscientious objection qua conscientious in healthcare. What matters for the purpose of justifying exemptions is not whether an objection is ‘conscientious’, but whether it is based on the principles and values informing the profession. I provide examples of acceptable forms of objection in healthcare. (shrink)

Although the COVID-19 pandemic is a serious public health and economic emergency, and although effective vaccines are the best weapon we have against it, there are groups and individuals who oppose certain kinds of vaccines because of personal moral or religious reasons. The most widely discussed case has been that of certain religious groups that oppose research on COVID-19 vaccines that use cell lines linked to abortions and that object to receiving those vaccine because of their moral opposition to abortion. (...) However, moral opposition to COVID-19 vaccine research can be based on other considerations, both secular and religious. We argue that religious or personal moral objections to vaccine research are unethical and irresponsible, and in an important sense often irrational. They are unethical because of the risk of causing serious harm to other people for no valid reason; irresponsible because they run counter to individual and collective responsibilities to contribute to important public health goals; and in the case of certain kinds of religious opposition, they might be irrational because they are internally inconsistent. All in all, our argument translates into the rather uncontroversial claim that we should prioritize people’s lives over religious freedom in vaccine research and vaccination roll out. (shrink)

We discuss whether and under what conditions people should be allowed to choose which COVID-19 vaccine to receive on the basis of personal ethical views. The problem arises primarily with regard to some religious groups’ concerns about the connection between certain COVID-19 vaccines and abortion. Vaccines currently approved in Western countries make use of foetal cell lines obtained from aborted foetuses either at the testing stage or at the development stage. The Catholic Church’s position is that, if there are alternatives, (...) Catholic people have a 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 argue that any consideration regarding free choice of the vaccine should apply to religious and non-religious claims alike, in order to avoid religion-based discrimination. However, we also argue that, in a context of limited availability, considering the significant differences in costs and effectiveness profile of the vaccines available, people should only be allowed to choose the preferred vaccine if: 1) this does not risk compromising vaccination strategies; and 2) they internalize any additional cost that their choice might entail. The State should only subsidize the vaccine that is more cost-effective for any demographic group from the point of view of public health strategies. (shrink)

Next SectionI challenge the idea that the argument from potential (AFP) represents a valid moral objection to abortion. I consider the form of AFP that was defended by Hare, which holds that abortion is against the interests of the potential person who is prevented from existing. My reply is that AFP, though not unsound by itself, does not apply to the issue of abortion. The reason is that AFP only works in the cases of so-called same number and same people (...) choices, but it falsely presupposes that abortion is such a kind of choice. This refutation of AFP implies that (1) abortion is not only morally permissible but sometimes even morally mandatory and (2) abortion is morally permissible even when the potential person’s life is foreseen to be worth living. (shrink)

How should we regulate genome editing in the face of persistent substantive disagreement about the moral status of this technology and its applications? In this paper, we aim to contribute to resolving this question. We first present two diametrically opposed possible approaches to the regulation of genome editing. A first approach, which we refer to as “elitist,” is inspired by Joshua Greene’s work in moral psychology. It aims to derive at an abstract theoretical level what preferences people would have if (...) they were committed to implementing public policies regulating genome editing in a context of ethical pluralism. The second approach, which we refer to as the democratic approach, defended by Francoise Baylis and Sheila Jasanoff et al., emphasizes the importance of including the public’s expressed attitudes in the regulation of genome editing. After pointing out a serious shortcoming with each of these approaches, we propose our own favored approach—the “enlightened democracy” approach—which attempts to combine the strengths of the elitist and democratic approaches while avoiding their weaknesses. (shrink)

Reliance on intuitive and emotive responses is widespread across many areas of bioethics, and the current debate on biotechnological human enhancement is particularly interesting in this respect. A strand of “bioconservatives” that has explicitly drawn connections to the modern conservative tradition, dating back to Edmund Burke, appeals explicitly to the alleged wisdom of our intuitions and emotions to ground opposition to some biotechnologies or their uses. So-called bioliberals, those who in principle do not oppose human bioenhancement, tend to rely on (...) rational arguments and to see intuitions and emotions mostly as sources of biases. This approach often translates into shifting the burden of proof onto bioconservatives and challenging them to provide arguments against the proposed enhancement to back what bioliberals perceive as merely intuitive, emotive, and irrational reactions. -/- In this article, I am going to show that the methodological divide between bioliberals and bioconservatives is less significant than at first glance it appears to be and less significant than it is often taken to be. I will do so by defending two theses. The first is that reliance on intuitions and emotions is not a prerogative of bioconservatives: bioliberals have their typical intuitions and emotive responses and are for this reason exposed to potential biases in the same way as bioconservatives are. The second thesis is that reliance on intuitions and emotions is not necessarily antithetic to reason and rationality. This latter thesis has been philosophically defended with particular reference to the debate on biotechnologies, while the former is perhaps more controversial and more difficult to accept—at least for bioliberals. In both cases, I will support the claims by drawing on resources from the field of moral psychology and the sciences of the mind and, particularly, by applying to some positions in the enhancement debate recent findings about the role of intuitions and emotions in human moral assessment. This new empirically informed perspective holds promises for solving the methodological controversy between bioconservatives and bioliberals, thus enabling proper dialogue and debate between the two sides. (shrink)

The debate around lockdowns as a response to the recent pandemic is typically framed in terms of a tension between freedom and health. However, on some views, protection of health or reduction of virus‐related risks can also contribute to freedom. Therefore, there might be no tension between freedom and health in public health restrictions. I argue that such views fail to appreciate the different understandings of freedom that are involved in the trade‐off between freedom and health. Grasping these distinctions would (...) allow to appreciate why different people give more weight to different aspects of limitations of freedom, including whether certain options are made simply risky or impossible, whether limitations of freedom are posed intentionally or happen accidentally, whether risks are beyond a threshold of acceptability, and who gets to decide that. I provide a conceptual analysis of the relationship between different types of freedom, public health policies, viruses and diseases. As I argue, identifying what freedom‐based reasons count for and against different types of public health restrictions requires distinguishing between viruses and diseases, between lockdowns and other types of restrictive policies, and between risks posed by viruses and threats of penalties involved by restrictive policies. (shrink)

The Australian Federal Government has announced a two-year trial scheme to compensate living organ donors. The compensation will be the equivalent of six weeks paid leave at the rate of the national minimum wage. In this article I analyse the ethics of compensating living organ donors taking the Australian scheme as a reference point. Considering the long waiting lists for organ transplantations and the related costs on the healthcare system of treating patients waiting for an organ, the 1.3 million AUD (...) the Australian Government has committed might represent a very worthwhile investment. I argue that a scheme like the Australian one is sufficiently well designed to avoid all the ethical problems traditionally associated with attaching a monetary value to the human body or to parts of it, namely commodification, inducement, exploitation, and equality issues. Therefore, I suggest that the Australian scheme, if cost-effective, should represent a model for other countries to follow. Nonetheless, although I endorse this scheme, I will also argue that this kind of scheme raises issues of justice in regard to the distribution of organs. Thus, I propose that other policies would be needed to supplement the scheme in order to guarantee not only a higher number of organs available, but also a fair distribution. (shrink)

Conscientious objection in healthcare is often granted by many legislations regulating morally controversial medical procedures, such as abortion or medical assistance in dying. However, there is virtually no protection of positive claims of conscience, that is, of requests by healthcare professionals to provide certain services that they conscientiously believe ought to be provided, but that are ruled out by institutional policies. Positive claims of conscience have received comparatively little attention in academic debates. Some think that negative and positive claims of (...) conscience deserve equal protection in terms of measures that institutions ought to take to accommodate them. However, in this issue of The Journal of Clinical Ethics (JCE), Abram Brummett argues against this symmetry thesis. He suggests that the relevant distinction is not between negative and positive claims of conscience, but between negative and positive rights of conscience. He argues that conscientious refusals and positive claims of conscience are both already protected as negative rights of conscience, but that this does not require institutions to accommodate positive claims of conscience. In this article I will argue that both Brummett and the authors he criticizes share a wrong view about the existence of conscience rights in healthcare. I will argue that there is no right to conscientious objection in healthcare, whether positive or negative. Thus, contra Brummett, I argue that the question whether such rights are positive or negative is as irrelevant as the question whether the claims of conscience are positive or negative. (shrink)

Antimicrobial resistance is one of the greatest public health crises of our time. The natural biological process that causes microbes to become resistant to antimicrobial drugs presents a complex social challenge requiring more effective and sustainable management of the global antimicrobial commons—the common pool of effective antimicrobials. This special issue of Health Care Analysis explores the potential of two legal approaches—one long-term and one short-term—for managing the antimicrobial commons. The first article explores the lessons for antimicrobial resistance that can be (...) learned from recent climate change agreements, and the second article explores how existing international laws can be adapted to better support global action in the short-term. (shrink)

Many parents are hesitant about, or face motivational barriers to, vaccinating their children. In this paper, we propose a type of vaccination policy that could be implemented either in addition to coercive vaccination or as an alternative to it in order to increase paediatric vaccination uptake in a non-coercive way. We propose the use of vaccination nudges that exploit the very same decision biases that often undermine vaccination uptake. In particular, we propose a policy under which children would be vaccinated (...) at school or day-care by default, without requiring parental authorization, but with parents retaining the right to opt their children out of vaccination. We show that such a policy is likely to be effective, at least in cases in which non-vaccination is due to practical obstacles, rather than to strong beliefs about vaccines, ethically acceptable and less controversial than some alternatives because it is not coercive and affects individual autonomy only in a morally unproblematic way, and likely to receive support from the UK public, on the basis of original empirical research we have conducted on the lay public. (shrink)

In this paper we clarify some issues related to our previous article ‘After-birth abortion: why should the baby live?’.

In this response paper, we respond to the criticisms that Michal Pruski raised against our article “Beyond Money: Conscientious Objection in Medicine as a Conflict of Interests.” We defend our original position against conscientious objection in healthcare by suggesting that the analogies Pruski uses to criticize our paper miss the relevant point and that some of the analogies he uses and the implications he draws are misplaced.

[book blurb:] The world is changing so fast that it's hard to know how to think about what we ought to do. We barely have time to reflect on how scientific advances will affect our lives before they're upon us. New kinds of dilemma are springing up. Can robots be held responsible for their actions? Will artificial intelligence be able to predict criminal activity? Is the future gender-fluid? Should we strive to become post-human? Should we use drugs to improve our (...) intimate relationships — or to reduce crime? Our intuitions about questions like these are often both weak and confused. -/- David Edmonds has put together a philosophical task force to get to grips with these challenges. Twenty-nine philosophers present provocative and engaging pieces about aspects of life today, and life tomorrow — birth and death, health and medicine, brain and body, personal relationships, wrongdoing and justice, the internet, animals, and the environment. The future won't look the same when you've finished this book. (shrink)

We discuss the relationship between expertise, expert authority, and trust in the case of vaccine research and policy, with a particular focus on COVID-19 vaccines. We argue that expert authority is not merely an epistemic notion, but entails being trusted by the relevant public and is valuable if it is accompanied by expert trustworthiness. Trustworthiness requires, among other things, being transparent, acknowledging uncertainty and expert disagreement (e.g., around vaccines’ effectiveness and safety), being willing to revise views in response to new (...) evidence, and being clear about the values that underpin expert recommendations. We explore how failure to acknowledge expert disagreement and uncertainty can undermine trust in vaccination and public health experts, using expert recommendations around COVID-19 vaccines as a case study. (shrink)