Europe’s ethical decision on vaccination: do no harm or let more people die?

This week, European public health organizations were faced with a staggering portrayal of what ethicists call the tram dilemma, with millions of lives at risk.

Imagine that we are faced with a change of needles. If we do nothing, a speeding streetcar will pass over three people on its way. If we move the lever, the tram will turn to an alternate lane where there is only one person. Which is the better option from a moral standpoint: to deliberately kill one person or to sit down and let three die?

In the European version, among the 1.6 million people who had received the AstraZeneca vaccine, German regulators detected seven cases in which a strange blood clot appeared in the brain; three of them were fatal. Regulators had no evidence that this was related, it was simply a statistical anomaly. However, continuing to vaccinate would make them responsible for endangering a handful of people, as would moving the lever on the tram tracks.

Instead, German authorities withdrew the vaccine’s authorization from Monday. Then neighboring countries did so, while waiting for the European Union’s pharmaceutical regulator to consider the vaccine safe, which it did on Thursday.

It may seem like an unusual option. Due to a third wave claiming thousands of lives a day in Europe, it seemed almost certain that even a brief hiatus would endanger many more lives than the very strange side effect that had yet to be proven.

However, medical ethics can be misleading. Academics tend to view Europe’s decision as an understandable, albeit risky, cost-benefit calculation or as “a catastrophic mistake,” according to Oxford University ethicist Jeff McMahan.

McMahan, who studies dilemmas of life and death, noted that likely deaths from COVID “would be by omission, or by doing nothing, rather than causing them.” But you have to ask yourself if that makes a difference in this context ”.

However, Ruth Faden, bioethicist and vaccine policy specialist at Johns Hopkins University, called the choice to take a break “an extremely difficult decision.”

Remove the ladder

The German Minister of Health said in a statement: “The State provides the vaccine and therefore has a particular obligation of vigilance”, such as the detection of risks and the response in the event of the outbreak of certain disorders; even, admits the press release, if the decision sacrificed more lives than it saved.

“This idea of ​​the preventive principle plays an important role in European Union policy,” said Govind Persad, a bioethicist at the University of Denver. This principle advocates stopping any policy likely to cause unforeseen harm in order to analyze this harm before moving forward. It would be wrong to blindly expose citizens to even minimal risk if they are unaware of it.

However, Persad mentioned that “he had never really been able to understand how this principle would apply in the event of a pandemic.”

On the one hand, although vaccines involve risk or mistrust, the risk and mistrust that was incorporated when they stopped applying them was surely greater, which allowed cases to increase. The contagions were not going to be stopped by a bureaucratic process.

In contrast, vaccines are voluntary.

“You don’t endanger people without their consent,” Persad said, nor, therefore, violate the precautionary principle. “We allow people to consensually protect themselves from a great risk by taking a very small risk.”

Imagine, he said, “someone is stuck on a subway track and there is a service ladder they want to use to get out.”

Europa’s position, he said, was like pulling off the ladder and telling the trapped person that they couldn’t use it until they had been tested to see if they were free. danger for the whole population.

“It is true that a lot of Britons use these types of scales and they are doing well,” he said, referring to the widespread application of the AstraZeneca vaccine in the UK. “But we can’t let you hurt yourself.”

Do no harm

“In Germany, there is a great reluctance to allow, in exchange situations, to positively harm people,” Persad noted. The emphasis is very clearly on doing no harm, although it is recognized that the harm is much greater due to inaction.

This unusually considerable aversion to anything that can be seen as a violation of autonomy or individual dignity by the government is, as is the case with many things in Germany, a reaction against that country’s Nazi past. .

Due to Germany’s leadership by its peers in the European Union and increased caution not to seem permissive about vaccine safety, other countries immediately followed suit, notably France, the ‘Italy and Spain.

However, the reasoning behind Europe’s decision also reflects something universal: the Hippocratic Oath which declares “first and foremost, do no harm”.

Under this oath, it might be considered unacceptable to administer even doses that have the same unproven chance of affecting patients as the chances of being struck by lightning.

“But when the alternative to doing little harm is to allow much greater harm, then the slogan ‘do no harm’ is a bad policy guide,” said McMahan, the Oxford ethicist.

Reassure or sow doubt

Faden, the vaccine bioethics specialist, stressed that if lawmakers want to make a decision entirely based on the medical aspect, they must also think about protecting the trust of the people.

In itself, there was already a lot of mistrust of vaccines in Europe, especially in the case of the AstraZeneca vaccine, on which Europe has focused its projects. According to some surveys, the percentage of people wanting to be vaccinated has fallen well below the 70 percent needed to gain community immunity.

“In a way, some realistic events with heavy media coverage that are very frightening control the imagination of the people,” Faden said.

He also added that taking a break could be a way “to assure the population that public health authorities or the government take any sign that appears too seriously.”

We hope this will build confidence in health officials and show that they exercise caution and safety before rushing to vaccinate. Even though people still don’t trust the vaccines per se, maybe relying on those who administer the vaccines could solve this problem.

Regarding ethics, however, Persad commented: “It seems worrying to say that a person’s access to treatment should depend on how it might affect the peace of mind or the psychological aspect of a third party. . “

It is also a risk. The delays imposed by European governments risk deepening the public’s doubts about the vaccine. And now authorities need to show they take these three deadly clots seriously, which means they’ll get more attention.

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