A COVID Trolley visits the Neighborhood of Make-Believe
It's a beautiful day to take a trolley ride into COVID-19 medical ethics and coerced vaccinations.
Funny Words
Hi neighbour. I’m glad we’re together again today. I know how interested you are in trolleys. Well, I found a storybook about trolleys1. The stories in this book discuss how to use trolleys to decide what is right and wrong in medicine. That topic is called medical ethics. One of the many interesting stories in this storybook is about a how medical ethics deals with new biotechnologies:
Again, the prime principle in medical ethics is first doing no harm. If, by trying to address a health problem out of a concern with beneficence, the doctor puts the patient in an even worse condition, then that procedure should not be done. That is why, amongst other things, when it comes to new biotechnologies, most ethicists prescribe a cautionary principle. For the most part, we do not have full knowledge of how some of the newer biotechnologies work, and it is therefore better to suspend the administration of those biotechnologies until further knowledge about their workings is gathered. Even if those biotechnologies offer good solutions to particular health problems, they may in fact cause even greater harm.
Some of those words sound funny, don’t they. Beneficence. That’s a funny word. Sometimes we can replace funny sounding words with simple words we understand. Beneficence means being kind and charitable. I bet you like to be kind and charitable. It sure feels good, doesn’t it.
Sometimes funny sounding words are important to understand. Biotechnology means applying the principles of engineering and technology development to the life sciences, often making use of biological substances such as microorganisms, enzymes, or mRNA. One example of a new biotechnology is a new, rapidly-developed vaccine to combat the outbreak of a pandemic, especially ones based on new methods of making vaccines.
You may have heard of vaccines like these recently, called mRNA vaccines. They are used to fight off the SARS-CoV-2 virus so that people don’t get Coronavirus Disease 2019, which we call COVID-19 for short. Perhaps you aren’t old enough yet to be given a COVID-19 vaccine. Right now they are only allowed to be given to people older than 12 years old. Maybe your older brother or sister have been allowed a COVID vaccine. Maybe your mommy and daddy have been allowed a COVID vaccine. If not, maybe they are being coerced into getting one.
Coerced is another funny word. It means to pressure somebody to do what you want by intimidation, force, or threat. Maybe they have been threatened to be fired from their job if they done take a vaccine. Maybe they aren't allowed to travel or go into stores if they don’t get a vaccine. Maybe they are intimidated by somebody with a lot of authority telling everyone that “those people” are a threat to their own children and everybody else’s children2. That is known by some other funny words too, including misinformation and demagoguery. I know that you know that children aren’t at risk from COVID-19, so there is no reason for you to be afraid, even though some people sometimes try to make people afraid, even children.
An example of somebody being coerced is Julie Ponesse. She is a teacher, except that she teaches adults at a university and is known as a professor. She teaches medical ethics, which is what we’re talking about today. We call people like Julie, experts. She has been teaching ethics for more than 20 years. That’s a long time. Her school is Huron University College. It is part of a bigger school known as the University of Western Ontario. It is a school that is well-known for teaching medicine. But she is in trouble now because she said she would not participate in the process of coercing people to get vaccines. She says that it is a violation of medical ethics3. Did I mention she is an expert in medical ethics?
I know what you are thinking, neighbour. When do we hear the trolley stories? I will get to them in a minute. I will ask now to be respectfully patient. We cannot have a discussion on medical ethics without respect for the patient.
Respect for the Patient
The collection of trolley stories I showed you earlier lists the four main parts of medical ethics that require balancing: non-maleficence, autonomy, beneficence, and justice. Non-maleficence is a funny word that means “do no harm”. The authors make a note that says,
It is commonly agreed that, ever since the beginnings of ethical reflection, non-maleficence has been the most important of all principles, and should be given priority when in conflict with others.
Although Hippocrates did not explicitly mention the phrase “first do no harm” in his Oath (the original version actually states, “Abstain from doing harm”), it is enshrined in the common medical understanding of ethics. And indeed, this principle prevails above others.
For example, each of the COVID-19 vaccines4 come with their own storybooks. We call those storybooks monographs. I told you about them in a previous story5. One of the vaccines is called the Pfizer-BioNTech vaccine. It has a monograph that was last updated on September 3, 20216. Another vaccine is called the Moderna vaccine. It’s monograph was also updated on September 3, 20217. There are others, but these two are the most popular. Section 7.1 of both monographs have some important notes. Let’s read them together:
7.1.1 Pregnant Women
The safety and efficacy of Pfizer-BioNTech COVID-19 Vaccine in pregnant women have not yet been established.
7.1.2 Breast-feeding
It is unknown whether Pfizer-BioNTech COVID-19 Vaccine is excreted in human milk. A risk to the newborns/infants cannot be excluded.
The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for immunization against COVID-19.
If a doctor wanted to behave ethically following the principle of non-maleficence, what do you think the doctor might do with this information if they had a patient who was pregnant or might become pregnant in the near future? That’s right, they might consider the potential risks to the baby from the vaccine and advise her not to get a vaccine at this time. Perhaps she should wait to get a vaccine until the vaccine makers and Health Canada had enough time and data to conclude that the baby would be safe even if she got the vaccine.
We also saw this situation before, didn’t we? That’s right. It was in the storybook about trollies when it talked about new biotechnologies, the cautionary principle, sometimes waiting to gather more information, and the potential for causing greater harm. I knew you’d remember because you are so smart. Did you know that many other people aren’t as smart as you. They didn’t remember this part of medical ethics at all, like those people who took away Julie’s teaching job or that said “those people” are a threat to children. Maybe they didn’t know that the vaccine makers and Health Canada say that taking the vaccines might be a risk to your children. If they did, maybe they wouldn’t be so mean.
What if the doctor thought that COVID-19 was a bigger risk to the patient and her baby than the vaccine, but the patient disagreed. Perhaps she thought that the unknown risks of the vaccines and unknown risks of COVID-19 to her baby were similar. If she took the vaccine she’d be taking 100% chance on the unknown vaccine risks. If she took a chance on avoiding COVID-19, she’d only have a small chance of running into the unknown COVID-19 risks. Plus, if she waited on the vaccine it could give more time for people to figure out the long-term risks.
In that case, the doctor might consider the patient’s right to decide for themselves. This is the second factor of medical ethics, called autonomy. This is an important one for most people. While many doctors might overrule a patient and refuse to give a treatment that a patient wants, it is rare that a doctor would overrule a patient and force a treatment that the patient doesn’t want. That is considered much less ethical.
Autonomy and non-maleficence don’t just apply to pregnant women and babies. They apply to every patient. The vaccine storybooks — the monographs we looked at before — include other known and unknown risks and considerations for doctors and patients to make decisions about. This is more than just for medical ethics; it is also how Health Canada manages the unknown risks of the vaccines. Yes, that’s right. They even wrote it down. Health Canada wrote their own storybook about each vaccine. They call it a “Regulatory Decision”. The Pfizer-BioNTech vaccine has a Regulatory Decision8 and so does the Moderna vaccine9. So do all of the others. They tell the story about why Health Canada is letting people use these vaccines even though they haven’t been fully tested and how these unknowns will be handled. Let’s read that part together:
One limitation of the data at this time is the lack of information on the long-term safety and efficacy of the vaccine. The identified limitations are managed through labelling and the Risk Management Plan. The Phase 3 Study is ongoing and will continue to collect information on the long-term safety and efficacy of the vaccine. There are post-authorization commitment for monitoring the long-term safety and efficacy of [the approved] Vaccine.
See, it isn’t just pregnant women and babies for which the effects aren’t known. It is also all people over the long-term. Long-term testing is known as Phase 3. Normally we don’t allow people to take vaccines or other drugs that have not been through Phase 3 to show they are safe and work in the long term. But, in the middle of a pandemic when many people are getting sick, we can decide to take the long-term risks because we know they work in the short-term to help stop people from getting sick.
The Problem with Trolleys
What about the trollies? OK, ok. I will tell you all about the trollies. The authors of the trolley storybook tell a story to describe the fourth pillar of medical ethics: justice:
A surgeon has five patients who are waiting for organ transplants. The patients will die if they do not receive the organs, but the organs are not available at the time. The whole prospect changes, however, when a young traveler comes to town and goes in for a routine checkup. The doctor is performing the checkup when he realizes that the traveler’s organs are healthy and incidentally compatible with his dying patients. The young man is the perfect donor, and no one would associate him with the surgeon if he were to disappear. The dilemma here is, should the doctor remove the organs from the healthy man in order to distribute them to the dying patients? Of-course not. Although it may be a more efficient and even just allocation of resources, it would still be a moral monstrosity to authorize such a transplant. The reasoning here is that non-maleficence takes precedence over the other ethical principles.
The writers later describe this as an example of the Trolley Problem. The Trolley Problem is a story that some people use, called philosophers, to figure out the difference between right and wrong when it is hard to tell. There is more than one Trolley Problem story. The authors tell five Trolley Problem stories.
What makes them all Trolley Problem stories is that they are about a trolley that is broken. Its brakes don’t work and it is going to run into five people and kill them. That would be very sad, wouldn’t it. But in each story there is a way you can save the people. It’s good to save people from dying, isn’t it. But, the way you save them is by hurting somebody else, and that person will die instead. That’s also very sad. So what do you do? Do you let the many people get hurt, or save them by hurting the other person. What makes all of the stories different is how you can save them and how the other person gets hurt.
In Story #1, you are the driver of the trolley and you can save the five people by moving a lever to switch tracks where you will kill the one person instead. When asked, most people think it would be best to switch tracks and kill the one person to death instead of five. The reason they give is because one person dying is less sad than five people dying. Philosophy thinkers call this comparison utilitarian. But wait. Isn’t that the same thing as the story above, taking the organs of one person to save the lives of five other people? Nobody things we should do that. Why do you think these stories might be different?
Philosophers think maybe we have a stronger duty to avoid doing things to hurt people, called negative duties, than to do things to help save people, called positive duties. The negative duty to not kill a person is more important than than the positive to duty to save five people from dying, so you shouldn’t kill the person to take their organs to save five people. The five people are dying from natural causes, not because you did something to cause them to die. In Trolley Story #1, you are are choosing between killing five people or killing one person with the trolley, so only one person is the better option. This solution reinforces the principle of non-maleficence, or doing no harm. Letting harm happen is a different idea. As an interesting side note, the philosophers believe this rule applies to medical ethics even if the organ donor agrees to kill himself to save the five people, meaning the doctor’s duty of non-maleficence overrules the autonomy of the person sacrificing himself.
Trolley Story #2 is similar to Story #1. In this story you aren’t the driver. You are a bystander who sees what is about to happen and can switch the tracks by pulling a lever. Should you do it then? In this case, you aren’t in charge of the trolley. We call being in charge of something responsibility. If the trolley hits the five people then you aren’t responsible. If you pull the lever then one person is hit by the trolley because of something you did. You are responsible. Should you do it? What do you think?
Philosophers say that this looks more like the organ donor case. You are now deciding between killing one person and letting five people die. If it is wrong to do it in the organ story, isn’t it wrong to do it here. Isn’t the non-maleficence the same? When many people are asked, most of them say they think you should pull the lever even though they say you shouldn’t take the organs. Can you spot the difference?
That’s right, its the means to an end. In the case of Trolley Story #2, if the one person could escape the track you would still save the five people and not hurt the one person. In the case of the organ donor, killing the person is necessary for the plan to succeed. The person getting hurt is a necessary means to the get the desired end outcome. This answer came from a famous philosopher long ago named Immanuel Kant, whose ethical philosophy concluded it was wrong to use people as a means to an end. It is a form of ethics, which is very different from utilitarian ethics, called deontological ethics. The writers note that this is very important:
Deontological ethics prescribes that moral agents do the right thing on the basis of duty, regardless of the consequences, or as the poetic phrase goes, “even if the heavens fall”.
…
Most legislations follow these Kantian principles, and medical ethics is for the most part deontological. The rule of first doing no harm holds most of the time. Yet, even in those cases where some harm must be done, the Kantian principle still applies: the harm done to someone must never be a means to achieve an end.
In Story #3, you are still a bystander but instead of pulling a lever, you have to push a fat man on the tracks to stop the trolley. Should you do it? It turns out that most people don’t think that is ethical, even if the same people though you should pull the lever in Story #2. This is similar to Story #2 because you have to chose between killing one person or letting five people die. But I’m sure you noticed a difference we just talked about. In Story #3, you are hurting the one person as a means to an end. If the fat man escape from your attempt, you would not accomplish your goal of saving the five people.
There is more here too. What if you aren’t sure if the fat man will be killed but you are sure his fall will stop the trolley. Unlike the organ donor who you know must die to save the five patients, you don’t intend for the fat man in the story to die and it isn’t required to succeed, but it is foreseeable as an outcome. Philosophers refer to this as the double-effect following from another famous person even longer ago, Thomas Aquinas.
What do you think Thomas meant by double-effect? That’s right. He meant there are two outcomes, one which is a good outcome and one which is a bad outcome. He said that when there is a double-effect, it is ok to cause harm if four conditions are met. First the action itself must have a purpose for doing good, or at least not doing something bad. Second, the good outcome can’t be something that happens only if the bad outcomes happens. Does this one sound familiar? That’s right, it is Kant’s rule about not being a means to an end. Third, the intent must be only for the good outcome. Fourth, the good must outweigh the bad. Does this last one also sound familiar? Right again. You are so smart. It must be utilitarian. How about you work out each of these conditions for Story #3 on your own and tell me what you get.
Trolley Story #4 tests the double-effect. You can now save the five people by pulling a lever that diverts the trolley to a track where it will only kill one person, like in Story #2, but that track loops around back to the five people. The trolley is only stopped if it runs into the one person and kills them, and that stops the trolley from reaching the five people. Now the person’s death is a means to an end so it fails both Kant’s deontological ethics and Aquinas’ double-effect. But, most people surveyed say you should pull the lever. Philosophers have come to believe that the difference here is because people consider how much a person directly participates in causing the person’s death. Throwing or pushing someone is much more direct than pulling a lever.
Trolly Story #5 tests the participation belief. It is much like Story #3, but instead of pushing the fat man you pull a lever that opens a trap door that drops him onto the track. That makes it closer to Story #4 with much less direct participation in killing somebody. As expected, more people prefer this option over pushing the man in Story #3.
Getting on the COVID Trolley
We learned a lot today, didn’t we. We learned about medical ethics and different things to think about, called principles. Let’s try practicing our medical ethics by thinking about these principles and COVID-19 vaccinations. The trolley storybook can even get us started. It mentions vaccinations two times. First, the authors note that vaccines can actually harm people, and sometimes even kill them.
Strictly speaking, vaccinators face the dilemma of killing a few versus letting many die. If the principle of non-maleficence were to be applied very strictly, then vaccinators should refrain from administering vaccines, because after all, they do cause some harm. Yet, vaccines are considered a great moral good. This is because the case of vaccines is of the same class as the bystander who must pull the lever, and of a different class than the surgeon who thinks of killing a person to distribute his organs to save five patients.
This means if a doctor or nurse gives a vaccine to a patient and it turns out to hurt them, the doctor or nurse have not been bad. They followed medical ethics properly even though something bad happened. But, if they knew it was going to hurt the patient, then they might have done something bad.
The ethics of vaccinating patients only lets doctors and nurses give vaccinations because nobody knows which ones will get hurt, if any. But what about if they know something about the patient that they were told could maybe result in getting hurt. Remember the vaccine storybooks, called monographs? They warn about known and unknown risks such as heart conditions, blood conditions, or potential for risks to babies. The vaccine approvals also warn that long-term risks are unknown because the long-term testing, called Phase 3, is not done yet.
What if the doctor gave the vaccination to somebody that fit one of these warnings and it ended up harming the patient? Do you think that doctor violated medical ethics? What about if the doctor and patient had a talk about the risks and agreed to try the vaccine? Doesn’t that seems fair, as long as they make that decision free from coercion, using their autonomy?
The second vaccination case in the trolley storybook applies the double-effect to the people who decide whether anybody should be allowed to try the vaccines at all:
A public health official may foresee that, when a vaccination campaign is begun, some people will die as a result of the vaccines themselves. Yet, the public health official will never intend such deaths, and he will anticipate that the few deaths caused by vaccines are far fewer than the lives saved by the vaccine, thus complying with the requisite of proportionality.
This means that the people who make the decisions on allowing vaccines are acting ethically for approving of vaccines to allow patients to get them, if they believe the vaccines can help many people. For COVID-19 vaccines in Canada, the person making that decision is the Minister of Health with help from the people who run Health Canada. This does not mean that these people decide if a patient should get the vaccine. They only allow doctors and nurses to give people the vaccine if that is what they and the patient decide to do.
This is very similar to the original Interim Order10 from the Minister of Health, who decided to approve the COVID-19 vaccines,
predicated on the Minister's determination that the evidence provided supports the conclusion that the benefits outweigh the risks associated with the drug, taking into account the uncertainties related to the benefits and risks, as well as the urgent public health need caused by COVID-19.
This Interim Order expired yesterday (Sept. 16, 2021)11. It was replaced with transitory regulations12 which continue the approvals on the same basis as the Interim Order.
I Said Get on the COVID-19 Trolley, or Face Consequences
The trolley storybook did not include any stories about coercing people to take vaccines, like what happened to Julie. Let us practice our lessons right here. The first thing we learned about are the four principles of medical ethics. Do you remember what they are?
Do you remember the principle of non-maleficence? It means to “do no harm” to the patient. Threatening the patient with harm does fit that, does it? No, it fails the principle of non-maleficence. If the patient does not wish to take a vaccine, do you remember what this is called? That’s right. Autonomy. If we coerce people to do things they don’t want to do, we have failed the principle of autonomy. The first funny word we learned today was beneficence. Threatening the patient to do something against their will is certainly not an act of kindness or charity, is it? So it fails the principle of beneficence. Remember that beneficence was why “most ethicists prescribe a cautionary principle” when it comes to new biotechnologies, “until further knowledge about their workings is gathered” such as Phase 3 results.
Remember the fourth principle is justice. Coercing people to get vaccinated is supposed to to help save the patient and others from getting COVID-19. Does that mean it is just? Consider that there are other ways to be safe too, such as regular testing, working remotely away from people, and even having immunity from COVID-19 because you already had it before. That is called natural immunity, and much of the science says natural immunity is as good as or better than immunity from vaccines. But the people coercing vaccines don’t have exceptions for any of these ways of being safe. They only want vaccination. And, vaccination still have those unknown long-term risks including potentially to babies. So is it just?
There is a different way to look a justice. We have laws that guide justice. One of the biggest and most important laws in all of Canada is the Canadian Charter of Rights and Freedoms. It has many sections. Section 7 says that everybody in Canada has the right to life, liberty and security of the person. Don’t worry if you don’t understand what that means. Many judges have already decided what it means over many years when people went to court to ask them. These decisions are called precedence. Many of them include decisions by the judges that tell the government that individual people in Canada have bodily autonomy. We already know what that means, don’t we. This just means it is also the law. Many decisions also say that people get to choose what medical treatments they get, or none at all. That includes vaccinations. There are limitations on how people can be punished or harmed for making these decisions.
Almost everybody agrees that coerced vaccinations violate several sections of the Charter. But, there is a way around it, maybe. Section 1 of the Charter allows some limits on these rights that people have in the other sections:
The Canadian Charter of Rights and Freedoms guarantees the rights and freedoms set out in it subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society.
Some people think the government can use this section to coerce vaccinations because COVID-19 is widespread, which we call a pandemic, and so it is reasonable to limit rights under these conditions. Other people think that this section won’t work because there are other ways to be safe that the government is ignoring, like the ones we just talked about. If there are other options that are safe and don’t limit rights, judges will usually prefer those options.
Still other people say there are many other things to consider. One is the small difference in risk to you from being around a vaccinated or unvaccinated person, especially if you are vaccinated yourself. Another thing is that vaccination is driving the evolution of more difficult version of the SARS-CoV-2 virus, called variants, which just delays when people will catch COVID-19 and that it is better to get it sooner with a weaker virus than later with stronger variants.
I don’t think you and I can answer what a judge would say if the vaccine coercions end up in a court case. But, remember the principle we are looking at here is justice, and the Charter and precedence have already decided what justice is for forced medical treatments including vaccines. Section 1 might be used to limit the justice under the belief these limits are reasonable and needed. But, it is clear that coerced vaccination is not consistent with the principles of justice itself.
This means coerced vaccination fails all four standard pillars of medical ethics.
Utilitarianism compares whether there is more good or bad without consideration for action or intent. The trolley storybook notes that for utilitarianism to properly apply we need to know all possible outcomes including long-term events and their chances of occurring. Since we don’t know their chances, we can’t determine the true utilitarian result.
It is easy to ignore these unknown risks because we don’t have much evidence for them yet. But this is a mistake that I told you about before. People often mistake that they don’t know anything about a risk, called “absence of evidence”, with knowing that there isn’t a risk, called “evidence of absence”. This mistake caused two spaceships to blow up. It also caused many babies to be born with birth defects from a medicine called thalidomide. All tragic accidents happen partly because of unknown risks.
Utilitarianism also depends on the circumstances of the individual patient, and what the best science says about their risks. Did you know that people who had COVID-19 before may have immunity to getting COVID-19 that is better than what you get from a vaccine? For that patient, the value of getting a vaccine is very small, if any benefit at all. But, they still have the unknown long-term risks if they take the vaccine. For this patient, the utilitarian answer suggests they may be best to not get a vaccine. Even for everybody else, the unvaccinated naturally immune patient is less likely to spread COVID-19 than a vaccinated person.
This all means there is insufficient information available to apply true utilitarianism, and the variables between individuals changes the calculations from positive to negative. Naïve utilitarian calculations can be performed based on a simple model of known short-term outcomes and risks. In this case, the net value of any additional coerced vaccines outweighs the harms.
This naïve short-term utilitarian calculation also ignores side-effect outcomes such as the subsequent loss of trust, divisiveness in society, harms caused by the threats being applied such as lost jobs, and exacerbating tribal psychology. At best the utilitarian calculation can only partly support coerced vaccinations.
The concept of negative and positive duties is that we have a stronger duty to avoid doing things to hurt people than to do things to help save people. Coerced vaccination clearly fails this criterion as both the coercive threat and the potential long-term risks from the vaccines represent harms, compared to the intent to help save people. The duty to avoid the harms always wins against the good intention in this criterion.
In Trolley Story #2, causal responsibility for the outcome is part of the ethical evaluation. In the case of both coercive threat, such firing from a job, and potential long-term harms occurring, both would result causally from actions of the coercion and those doing the coercing are responsible for the outcomes. The vaccine harms might not be intended, but the action of vaccination would be the direct cause of the harm if it occurs. By way of comparison, if the patient and subsequent people catch COVID-19 and harms come to them, that is not directly caused by the health care providers or government for failing to force the vaccination. Just as it is worse to kill the organ donor than to let the five recipients die, the criterion here would dictate that it is worse to do harm to the patient by carrying out the threat or by causing vaccine-related harms than it would to let the patient and others catch COVID-19. Coerced vaccination hence fails the responsibility criterion.
Applying Kant’s deontological means to an end ethic, the coercion of the patient to get a vaccination is the means to get the public outcome desired, whether it be herd immunity or general reduced risk, or as many claim to allow things to “return to normal”.
Applying the double-effect of Thomas Aquinas means all four components must be met. The purpose of coerced vaccination is to do good by reducing COVID-19 cases so the first component is met. The good outcome of reducing COVID-19 does not require the bad outcomes to happen, such as lost jobs or harms from vaccinations, so the second component is met. Third, is the intent only for the good outcome? Arguably, the demagoguery and tribal psychology drives a lot of divisive hatred and there are many examples of people hoping for bad outcomes for unvaccinated people. But, that divisive environment is an unintended, but foreseeable, outcome of coerced vaccinations. The intent of the coerced vaccination itself is not to cause the divisiveness or harm. Alternatively, it could be argued that the use of the coercive threats itself is an intent to harm the target individuals, not by having the threat come true but by the target individuals suffering the psychological harms of threats and capitulation.
This is an important differentiation. If the argument is that the intent is good because the intent is for the person to be vaccinated and healthy, then there is no analytical difference between a coercive threat versus a coercive benefit in terms of ethics. That is, threating to fire somebody for not being vaccinated would be ethically no different from offering to pay somebody to become vaccinated, since they both have the same good intention as far as vaccination and safety. Clearly this does not get at the ethical differences between threatening and paying as mechanisms. Applying the double-effect requires addressing the intent as far as the target individual’s psychology in terms of why they would get vaccinated as a result of the action. In the case of offering a payment, the intent of the offerer is to make the target individual happy to make the choice to get vaccinated. In the case of using a threat, the intent of the person threatening is to cause the target individual to become unhappy and have to choose the option that makes them less unhappy.
Also consider the earlier comparison of this third component with the means to an end criterion. In the case of coercive vaccination, it is not so much the intent to benefit the target individual as it is to reduce COVID-19 in general, and many have described their interest of coercion as a “return to normal” or similar, in a somewhat selfish manner for themselves, not the benefit of the coerced individual. In that case, even a beneficial coercion might not truly pass if the intent is selfish self-interest.
Based on these details, the third component for double-effect must fail. Coercion via benefit might pass, but not coercion by threat.
The fourth component is that the good must outweigh the bad. This is the utilitarian calculation above which cannot be completed given the unknown risks and social outcomes of such coercion. At best a naïve utilitarian calculation could partially pass the criterion. Since component three fails and four is at best a partial pass, the double-effect criterion must fail.
The final criterion is the degree of direct participation in the bad outcome. In the case of the threatened outcome, such as a lost job, the coercing entity is a direct participant. In the case of a coerced vaccination that results in a harmful outcome, whether short-term or long-term, the coercing entity is not a direct participant but the health care provider who administers the vaccine, knowing that the patient was coerced and does not wish to get the vaccine, is a complacent, direct participant and therefore subject to the ethical evaluation.
All principles of medical and moral ethics here failed with respect to coercive vaccination. At best, a naïve utilitarian calculation can give partial justification, but it fails to take into account the unknown risks, effectiveness, or the divisive social outcomes. The failure of all other factors implies that coercive vaccinations based on threats cannot be consistent with medical or moral ethics. I bet I’m thinking the same thing you are; Julie may have been right.
Coercive vaccinations may or may not have good intentions or motivations. That is a topic for a later article. But it seems clear they are not ethical. Some would consider them to be bullying or just mean. I think the best ethical response to that is described by one of the most ethical individuals we’ve yet encountered:
“You know that the toughest thing is to love somebody who has done something mean to you, especially when that somebody has been yourself. Have you ever done anything mean to yourself? Well it’s very important to look inside yourself and find that loving part of you. That’s the part that you must take good care of, and never be mean to, because that’s the part of you that allows you to love your neighbour. And your neighbour is anyone you happen to be with at any time of your life. Respecting and loving your neighbour can give everybody a good feeling.”
Cover photo attribution: David Pinkerton, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons. Cropped for size.
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