Healthcare providers have been central actors in containing the COVID-19 pandemic. Although potentially very beneficial, the implementation of large-scale rapid serological tests raises ethical dilemmas and affects HCPs’ capacity to work in optimal conditions. In this regard, we call for attention to address specific and urgent ethical issues distinctively affecting HCPs following the availability and possible mandatory use of rapid serological tests for COVID-19.

Vaccination policy is an ethically challenging domain of public policy. It is a matter of collective importance that reaches into the most private sphere of citizens and unavoidably conflicts with individual-based ethics. Policy makers need to walk a tight rope in order to complement utilitarian public health values with individual autonomy rights, protection of privacy, non-discrimination and protection of the worst-off. Whether vaccination is voluntary or compulsory, universal or targeted, every option faces complex ethical hurdles because of (...) the interdependence of humans in infectious disease matters. In this article, we explore the following three policy questions. (i) Ethically, which policy measures should be addressed when vaccination coverage is insufficient in a population? Information campaigns, legal compulsion, or the use of financial incentives can all be effective, but also controversial policy options. (ii) Is it ethical to target vaccination programs at certain risk-groups? If such measures are necessary, we argue that policymakers will often have to decide which is more important to uphold: non-discrimination or the protection of privacy. And (iii), what is the ethical significance of adverse herd immunity effects? Some vaccination programs will improve average population health, but will at the same time increase the risk of severe morbidity and mortality for individuals in the worst-off groups of society. (shrink)

Abstractabstract:Public health emergencies are fraught by epistemic uncertainty, which raises policy issues of how to handle that uncertainty and devise sustainable public health responses. Among such responses, a herd immunity policy might be an option. Particularly before the development of vaccines, the current COVID-19 pandemic has highlighted the polarized nature of the political debate concerning the ethical feasibility of herd immunity strategies. This article provides a conceptual framework tailored to uncover the ethical rationale behind such strategies. Clarity on (...) this issue is important in order to facilitate the terms of the political debate when tackling future health emergencies. (shrink)

Government policies and practices can exert significant influence on ethical behavior in a society. Many governments still rely ona long-standing prerogative of sovereigns, the defense of sovereign immunity, to avoid public inquiry about acts that are clearly immoral. However, the basic theory and frequent practice of invoking sovereign immunity cannot be ethically justified. Moreover, such practices model conduct based on power rather than reason, fairness, or justice, and invite both nations and individuals to view politics and business as a power (...) game to be played and won, rather than as a process of buiIding communities that emphasize reciprocity and commitment to moral principles. (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)

The COVID-19 pandemic has led a number of countries to introduce restrictive ‘lockdown’ policies on their citizens in order to control infection spread. Immunity passports have been proposed as a way of easing the harms of such policies, and could be used in conjunction with other strategies for infection control. These passports would permit those who test positive for COVID-19 antibodies to return to some of their normal behaviours, such as travelling more freely and returning to work. The introduction of (...) immunity passports raises a number of practical and ethical challenges. In this paper, we seek to review the challenges relating to various practical considerations, fairness issues, the risk to social cooperation and the impact on people’s civil liberties. We make tentative recommendations for the ethical introduction of immunity passports. (shrink)

The public health benefits of herd immunity are often used as the justification for coercive vaccine policies. Yet, ‘herd immunity’ as a term has multiple referents, which can result in ambiguity, including regarding its role in ethical arguments. The term ‘herd immunity’ can refer to (1) the herd immunity threshold, at which models predict the decline of an epidemic; (2) the percentage of a population with immunity, whether it exceeds a given threshold or not; and/or (3) the indirect benefit afforded (...) by collective immunity to those who are less immune. Moreover, the accumulation of immune individuals in a population can lead to two different outcomes: elimination (for measles, smallpox, etc) or endemic equilibrium (for COVID-19, influenza, etc). We argue that the strength of a moral obligation for individuals to contribute to herd immunity through vaccination, and by extension the acceptability of coercion, will depend on how ‘herd immunity’ is interpreted as well as facts about a given disease or vaccine. Among other things, not all uses of ‘herd immunity’ are equally valid for all pathogens. The optimal conditions for herd immunity threshold effects, as illustrated by measles, notably do not apply to the many pathogens for which reinfections are ubiquitous (due to waning immunity and/or antigenic variation). For such pathogens, including SARS-CoV-2, mass vaccination can only be expected to delay rather than prevent new infections, in which case the obligation to contribute to herd immunity is much weaker, and coercive policies less justifiable. (shrink)

Digital COVID certificates are a novel public health policy to tackle the COVID-19 pandemic. These immunity certificates aim to incentivize vaccination and to deny international travel or access to essential spaces to those who are unable to prove that they are not infectious. In this article, we start by describing immunity certificates and highlighting their differences from vaccination certificates. Then, we focus on the ethical, legal, and social issues involved in their use, namely autonomy and consent, data protection, equity, (...) and international mobility from a global fairness perspective. The main conclusion of our analysis is that digital COVID certificates are only acceptable if they meet certain conditions: that they should not process personal data beyond what is strictly necessary for the aimed goals, that equal access to them should be guaranteed, and that they should not restrict people’s autonomy to access places where contagion is unlikely. We conclude that, if such conditions are guaranteed, digital COVID certificates could contribute to mitigating some of the most severe socioeconomic consequences of the pandemic. (shrink)

Efforts to retrieve John Courtney Murray's thought must address two questions: What has changed in the quarter-century since Murray's death? What resources does his oeuvre offer for the present situation? In examining Murray's contribution to current policy debates about church-state relations, I will first review the historically conscious methodology he drew upon and the details of his argument in favor of religious liberty. However, in the years since Murray wrote, American religious communities have been severely eroded, with the consequence (...) that Murray's argument no longer has the same force. I therefore propose a reformulation of the basis for religious freedom in order to take into account the need to maintain the social conditions necessary for the exercise of religious freedom. Such a reformulation has significant implications with regard to the question of public funding for religiously affiliated private schools. (shrink)

We are, at present, at a crisis point where the rhetoric and policy practices surrounding the preservation of the American state, as espoused by its highest-ranking officials, has ceased to mask the racism and xenophobia that have long characterized it. Faced with a state politics that is more than ever desirous of visiting its fears upon the most vulnerable, an intervention in the political via critical practice—practice capable of lending nuance to the conception of the political and exposing its (...) vulnerabilities—is urgently necessary. To do so requires an approach capable of engaging in a rigorous way with the state’s conception of itself and the machinery it employs to pursue that conception, a machinery that... (shrink)

Interest groups are advancing new statutory provisions to limit the liability of persons involved in equine activities. The first statute was adopted in Washington State five years ago, and subsequently twenty-nine other states have proceeded to adopt legislation regarding this issue. The new statutes, termed “Equine Liability Statutes,” provide immunity from liability for injuries and death arising from ordinary risks of equine activities. Drawing from policies involving the provision of assistance for needy interest groups and voluntary social prerequisites, two recommendations (...) may be proffered. First, the good samaritan and recreational use models suggest that the statutes might require a donation to offset the loss of participants' rights before a person could qualify for the statutory dispensation. Second, an additional safety prerequisite regarding a helmet to encourage action to reduce head injuries may be appropriate to foster safer equine activities. (shrink)

Certifications of immunity are sometimes called “immunity passports” but are better conceptualized as immunity-based licenses. Such policies raise important questions about fairness, stigma, and counterproductive incentives but could also further individual freedom and improve public health. Immunity licenses should not be evaluated against a baseline of normalcy, ie, uninfected free movement. Rather, they should be compared to the alternatives of enforcing strict public health restrictions for many months or permitting activities that could spread infection, both of which exacerbate inequalities and (...) impose serious burdens. This Viewpoint presents a framework for analyzing the ethics of immunity licenses. (shrink)

This paper argues for a policy of assassination. Foreign leaders causing unjust wars forfeit their rights against being killed. Killing them also satisfies the conditions on defensive violence that accompany forfeiture (consider, for example, imminence, necessity, and proportionality). Assassination sometimes maximizes the good. In some cases, then, assassination is right and good. A separate issue is whether it is good policy. To the extent that traditional just war theory disallows assassination, it should be revised or rejected.

Most literature about vaccine hesitancy has been focused on parental attitudes. Less attention has been devoted to both scientists and experts who raise criticism about immunization policies and intervene in the public debate. This consideration aims to balance the current emphasis in the literature on parents’ attitudes about vaccination, offering a complementary angle to reframe and widen the controversy. Focusing on scientists and experts, an unattended complex picture of multiple attitudes towards vaccines and vaccinations has been discovered through a (...) qualitative content analysis of texts related to the harsh public debate, held between March 2017 and November 2018, triggered by the legislative proposal of making ten vaccinations mandatory for children. Unlike oversemplications that misleading dichotomies reproduce, the analysis reveals nine different positions along the continuum of immunisation attitudes, ranging from radical acceptance of vaccinations to radical rejection, which constitute a fuzzy set. Consequently, a twofold reality emerges: on the surface, the conflict seems between pro-vaxxers versus hesitant, pro-choice and anti-vaxxers; beneath it is amid standardized versus a varieties of contextual and personalised approaches to health. (shrink)

Marshall and O’Leary’s thoughtful response to our article suggests that dismissal policies are ethically justifiable because they might induce parents to immunize their children. This outcome is conceivable, but we have only anecdotes about how often it occurs. Such evidence became the thin reed on which the American Academy of Pediatrics rested its new policy of tolerating the practice of dismissing vaccine-hesitant parents. It seems likely that relatively few parents would agree to vaccinate because they were threatened with dismissal. (...) Other heavy-handed interventions have failed to move most such parents. When Washington state made nonmedical exemptions more difficult to obtain, nearly two-thirds of vaccine refusers were unmoved and their children remained unvaccinated. Even if dismissal threats led some parents to accept vaccines, this alone would not justify a dismissal policy. The benefits would still have to be weighed against the risks of dismissing those families who do not change their minds. (shrink)

Vaccination involves priming the immune system with an antigenic agent that mimics a virus or bacterium, which results in immunity against the “real” microorganism. Collective vaccination policies have played an important role in the control of infectious disease worldwide. They can serve the utilitarian aim to protect public health – hence welfare – and also promote fairness: making essential vaccines accessible to all members of the public. Yet as more and more vaccines are developed, societies face the question of how (...) far to go in expanding public programs. Decisions about adopting new vaccines in the program will require combining scientific evidence about the disease and the vaccine, with value judgments about, for example, the extent to which a disease poses a threat to public health. It makes sense to promote transparency of such deliberations because one cannot expect that citizens simply accept every government vaccination policy. (shrink)

COVID-19 vaccine requirements have generated significant debate. Here, we argue that, on the evidence available, such policies should have recognised proof of natural immunity as a sufficient basis for exemption to vaccination requirements. We begin by distinguishing our argument from two implausible claims about natural immunity: natural immunity is superior to ‘artificial’ vaccine-induced immunity simply because it is ‘natural’ and it is better to acquire immunity through natural infection than via vaccination. We then briefly survey the evidence base for the (...) comparison between naturally acquired immunity and vaccine-induced immunity. While we clearly cannot settle the scientific debates on this point, we suggest that we lack clear and convincing scientific evidence that vaccine-induced immunity has a significantly higher protective effect than natural immunity. Since vaccine requirements represent a substantial infringement of individual liberty, as well as imposing other significant costs, they can only be justified if they are necessary for achieving a proportionate public health benefit. Without compelling evidence for the superiority of vaccine-induced immunity, it cannot be deemed necessary to require vaccination for those with natural immunity. Subjecting them to vaccine mandates is therefore not justified. We conclude by defending the standard of proof that this argument from necessity invokes, and address other pragmatic and practical considerations that may speak against natural immunity exemptions. There are no data in this work. (shrink)

Despite the availability of safe vaccines against SARS-CoV-2, some people will remain vulnerable because they will not be vaccinated. Who are these non-vaccinated people? We can distinguish two groups: (i) persons who cannot be vaccinated for clinical reasons and who, despite having been vaccinated, have not achieved immunity; (ii) persons who voluntarily refuse to get vaccinated. These groups have in common an immune system that will make them vulnerable to COVID-19. The reasons for their vulnerability and the ethical judgment they (...) deserve are different; the solutions offered to them are also different. In the case of those who voluntarily avoid vaccination, States are not compromised to introduce new protective policies. In the case of people who remain involuntarily vulnerable, instead, the response should be articulated on the same rules and principles that inform the social model of disability because they will live with an organic disability. (shrink)

Critics of international trade agreements often cast them as threats to human health, and they can point to some sobering warnings from world history. Infectious diseases have swept across political boundaries, carried by traders, colonists, and other agents of globalization. Transnational epidemics have laid economies low, undermining political stability. The spread of viruses and bacteria to peoples previously unexposed and therefore lacking immunity has decimated populations and changed the political course of continents. Trade, exploration, and warfare have repeatedly produced encounters (...) between peoples at different levels of agricultural and technological development. Often, the results have been devastating for the disadvantaged group — economic marginalization, loss of sovereignty and culture, and collapse of public health. Yet the rise of civilization — plant and animal domestication, division of labor, technology, and resulting prosperity — was powered in large part by movement of products and knowledge along routes of trade and migration. (shrink)

Critics of international trade agreements often cast them as threats to human health, and they can point to some sobering warnings from world history. Infectious diseases have swept across political boundaries, carried by traders, colonists, and other agents of globalization. Transnational epidemics have laid economies low, undermining political stability. The spread of viruses and bacteria to peoples previously unexposed and therefore lacking immunity has decimated populations and changed the political course of continents. Trade, exploration, and warfare have repeatedly produced encounters (...) between peoples at different levels of agricultural and technological development. Often, the results have been devastating for the disadvantaged group — economic marginalization, loss of sovereignty and culture, and collapse of public health. Yet the rise of civilization — plant and animal domestication, division of labor, technology, and resulting prosperity — was powered in large part by movement of products and knowledge along routes of trade and migration. (shrink)

Subject: Volume dedicated to the question of how dance, both in its historical and in its contemporary manifestations, is intricately linked to conceptualisations of the political. Whereas in this context the term "policy" means the reproduction of hegemonic power relations within already existing institutional structures, politics refers to those practices which question the space of policy as such by inscribing that into its surface which has had no place before. The art of choreography consists in distributing bodies and (...) their relations in space. It is a distribution of parts that within the field of the visible and the sayable allocates positions to specific bodies. Yet in the confrontation between bodies and their relations, a deframing and dislocating of positions may take place. The essays included in this book are aimed at the multiple connections between politics, community, dance, and globalisation from the perspective of e.g. Dance and Theatre Studies, History, Philosophy, and Sociology. (shrink)

Immunization plays a crucial role in global health security, preventing public health emergencies of international concern and protecting individuals from infectious disease outbreaks, yet these critical public health benefits are dependent on immunization law. Where public health law has become central to preventing, detecting, and responding to infectious disease, public health law reform is seen as necessary to implement the Global Health Security Agenda. This article examines national immunization laws as a basis to implement the GHSA and (...) promote the public's health, analyzing the scope and content of these laws to prevent infectious disease across Sub-Saharan Africa. Undertaking policy surveillance of national immunization laws in 20 Sub-Saharan African countries, this study: developed a legal framework to map the legal attributes relevant to immunization; created an assessment tool to determine the presence of these attributes under national immunization law; and applied this assessment tool to code national legal landscapes. An analysis of these coded laws highlights legal attributes that govern vaccine requirements, supply chains, vaccine administration standards, and medicines quality and manufacturer liability. Based upon this international policy surveillance, it will be crucial to undertake legal epidemiology research across countries, examining the influence of immunization law on vaccination rates and disease outbreaks. (shrink)

In an effort to contain the spread of COVID-19, many states and countries have adopted public health restrictions on activities previously considered commonplace: crossing state borders, eating indoors, gathering together, and even leaving one’s home. These policies often focus on specific activities or groups, rather than imposing the same limits across the board. In this Article, I consider the law and ethics of these policies, which I call tailored policies. In Part II, I identify two types of tailored policies--activity-based and (...) group-based. Activity-based restrictions respond to differences in the risks and benefits of specific activities, such as walking outdoors and dining indoors. Group-based restrictions consider differences between groups with respect to risk and benefit. Examples are policies that treat children or senior citizens differently, policies that require travelers to quarantine when traveling to a new destination, and policies that treat individuals differently based on whether they have COVID-19 symptoms, have tested positive for COVID-19, have previous COVID-19 infection, or have been vaccinated against COVID-19. In Part III, I consider the public health law grounding of tailored policies in the principles of “least restrictive means” and “well-targeting.” I also examine how courts have analyzed tailored policies that have been challenged on fundamental rights or equal protection grounds. I argue that fundamental rights analyses typically favor tailored policies and that equal protection does not preclude the use of tailored policies even when imperfectly crafted. In Part IV, I consider three critiques of tailored policies, centering on the claims that they produce inequity, cause harm, or unacceptably limit liberty. I argue that we must evaluate restrictions comparatively: the question is not whether tailored policies are perfectly equitable, wholly prevent harm, or completely protect liberty, but whether they are better than untailored ones at realizing these goals in a pandemic. I also argue that evaluation must consider indirect harms and benefits as well as direct and apparent ones. (shrink)

Any case raising the profile of ‘assisted-dying’ and public policy naturally causes consternation, excitement, heated debate and concerns from different parties, worried that the law is unclear, unfair, too conservative, too permissive, neglectful of ‘the vulnerable’ or indifferent to the proper scope of freedom for ‘the competent’. It was unsurprising, then, that much attention focused on the litigation between Debbie Purdy and the Director of Public Prosecutions .1–4 Ms Purdy has muscular sclerosis, and would like to be free, at (...) a time of her choosing, to travel to receive assisted suicide in a jurisdiction that permits this. To do so, she will need the help of her husband. In contrast with the famous Pretty case,5 Ms Purdy did not seek a proleptic immunity from prosecution under the Suicide Act 1961. Rather, she invoked her human right to respect for private and family life, and argued that the DPP should publish guidance detailing the basis on which he exercises his discretion to bring a prosecution for the crime of aiding, abetting, counselling or procuring a suicide in England and Wales. Her case, when heard in the House of Lords, was successful. 3A decision to prosecute cases of assisted suicide pivots on the satisfaction of two key issues: the ‘evidential test’—is there sufficient evidence to justify bringing a prosecution?; and the ‘public interest test’—is it in the public interest to bring a prosecution? Rightly or wrongly, the threshold for meeting the evidential test seems to be set very low.6 Focus tends to fall, therefore, on the public interest aspect of the decision. In September 2009, the DPP published interim guidance, which detailed the offence of ‘assisting a …. (shrink)

Umbilical cord blood has become the focus of intense efforts to collect, screen and bank haematopoietic stem cells in hundreds of repositories around the world. UCB banking has developed through a broad spectrum of overlapping banking practices, sectors and institutional forms. Superficially at least, these sectors have been widely distinguished in bioethical and policy literature between notions of the ‘public’ and the ‘private’, the commons and the market respectively. Our purpose in this paper is to reflect more critically on (...) these distinctions and to articulate the complex practical and hybrid nature of cord blood as a ‘bio-object’ that straddles binary conceptions of the blood economies. The paper draws upon Roberto Esposito’s reflections on biopolitics and his attempt to transcend the dualistic polarisations of immunity and community, or the private and the public. We suggest that his thoughts on immunitary hospitality resonate with many of the actual features and realpolitik of a necessarily internationalised and globally distributed UCB ‘immunitary regime’. (shrink)

This article proposes a novel defense of vaccine mandates: such policies are justifiable because they protect the capabilities of individuals who cannot cultivate individual immunity against infection. We begin by considering a nearby argument that has recently enjoyed popularity, which claims individuals have an enforceable obligation to get vaccinated because they have benefited from community protection (often referred to as ‘herd immunity’), and thus they ought to do their fair share in sustaining that public good by getting vaccinated. We object, (...) however, that this kind of argument misstates the ethical basis for vaccine mandates because community protection primarily protects unvaccinated people. We contend that the duty to vaccinate is not fundamentally an obligation to make a fair contribution to a public good from which vaccinated people benefit, but a duty to protect the wellbeing of otherwise vulnerable third parties. We flesh out our view by drawing on Martha Nussbaum's capabilities approach. (shrink)

Political communities across the world have recently sought to tackle rising rates of vaccine hesitancy and refusal, by implementing coercive immunization programs, or by making existing immunization programs more coercive. Many academics and advocates of public health have applauded these policy developments, and they have invoked ethical reasons for implementing or strengthening vaccine mandates. Others have criticized these policies on ethical grounds, for undermining liberty, and as symptoms of broader government overreach. But such arguments often obscure or (...) abstract away from the diverse values that are relevant to the ethical justifications of particular political communities’ vaccine‐mandate policies. We argue for an expansive conception of the normative issues relevant to deciding whether and how to establish or reform vaccine mandates, and we propose a schema by which to organize our thoughts about the ways in which different kinds of vaccine‐mandate policies implicate various values. (shrink)

The recent decrease in public confidence in the measles, mumps and rubella vaccine has important implications for individuals and public health. This article presents moral arguments relating to conflicts between individual autonomy and collective responsibilities in vaccination decisions with a view to informing and advising health professionals and improving the effectiveness of education policies in avoiding resurgence of endemic measles. Lower population immunity, due to falling uptake, is hastening the need for greater public awareness of the consequences for the population. (...) Vaccination refusals go hand in hand with responsibilities owed to future generations and society in not knowingly contributing to preventable harms. Issues such as parents’ rights are considered and balanced against: collective responsibilities for public health; permissibility of ‘free-riding’; conflicting duties of health professionals; and possible enforcement of vaccination. It is suggested that the arguments may form a persuasive tool for the practice of health professionals involved in informing and supporting parents’ vaccination decisions. (shrink)

Background Policy decisions about childhood vaccination require consideration of multiple, sometimes conflicting, public health and ethical imperatives. Examples of these decisions are whether vaccination should be mandatory and, if so, whether to allow for non-medical exemptions. In this article we argue that these policy decisions go beyond typical public health mandates and therefore require democratic input.Methods We report on the design, implementation, and results of a deliberative public forum convened over four days in Ontario, Canada, on the topic (...) of childhood vaccination.Results 25 participants completed all four days of deliberation and collectively developed 20 policy recommendations on issues relating to mandatory vaccinations and exemptions, communication about vaccines and vaccination, and AEFI (adverse events following immunization) compensation and reporting. Notable recommendations include unanimous support for mandatory childhood vaccination in Ontario, the need for broad educational communication about vaccination, and the development of a no-fault compensation scheme for AEFIs. There was persistent disagreement among deliberants about the form of exemptions from vaccination (conscience, religious beliefs) that should be permissible, as well as appropriate consequences if parents do not vaccinate their children.Conclusions We conclude that conducting deliberative democratic processes on topics that are polarizing and controversial is viable and should be further developed and implemented to support democratically legitimate and trustworthy policy about childhood vaccination. (shrink)

We would like to thank each of the commentators on our feature article for their thoughtful engagement with our arguments. All the commentaries raise important questions about our proposed justification for natural immunity exemptions to COVID-19 vaccine mandates. Thankfully, for some of the points raised, we can simply signal our agreement. For instance, Reiss is correct to highlight that our article did not address the important US-centric considerations she helpfully raises and fruitfully discusses. We also agree with Williams about the (...) need to provide a clear rationale for mandates, and to obtain different kinds of data in support of possible policies.Unfortunately, we lack the space to engage with every one of the more critical comments raised in this rich set of commentaries; as such, in this response, we shall focus on a discussion of hybrid immunity, which underlies a number of different arguments evident in the commentaries, before concluding with some reflections responding to Lipsitch’s concern about the appropriate standard of proof in this context. (shrink)

In Voyous, Jacques Derrida develops his argument starting from the presupposition that democracy as such is the entity whose integrity and immunity are at stake and, therefore, under investigation. This gesture reflects the setting in which ten years before, in Foi et savoir, he had cast his reasoning about the logic of immunity. There, it was one of the sources of religion, the immunity of the sacred, that operated according to this logic. The hyphen between these two essays, beside Derrida’s (...) own crossed references, is the genealogical reasoning on the meaning and essence of the concept of democracy: contrary to what Derrida claims, it will be maintained that Athenian democracy had a clear immune matrix, whose constant exercise is clearly defined, in spite of himself, by Vernant, and it will be shown how modern democracy has been forced to change policy. Modern democracy is an entity characterized by an immune deficiency. In order to save Derrida’s intuition from both the collapse of different vantage points and from a quite bizarre reticence in taking into account of the immune value of rituals, our starting point will be René Girard’s œuvre and his reading of the role of immune logic in sacred systems and, more generally, in modernity. The threshold between the auto-immune reaction, immune deficiency and auto-immune disease, between the sacrifice who delimits and constitutes the self and the holocauste du peuple en détail, is the space where, constantly exposed to the risk of auto-denial, democracy lives. (shrink)

The 2019–2020 to 2020–2021 influenza seasons in the USA saw a dramatic 99.5% decrease in paediatric mortality, with only one influenza death recorded during the latter season. This decrease has been attributed to a substantial reduction in transmission, resulting from the various restrictive measures enacted during the COVID-19 pandemic, onset March 2020. The relative disappearance of influenza raises specific policy questions, such as whether these measures should be kept in place after COVID-19 transmission reaches acceptable levels or herd immunity (...) is achieved. Given the nature of these measures as liberty restricting, it is worth discussing their intended outcome and what values they promote. Do these measures in fact promote health, or simply give the comfort of safety while undermining long-term health and individual liberties? I argue that the year-long endurance of the pandemic well into 2021 may have flattened our value landscape into one where health reigns supreme. Discussions are underway regarding whether we should modify previously accepted health risks, such as the risk of contracting influenza. In this paper, I attempt to clarify the values that motivate our policies and discuss how our present historical context has appreciated the value of health. I also provide an analysis of various pandemic policies and their relation to influenza paediatric deaths. Ultimately, the cost of certain measures on values such as education, socialisation and liberty, among others, is too high to justify their use beyond regulating the spread of COVID-19. (shrink)

In a recent paper published in this journal, Giubilini, Douglas and Savulescu argue that we have given insufficient weight to the moral importance of fairness in our account of the best policies for non-medical exemptions to childhood immunization requirements. They advocate for a type of policy they call Contribution, according to which parents must contribute to important public health goods before their children can receive NMEs to immunization requirements. In this response, we argue that Giubilini, Douglas and (...) Savulescu give insufficient weight to the moral importance parental liberty in ways that count against their preferred type of NMEs policy and threaten public support for mandatory vaccination laws and public health initiatives generally. (shrink)

Increasing vaccine hesitancy among parents in high income countries and the resulting drop in early childhood immunisation constitute an important public health problem, and raise the issue of what policies might be taken to promote higher rates of vaccination. This article first outlines the background of the problem of increasing vaccine hesitancy. It then explores the pros and cons of three types of policy: 1) Interventions focused on increasing awareness of the benefits of vaccination while eliminating mistaken perceptions of (...) risks. 2) “Nudges”, which make certain choices more likely to be voluntarily chosen by manipulating the decision environment. 3) Policies that impose costs to make non-vaccination undesirable even for parents who are hesitant. It argues that a wide range of policies, including coercive policies, is desirable from a public health perspective, as the least intrusive policies alone are unlikely to achieve and sustain the important public good of herd immunity. (shrink)

In a paper recently published in this journal, Navin and Largent argue in favour of a type of policy to regulate non-medical exemptions from childhood vaccination which they call ‘Inconvenience’. This policy makes it burdensome for parents to obtain an exemption to child vaccination, for example, by requiring parents to attend immunization education sessions and to complete an application form to receive a waiver. Navin and Largent argue that this policy is preferable to ‘Eliminationism’, i.e. to (...) policies that do not allow non-medical exemptions, because Inconvenience has been shown to maintain exemption rates low while not harming parents by forcing them to do something that goes against their beliefs. We argue that it is at least doubtful that Inconvenience is ethically preferable to Eliminationism: while the latter disregards the value of liberty, Inconvenience disregards the value of fairness in the distribution of the burdens entailed by the preservation of a public good like herd immunity. We propose a variant of Inconvenience, which we call ‘Contribution’, which we think is preferable to the versions of Inconvenience discussed by Navin and Largent in that it successfully strikes a balance between the values of parents’ liberty, fairness and expected utility. (shrink)

Vaccination is one of history's most successful public health interventions. Since 2000, vaccination campaigns against measles, which is highly contagious but preventable through the measles‐mumps‐rubella (MMR) vaccine, have reduced both the global incidence of the disease and measles deaths by 80 percent. However, progress toward measles elimination has slid backward in several previously well‐protected global regions. With more communities below or at risk of falling below the 95 percent immunization rates required for herd immunity—due more and more to vaccine (...) skepticism and declination rather than lack of access—many U.S. states and countries must reappraise their vaccination policies and programs. (shrink)

Neither the English courts nor the National Health Service (NHS) have been immune to the modern mantra of patient choice. This article examines whether beneath the rhetoric any form of real choice is endorsed either in law or in NHS policy. I explore the case law on ‘consent’, look at choice within the NHS and highlight the dilemmas that a mismatch of language and practice poses for clinicians. Given the variance in interpretation and lack of consistency for the individual (...) patient I argue for a semantic change that obviates the use of ‘choice’, focussing instead on the options for treatment that are available and accessible, with due acknowledgement of individual patient preferences, without raising unfettered and false expectations. (shrink)

This article offers an integrated account of two strands of global health justice: health-related human rights and health-related common goods. After sketching a general understanding of the nature of human rights, it proceeds to explain both how individual human rights are to be individuated and the content of their associated obligations specified. With respect to both issues, the human right to health is taken as the primary illustration. It is argued that the individuation of the right to health is fixed (...) by reference to the subject matter of its corresponding obligations, and not by the interests it serves, and the specification of the content of that right must be properly responsive to thresholds of possibility and burden. The article concludes by insisting that human rights cannot constitute the whole of global health justice and that, in addition, other considerations—including the promotion of health-related global public goods—should also shape such policy. Moreover, the relationship between human rights and common goods should not be conceived as mutually exclusive. On the contrary, there sometimes exists an individual right to some aspect of a common good, including a right to benefit from health-related common goods such as programmes for securing herd immunity from diphtheria. (shrink)

The COVID-19 vaccine has been a miraculous, life-saving advance, offering staggering efficacy in adults, and was developed with astonishing speed. The time from sequencing the virus to authorizing the first COVID-19 vaccine was so brisk even the optimists appear close-minded. Yet, simultaneously, United States’ COVID-19 vaccination roll-out and related policies have contained missed opportunities, errors, run counter to evidence-based medicine, and revealed limitations in the judgment of public policymakers. Misplaced utilization, contradictory messaging, and poor deployment in those who would benefit (...) most—the elderly and high-risk—alongside unrealistic messaging, exaggeration, and coercion in those who benefit least—young, healthy Americans—is at the heart. It is important to consider the history of COVID-19 vaccines to identify where we succeeded and where we failed, and the effects that these errors may have more broadly on vaccination hesitancy and routine childhood immunization programs in the decades to come. (shrink)

This paper presents, defends and applies a conception of public health ethics as focused on liberty-limiting public health action. This approach has been persistently criticised, but the criticism is ambiguous between two challenges: that the focus on liberty makes an objectionable presumption in favour of liberal values and that the focus on liberty fails to address institutionalised social injustice. Part One of the paper addresses both challenges to show they can be met by a nuanced account of a liberty-oriented public (...) health ethics. Part Two establishes that debates about policy responses to the current Covid-19 pandemic illustrate and vindicate this conception of public health ethics as focused on liberty-limiting public health action. The discussion then turns to the methodological question as to how public health policies are to be evaluated, focusing particular on the role of normative theory in such evaluations. The methodology of ‘wide reflective equilibrium’ is described and endorsed; the paper ends with a case study to illustrate this evaluative methodology, focused on the ethics of COVID-19 immunity passports. (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)

As a political movement inspired by a belief in fundamental equality and committed to eradication of embodied injustices, feminists have illuminated the politics of exclusion—the use of law and policy to grant rights, opportunities, privileges, and immunities to particular elite men while denying them to marginalized others. With the theorization of gender as an analytical category, feminist scholars have investigated how manifold policies have discursively produced hierarchies of citizenship structured by gender, race, and sexuality. This chapter provides an overview (...) of feminist contributions to policy studies, including key critiques of mainstream policy scholarship, an examination of feminist policy interventions and their mixed results ranging from attempts to eradicate sex discrimination in law and policy, the creation of women’s policy agencies, and the shift to gender mainstreaming. The chapter concludes with a discussion of the politics of equality, comparing nondiscrimination and equal opportunity approaches with structural and substantive conceptions of equality. (shrink)

Organ donation after cessation of circulation and respiration, both controlled and uncontrolled, has been proposed by the Institute of Medicine as a way to increase opportunities for organ procurement. Despite claims to the contrary, both forms of controlled and uncontrolled donation after cardiac death raise significant ethical and legal issues. Identified causes for concern include absence of agreement on criteria for the declaration of death, nonexistence of universal guidelines for duration before stopping resuscitation efforts and techniques, and assumption of presumed (...) intent to donate for the purpose of initiating temporary organ-preservation interventions when no expressed consent to donate is present. From a legal point of view, not having scientifically valid criteria of cessation of circulation and respiration for declaring death could lead to a conclusion that organ procurement itself is the proximate cause of death. Although the revised Uniform Anatomical Gift Act of 2006 provides broad immunity to those involved in organ-procurement activities, courts have yet to provide an opinion on whether persons can be held liable for injuries arising from the determination of death itself. Preserving organs in uncontrolled donation after cardiac death requires the administration of life-support systems such as extracorporeal membrane oxygenation. These life-support systems can lead to return of signs of life that, in turn, have to be deliberately suppressed by the administration of pharmacological agents. Finally, allowing temporary organ-preservation interventions without expressed consent is inherently a violation of the principle of respect for a person's autonomy. Proponents of organ donation from uncontrolled donation after cardiac death, on the other hand, claim that these nonconsensual interventions enhance respect for autonomy by allowing people, through surrogate decision making, to execute their right to donate organs. However, the lack of transparency and the absence of protection of individual autonomy, for the sake of maximizing procurement opportunities, have placed the current organ-donation system of opting-in in great jeopardy. Equally as important, current policies enabling and enhancing organ procurement practices, pose challenges to the constitutional rights of individuals in a pluralistic society as these policies are founded on flawed medical standards for declaring death. (shrink)

Measured against the gloomy pre-COVID-19 predictions, Africa has fared far better than most regions in managing the pandemic. This much, however, has received less attention. This paper answers the question: how have the new rituals of self determination in public health affected the successful management of COVID-19 in Africa, and how can the continent and the rest of the world build on such models/lessons in the post-pandemic era? I employ emancipatory theorising in reviewing literature on approaches to governance of COVID-19. (...) The rationale is to empower the grassroots and to accentuate the urgency for a decolonized local ownership of the governance of all public health crises. I argue that while traditional international cooperation is necessary for additional resource and expertise from the global North for sustainable health, the political will of Southern governments remains fundamental for any extraordinary success due to its grassroots/community orientation towards non-pharmaceutical interventions and initial pre-emptive rituals. The novelty in this paper is that it lays bare the ignored African responses and lessons and reveals how to harness protective communitarian ethos in solving future crises. The paper further provides population health as an ‘immune system’ policy framework for explaining and predicting how a scientific and human-centrered grassroots leadership can yield optimal outcomes in any future crisis. (shrink)

Destination therapy is the permanent implantation of a left ventricular assist device in patients with end-stage, severe heart failure who are ineligible for heart transplantation. DT improves both the quality of life and prognosis of patients with end-stage heart failure. However, there are also downsides to DT such as life-threatening complications and the potential for the patient to live beyond their desired length of life following such major complications. Because of deeply ingrained cultural and religious beliefs regarding death and the (...) sanctity of life, Japanese society may not be ready to make changes needed to enable patients to have LVADs deactivated under certain circumstances to avoid needless suffering. Western ethical views that permit LVAD deactivation based mainly on respect for autonomy and dignity have not been accepted thus far in Japan and are unlikely to be accepted, given the current Japanese culture and traditional values. Some healthcare professionals might regard patients as ineligible for DT unless they have prepared advance directives. If this were to happen, the right to prepare an advance directive would instead become an obligation to do so. Furthermore, patient selection for DT poses another ethical issue. Given the predominant sanctity of life principle and lack of cost-consciousness regarding medical expenses, medically appropriate exclusion criteria would be ignored and DT could be applied to various patients, including very old patients, the demented, or even patients in persistent vegetative states, through on-site judgment. There is an urgent need for Japan to establish and enact a basic act for patient rights. The act should include: respect for a patient’s right to self-determination; the right to refuse unwanted treatment; the right to prepare legally binding advance directives; the right to decline to prepare such directives; and access to nationally insured healthcare. It should enable those concerned with patient care involving DT to seek ethical advice from ethics committees. Furthermore, it should state that healthcare professionals involved in the discontinuation of life support in a proper manner are immune to any legal action and that they have the right to conscientiously object to LVAD deactivation. (shrink)

Background Destination therapy is the permanent implantation of a left ventricular assist device in patients with end-stage, severe heart failure who are ineligible for heart transplantation. DT improves both the quality of life and prognosis of patients with end-stage heart failure. However, there are also downsides to DT such as life-threatening complications and the potential for the patient to live beyond their desired length of life following such major complications. Because of deeply ingrained cultural and religious beliefs regarding death and (...) the sanctity of life, Japanese society may not be ready to make changes needed to enable patients to have LVADs deactivated under certain circumstances to avoid needless suffering. Main text Western ethical views that permit LVAD deactivation based mainly on respect for autonomy and dignity have not been accepted thus far in Japan and are unlikely to be accepted, given the current Japanese culture and traditional values. Some healthcare professionals might regard patients as ineligible for DT unless they have prepared advance directives. If this were to happen, the right to prepare an advance directive would instead become an obligation to do so. Furthermore, patient selection for DT poses another ethical issue. Given the predominant sanctity of life principle and lack of cost-consciousness regarding medical expenses, medically appropriate exclusion criteria would be ignored and DT could be applied to various patients, including very old patients, the demented, or even patients in persistent vegetative states, through on-site judgment. Conclusion There is an urgent need for Japan to establish and enact a basic act for patient rights. The act should include: respect for a patient’s right to self-determination; the right to refuse unwanted treatment; the right to prepare legally binding advance directives; the right to decline to prepare such directives; and access to nationally insured healthcare. It should enable those concerned with patient care involving DT to seek ethical advice from ethics committees. Furthermore, it should state that healthcare professionals involved in the discontinuation of life support in a proper manner are immune to any legal action and that they have the right to conscientiously object to LVAD deactivation. (shrink)

Although science and law employ different methods to gather and weigh evidence, their conclusions are remarkably convergent with regard to the effect that workplace stress has on the health of employees. Science, using the language of probability, affirms that certain stressors predict adverse health outcomes such as disabling anxiety and depression, cardiovascular disease, certain types of injury, and a variety of immune system disorders. Law, using the language of reasonable foreseeability, affirms that these adverse outcomes are predictable under certain conditions, (...) typically defined in relation to what a reasonable person should know. Society is arguably in a position to establish standards for the abatement of certain types of workplace stress. As part of this process, we need to conceptualize an ideal form of conduct that exemplifies the standards to which both law and science urge us to aspire. For this purpose, the concept of the neighbor at work is proposed. (shrink)

Increasing geographical mobility and international travel augment the ease and speed by which infectious diseases can spread across large distances. It is therefore incumbent upon each state to ensure that immunisation programmes are effective and that herd immunity is achieved. Across Europe, a range of immunisation policies exist: compulsion, the offer of financial incentives to parents or healthcare professionals, social and professional pressure, or simply the dissemination of clear information and advice. Until recently, immunisation against particular communicable diseases was compulsory (...) in Italy. The Italian National Vaccination Plan paved the way for regions to suspend the sanctions associated with compulsory vaccinations for children when certain criteria are met—for example when immunisation coverage is high and when effective monitoring/surveillance systems are in place—and thus marked a milestone in the move from compulsory to voluntary immunisation. The forthcoming NVP for 2008–10 confirms the liberal approach to vaccination in Italy as it entrusts to the regions responsibility for the achievement and maintenance of herd immunity. This paper reviews the arguments for and against compulsory and voluntary immunisation in relation to the Italian NVP and in the context of the diverse immunisation policies that exist across Europe. It concludes with cautious support for the NVP and an associated shift from compulsory to voluntary immunisation in Italy, and draws similarities between issues concerning regional variation in immunisation policy in Italy and national variation in immunisation policy across Europe and beyond. (shrink)