The Ethics of Public Health Infectious Disease Policy

“Because to take away a man's freedom of choice, even his freedom to make the wrong choice,
is to manipulate him as though he were a puppet and not a person.”

- Madeline L'Engle (1)

Coronavirus Disease 2019 (COVID-19) infection prevention and control (IPC) guidance measures are the same as for infectious disease. Current liberty-infringing measures to control severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including in particular, mandatory vaccines, rank towards the top of a public health intervention ladder known as the Nuffield intervention ladder. Whether a public health measure is acceptable depends on whether or not it is 'proportionate'. Here I would like to discuss the public health frameworks and ethics surrounding IPC during the COVID-19 pandemic and compare and contrast the approaches of the nanny state / nightwatchmen. Finally, I’d like to describe the inverse correlation between stricter controls and compliance.

Nanny state and night watchmen

There are two rival approaches offered by the state. In one, the state serves as a nanny to provide for the welfare of its members; the other provides only the service of a night-watchman and requires people to look after themselves. Ensuring people's freedom means leaving them to their own devices and destiny. Whilst this dichotomy is supposed to invoke debates about public health interventions, much of humanity appears to relish the freedom from personal responsibility and freedom from choice. Whilst solid arguments may exist against the nightwatchman approach and scientific ethicists argue that the nanny state is good for us, many other scientific ethicists and civil libertarians would beg to differ. As a population, we need to critically analyse and openly debate current policies that strip us of our autonomy (2, 3).

Nuffield intervention ladder

Britain’s Nuffield 'intervention ladder' is a way of thinking about the acceptability and justification of different public health policies. The possibilities on this ladder escalate from doing nothing (night watchmen) to providing information to enable choice, to restricting or eliminating choice (nanny state). This intervention ladder is currently being used to provide ethical justifications for draconian policies that restrict our liberties (4). Below the ladder shows interventions ranging from the most restrictive to the least restrictive. A balanced intervention ladder embodies the assumption that personal autonomy is maximised by non-intervention. 

Figure 1: Intervention ladder (adapted from Nuffield Council on Bioethics - 2007) (5)

Carrots and sticks; nudges and regulations

One of the most extensively debated topics in behavioural psychology is whether punishment or reward is more effective for producing desired changes in our behaviour. The methods public health employ during COVID-19 to increase our compliance are known as carrots and sticks, and nudges and regulations. A carrot is seen as a reward and a soft preventive measure. A stick is a punishment and hard preventive measure. An example of a carrot is business subsidies to compensate for income losses due to COVID-19 restrictions. An example of a stick is fining organisers of social gatherings exceeding 50 persons, or imposing curfews in cities. An example of a Thor hammer is Austrians who refuse to get a COVID-19 vaccine will face fines of up to €3600 (US$4000) once mandatory vaccination rules come into force (6). A nudge is something that people can opt-out of and includes hand hygiene, social distancing and voluntarily self-quarantine upon being found symptomatic.

Kass’s six-step framework for ethical decision making

Within public health sits a six-step ethical framework aiming to balance state interventions and personal liberty in public health policy (7). This framework is known as Kass’s Six-Step Ethical Framework and includes the following;

1. What are the health goals of the proposed policy?

2. How effective is the policy in achieving its stated goals?

3. What are the known or potential burdens of the policy?

4. Can the burdens be minimised? Are there alternative approaches?

5. Is or can the policy be implemented fairly?

6. How can the benefits and the burdens of the policy be fairly balanced?
   

There following five ‘justificatory conditions’ are used to balance the ethics and morals of public health interventions;

• Effectiveness: Infringing on ethical considerations will probably protect public health.

• Proportionality: The probable public health benefits outweigh the general ethical considerations.

• Necessity: Is there a strategy less morally troubling to reach the same public health goal?

• Least infringement: Seek the least intrusive and restrictive alternative.

• Public justification: Obligation to justify and explain infringement.
  

Concerning the overtly restrictive public policy measures to limit COVID-19, it is my opinion that the five ‘justificatory conditions of effectiveness, proportionality, necessity, least infringement and public justification, used to balance the ethics and morals of public health interventions have not been met. I have provided a few examples here to support my opinion and invite you to share your experience as to how these measures are disproportionate in our online conversation thread. 

Fear increases acceptability and justification of public health policies

Fear-based media is used to strip us of our personal liberty, and the current use of fear-based media is highly ethically questionable. As previously explained in ‘The Impact of Fear and Anxiety on the Human Immune System Part 1’ the fear surrounding COVID-19 is disproportionate. It is this fear that justifies the obliteration of our personal liberties. Public health’s ‘Seven-Step Recipe for Generating Interest in, and Demand for, Influenza (or any other) Vaccination’ includes using the mainstream media to drive fear and anxiety (8). Fear also generates income for media. News programmers have a philosophy to capture viewer attention known as ‘If it bleeds it leads’ (9). ‘If it bleeds, it leads’ serves two purposes; the first of which is to capture the viewer's attention, the second of which is to persuade the viewer of a magic solution for reducing the identified fear (10). We are all too familiar with this; Omicron and get boosted. Our preferred policies in fact, depend on how fearful we are. Studies comparing public support for soft and hard preventive measures during the COVID-19 pandemic have found that the higher the level of risk perception, the more likely one is to accept draconian measures (11). A survey conducted in Sweden found that fearful individuals are fine with nudges but that they actually prefer traditional methods of government interventions such as economic incentives (carrots), mandates (sticks) (12). 

COVID laws are an affront to both democracy and civil liberties

In relation to the five ‘justificatory conditions’ used to balance the ethics and morals of public health interventions; effectiveness, proportionality, necessity, least infringement and public justification, many public health ethicists and civil liberties groups argue that the public health interventions in place are not effective and are disproportionate, unnecessary, of great infringement and not justified. The Irish Council for Civil Liberties (ICCL) recently highlighted its concerns at the recent steamrolling of the Health (Amendment) Bill (No.3) 2021, describing the bill as an affront to our democratic system of law-making. The Bill proposes to introduce a system of mandatory quarantine and forced removal in the state of Ireland (13). 

COVID-19 vaccines are ineffective at stopping transmission

Many would argue that COVID-19 vaccines are ineffective and that vaccine certificates are merely a tool of coercive control. Fully vaccinated individuals with breakthrough infections have peak viral load similar to unvaccinated cases and can efficiently transmit infection in household settings, including fully vaccinated contacts (14). A Lancet study in December 2021 found that the prevalence of the virus is increasing in fully vaccinated people. German data shows that the prevalence in those fully vaccinated over 60, rose from 16.9% in July 2021 to 58.9% in Oct 2021, representing a 42% increase. The double-jabbed are in fact a major source of SARS-CoV-2 transmission (15). The BMJ said that there is insufficient evidence to back mandatory COVID-19 vaccines in NHS staff as mandating the vaccine in the 8% of NHS workers who have refused the COVID-19 vaccine would result in the loss of 5.4% of NHS staff (16). 

Vaccine mandates are medical coercion and can increase vaccine hesitancy

Many would argue that COVID-19 vaccines mandates are also ineffective. Like all coercive policies, vaccine mandates restrict personal liberty. Vaccine hesitancy (VH) is according to the World Health Organisation (WHO), a top ten threat to global health (17).  I believe designating VH as a major global health threat was a purposeful action created to move vaccination policy towards the top of the Nuffield Ladder, in order to justify the stripping of our personal liberties (18). While mandatory vaccination can increase vaccine uptake rates they have also caused a backlash among some parents. Studies found that parents perceived mandatory vaccination schemes as an infringement of their rights, and particularly disliked schemes offering financial incentives for vaccination (19). An article exploring public attitudes toward COVID-19 vaccine mandates published in JAMA suggests that COVID-19 vaccine mandates, particularly for adults, maybe ineffective or, worse, prompt backlash (20).  

President of the European Commission Ursula von der Leyen recently said that 1/3 of European Union (EU) citizens have refused the COVID-19 vaccine (21). That’s 150,000 EU citizens. This figure does not include the growing number of people who are not showing up for their booster. Mandating vaccines is medical coercion, and coerced consent is worse than no consent. Nudging or persuasive messaging is increasingly used in public health interventions to encourage health-promoting behavioural changes, including nudging us toward vaccination (22). However, I would describe the persuasive messaging being used to nudge us toward COVID-19 vaccine uptake as covert messaging. Persuasion, not coercion or incentivisation, is the best means of promoting COVID-19 vaccination (23). Regardless of anyone’s personal opinion on vaccines, it will be impossible to enforce mandatory vaccines through law alone. Nudging will be needed to support the legalities during the global COVID-19 pandemic (24). 

COVID-19 vaccine risk and benefit

Many would argue that the COVID-19 vaccine risks outweigh the benefits. Public health institutions require public participation to restrict the infectious spread of COVID-19. However, the lack of transparency and minimal information surrounding the vaccines is more than a major hurdle in increasing public compliance, it is a solid wall. Many would argue that mandating COVID-19 vaccines is not a reasonable and legitimate response, thus disproportionate. There are three named blood clots linked to COVID-19 vaccines. Scientists named one unusual prothrombotic syndrome reaction, vaccine-induced immune thrombotic thrombocytopenia (VITT) (25). VITT is also called thrombosis with thrombocytopenia syndrome (TTS) and vaccine-induced prothrombotic immune thrombocytopenia (VIPIT) (26). The second vaccine-associated blood clot is a clot in the vessels draining blood from the brain, known as cerebral venous sinus thrombosis (CVST). On April 2nd 2021, Oxford announced it had paused its COVID-19 vaccine study in children as it awaited more data on blood CVST after the AstraZeneca vaccine, Vaxevria (27). Between March 2nd and April 21st 2021, case reports of CVST with thrombocytopenia were noted after Janssen COVID-19 vaccination (28). A third named vaccine-associated blood clot is multiple blood clots in multiple blood vessels, which is known as disseminated intravascular coagulation (DIC). An Oxford University study found the number of people who report blood clots after receiving COVID-19 vaccines is approximately the same for those who received either the Pfizer, Moderna or the AstraZeneca vaccine (29).

A preprint Oxford study recently determined that the risk of cerebral blood clots from COVID-19 disease is ten times that from COVID-19 vaccination (30). The Oxford study is flawed as it compared blood clots in hospitalised COVID-19 patients only, with blood clots in recipients of the COVID-19 vaccines. As obesity is the main risk factor for hospitalisation in COVID-19, hospitalised COVID-19 patients are statistically far more likely to be obese (31). Being obese or overweight predisposes individuals to increased risk of thrombotic (clotting) disorders such as myocardial infarction (heart attack), stroke, and venous thromboembolism (a clot that moves) (32). Sound science would compare blood clots in all COVID-19 populations, not just in those hospitalised. 

Myocarditis following COVID-19 vaccination

In August 2021, a case report published in Radiology Case Reports discussed the more serious side effects of myocarditis associated with the Pfizer-BioNTech and Moderna mRNA vaccines. This article noted that the Israeli Ministry of Health had received 62 reports of cases of myocarditis in patients vaccinated for COVID-19 out of 5 million people having received vaccinations. Most cases had occurred after the second mRNA vaccine dose. The prevalence was found to be higher in men under the age of 30 years. Two of these 62 patients died (33). By June 2021, the CDC was investigating heart inflammation cases after Pfizer and Moderna COVID-19 vaccination. The CDC said the vaccine link to heart inflammation is stronger than previously thought. However, low and behold! The reports of myocarditis and pericarditis were already in June 2021, reported as being lower than the incidence of myocarditis and pericarditis after SARS-CoV2 infection (34). 

Pediatric cardiologists have a message for us parents: COVID-19 should scare us a lot more than the vaccine (35). Many parents are aware however, that the evidence shows the benefits of COVID-19 vaccination do not outweigh the risks. In September 2021, a University College London (UCL) study found that confirmed SARS-CoV-2 positive children had a 1-in 50,000 chance of being admitted to the intensive care unit (ICU)  with COVID-19 and a 2-in-a-1 million chance of dying (36). The UK Joint Committee on Vaccination and Immunisation (JCVI) opted not to recommend universal COVID-19 vaccination of 12-15 year olds, saying there is a 60 in 1 million chance of developing heart inflammation (37, 38). 

Kass’ ethical decision making includes asking; are there alternatives?

Many would argue that methods exist to control SARS-CoV-2 that are far less infringing on civil liberties. According to Kass’s six-step framework for ethical decision making, public health is supposed to ask, are there alternative approaches (39)? There are many in fact that I will discuss in future articles on VSS, however I will provide one example here; the UK National Health Service (NHS) is recommending vitamin D to prevent and treat COVID-19. Prior to the UK COVID-19 vaccine rollout in November 2020, the UK government gave four months worth of free vitamin D supplements to more than 2.5 million vulnerable and elderly population (40). Scotland also rolled out vitamin D to its vulnerable and elderly population. The National Institute for Health and Care Excellence (NICE) and Public Health England (PHE) advice to then health minister Matt Hancock on the use of vitamin D was, “NICE and PHE received a formal request to produce recommendations on vitamin D for prevention and treatment of COVID from Matt Hancock, on October 29th 2021” (41). If the NHS and the CDC recommend taking vitamin D to prevent and treat COVID-19, why are we being coerced into taking multiple COVID-19 vaccines, particularly as there is no conclusive evidence that the vaccines prevent nasal SARS-CoV-2 infection to block transmission (42). 

Conclusion

The World Economic Forum (WEF) themselves say that even Napoleon couldn’t force everyone to get vaccinated. Whilst Napoleon managed to bend most of Europe to his will, when it came to smallpox vaccines, Napoleon could only encourage his compatriots to get a smallpox vaccine as a civic duty (43). In some ways, not much has changed; the unvaccinated still remain unconvinced. The segregation and discrimination currently imposed on the unvaccinated resulting from these draconian public health strategies is completely unjustified. The five ‘justificatory conditions’ of effectiveness, proportionality, necessity, least infringement and public justification, used to balance the ethics and morals of public health interventions have not been met. The probable public health benefits do not outweigh the ethical considerations and are disproportionate. Strategies exist to reach the same public health goals that are less morally troubling and less intrusive and restrictive. The COVID-19 vaccines are ineffective at reducing transmission and the risk outweighs the benefit.  

Yet we are heading in a frightening direction. COVID-19 emergency laws that mandate masks, mandate social distancing, mandate curfews, mandate quarantine, mandate forced removals and, now coming to a United Nation (UN) member state near you, mandate vaccines, are an insult to our autonomy. The COVID passport or ‘green pass’ is an affront to Article 14 of the Human Rights Act which is to protect us from discrimination. Discrimination is outlawed on nine grounds including gender, marital status, family status, age disability, sexual orientation, race, religion and being a member of a minority community such as the travelling community here in Ireland (44). ‘Vaccination passports’ and ‘no jab, no job’ policies are without a doubt, discriminatory. Discrimination against those who do not get a COVID-19 vaccination needs to be outlawed. We as individuals must remain sovereign over our own body. We as a collective of free people need to lobby to have ‘immunisation status’ added to equal status acts globally, to end the threat of medical tyranny once and for all. 

‍

Abbreviations

- Coronavirus Disease 2019 (COVID-19)

- Herd Immunity Level (HIL)

- Infection prevention and control (IPC)

- Joint Committee on Vaccination and Immunisation (JCVI)

- National Health Service (NHS) 

- Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) 

- United Kingdom (UK)

‍

References:

1. L'Engle M. Because to take away a man's freedom of choice, even his freedom to make the wrong choice, is to manipulate him as though he were a puppet and not a person San Fransisco, US: Goodreads; 2021
   [Available from: https://www.goodreads.com/quotes/68139-because-to-take-away-a-man-s-freedom-of-choice-even].

2. Pettit P. Freedom and the state: nanny or nightwatchman? Public Health. 2015;129(8):1055-60.

3. Chapman S. One hundred and fifty ways the nanny state is good for us. The Coversation. 2013 Jul 01 

4. Griffiths PE, West C. A balanced intervention ladder: promoting autonomy through public health action. Public Health. 2015;129(8):1092-8.

5. H. S. Public Health Ethics: Cases Spanning the Globe. H. Barrett D WOL, Dawson A, et al., , editor. New York, New York, United States: Springer; 2016 Apr 13.

6. Eder M. Vaccine Holdouts Face $4,000 Fine in Austria’s Virus Crackdown  New York, New York, United States: Bloomberg; 2021 Nov 22
   [Available from: https://www.bloombergquint.com/politics/vaccine-holdouts-face-4-000-fine-in-austria-s-virus-crackdown].

7. Dawson AJ. Snakes and ladders: state interventions and the place of liberty in public health policy. J Med Ethics. 2016;42(8):510-3.

8. CDC GNAdMR. Increasing Awareness and Uptake of Influenza Vaccine  "Getting Ready for 2004-2005: Lessons (Re-) Learned [Including the Seven-Step Recipe for Generating Interest in, and Demand for, Flu (or any other) Vaccination]2004.

9. Cooper CP, Roter DL. "If it bleeds it leads"? Attributes of TV health news stories that drive viewer attention. Public Health Rep. 2000;115(4):331-8.

10. Serani D. If It Bleeds, It Leads: Understanding Fear-Based Media New York City, NY, US: Psychology Today 2021
    [Available from: https://www.psychologytoday.com/us/blog/two-takes-depression/201106/if-it-bleeds-it-leads-understanding-fear-based-media].

11. Dudás L, Szántó R. Nudging in the time of coronavirus? Comparing public support for soft and hard preventive measures, highlighting the role of risk perception and experience. PLoS One. 2021;16(8):e0256241.

12. Andersson GAaP. Carrots, sticks, sermons, and nudges during the pandemic.  Sweden Through the Crisis Stockholm, Sweden: Stockholm School of Economics Institute for Research; 2021.

13. Liberties TICfC. ICCL sends briefing to Oireachtas: Mandatory Quarantine and Human Rights Concerns: ICCL; 2021
    [Available from: https://www.iccl.ie/news/iccl-sends-briefing-to-oireachtas-mandatory-quarantine-and-human-rights-concerns/].

14. Seran Hakki et al. Community transmission and viral load kinetics of the SARS-CoV-2 delta (B.1.617.2) variant in vaccinated and unvaccinated individuals in the UK: a prospective, longitudinal, cohort study. The Lancet Infectious Diseases. 2021 Oct 29.

15. Kampf G. The epidemiological relevance of the COVID-19-vaccinated population is increasing. Lancet Reg Health Eur. 2021;11:100272.

16. Kmietowicz Z. Evidence is insufficient to back mandatory NHS staff vaccination, says House of Lords committee. BMJ. 2021;375:n2957.

17. WHO. Ten threats to global health in 2019 2019
    [Available from: https://www.who.int/emergencies/ten-threats-to-global-health-in-2019].

18. Clarke C, Dixon G, Holton A, McKeever B. Including “Evidentiary Balance” in News Media Coverage of Vaccine Risk2014. 1-12 p.

19. Smith LE, Hodson A, Rubin GJ. Parental attitudes towards mandatory vaccination; a systematic review. Vaccine. 2021;39(30):4046-53.

20. Largent EA, Persad G, Sangenito S, Glickman A, Boyle C, Emanuel EJ. US Public Attitudes Toward COVID-19 Vaccine Mandates. JAMA network open. 2020;3(12):e2033324-e.

21. Desk N. Time to 'think about mandatory vaccination': European Commission chief Ursula von der Leyen. The Economic Times 2021 Dec 21.

22. Reñosa MDC, Landicho J, Wachinger J, Dalglish SL, Bärnighausen K, Bärnighausen T, et al. Nudging toward vaccination: a systematic review. BMJ Glob Health. 2021;6(9).

23. Pennings S, Symons X. Persuasion, not coercion or incentivisation, is the best means of promoting COVID-19 vaccination. Journal of Medical Ethics. 2021;47(10):709-11.

24. Jakub M. Krawiec OMP, Piotr F. Piesiewicz & Wojciech Białaszek. Tools for public health policy: nudges and boosts as active support of the law in special situations such as the COVID-19 pandemic. Globalization and Health. 2021;17.

25. Andreas Greinacher KS, Jan Wesche et al. Towards Understanding ChAdOx1 nCov-19 Vaccine-induced Immune Thrombotic Thrombocytopenia (VITT). Research Square. 2021 Apr 20 PREPRINT 

26. Cuker TEWaA. COVID-19: Vaccine-induced immune thrombotic thrombocytopenia (VITT) Philadelphia, Pennsylvania, United States: UpToDate; 2021 Apr 30
    [Available from: https://www.uptodate.com/contents/covid-19-vaccine-induced-immune-thrombotic-thrombocytopenia-vitt].

27. Staff R. Oxford pauses COVID-19 vaccine study in kids, awaits more data on blood clot issues Toronto, Canada: Thomson Reuters; 2021 Apr 06
    [Available from: https://www.reuters.com/article/uk-health-coronavirus-britain-vaccine-idUSKBN2BT2F5].

28. See I, Su JR, Lale A, Woo EJ, Guh AY, Shimabukuro TT, et al. US Case Reports of Cerebral Venous Sinus Thrombosis With Thrombocytopenia After Ad26.COV2.S Vaccination, March 2 to April 21, 2021. Jama. 2021.

29. al MTe. Cerebral venous thrombosis and portal vein thrombosis: a retrospective cohort study of 537,913 COVID-19 cases. Oxford, UK: Oxford Health NHS Foundation Trust; 2021 Apr.

30. Taquet M HM, Geddes JR, Luciano S, Harrison PJ. . Cerebral venous thrombosis: a retrospective cohort study of 513 284 confirmed COVID-19 cases and a comparison with 489 871 people receiving a COVID-19 mRNA vaccine. Oxford, UK: Oxford University; 2021.

31. Bellini B, Cresci B, Cosentino C, Profili F, Bartolacci S, Scoccimarro D, et al. Obesity as a risk factor for hospitalization in COronaVirus Disease-19 (COVID-19) patients: Analysis of the Tuscany regional database. Nutr Metab Cardiovasc Dis. 2021;31(3):769-73.

32. Blokhin IO, Lentz SR. Mechanisms of thrombosis in obesity. Curr Opin Hematol. 2013;20(5):437-44.

33. Albert E, Aurigemma G, Saucedo J, Gerson DS. Myocarditis following COVID-19 vaccination. Radiol Case Rep. 2021;16(8):2142-5.

34. Lee BY. CDC Further Investigating Heart Inflammation Cases After Pfizer, Moderna Covid-19 Vaccination. Forbes. 221 Jun 13.

35. Cohen E. Doctors explain myocarditis and why teens should still get a COVID-19 vaccine | Toronto, Canada: CTV News; 2021 June 13
    [Available from: https://www.ctvnews.ca/health/coronavirus/doctors-explain-myocarditis-and-why-teens-should-still-get-a-covid-19-vaccine-1.5468605].

36. Gibbons K. Children face two-in-a-million Covid death risk, study finds. The Times. 2021 Jul 09.

37. Triggle PRaN. Scientists not backing Covid jabs for 12 to 15-year-olds London, UK BBC 2021 Sep 04
    [Available from: https://www.bbc.com/news/health-58438669].

38. Iacobucci G. Covid-19: JCVI opts not to recommend universal vaccination of 12-15 year olds. BMJ. 2021;374:n2180.

39. Kass NE. An ethics framework for public health. American journal of public health. 2001;91(11):1776-82.

40. Desk BN. Covid: Free Vitamin D pills for 2.5 million vulnerable in England London, UK: BBC Global News Ltd; 2020 Nov 28
    [Available from: https://www.bbc.com/news/health-55108613].

41. desk N. Covid: UK government requests guidance on vitamin D use. The Guardian. 2020 Nov 14.

42. Bleier BS, Ramanathan M, Jr., Lane AP. COVID-19 Vaccines May Not Prevent Nasal SARS-CoV-2 Infection and Asymptomatic Transmission. Otolaryngol Head Neck Surg. 2021;164(2):305-7.

43. Letzing J. Are COVID-19 vaccine mandates human rights violations? Cologny, Switzerland: World Economic Forum; 2021
    [Available from: https://www.weforum.org/agenda/2021/08/are-covid-19-vaccine-mandates-a-human-rights-violation/].

44. IHREC. Equal Status Acts Dublin, Ireland: Irish Human Rights and Equality Commission; 2021
    [Available from: https://www.ihrec.ie/guides-and-tools/human-rights-and-equality-in-the-provision-of-good-and-services/what-does-the-law-say/equal-status-acts/].