By Nancy S. Jecker
The Director-General of the World Health Organization (WHO) has urged a temporary halt to COVID-19 boosters to enable 10% of the people of every nation to be vaccinated. Despite solid ethical backing for this stance, a spate of countries has gone full steam ahead with booster shots. Israel was the first, offering boosters to people 60 years and up in July 2021 and shortly after, in August 2021, Israel opened the floodgate, offering booster to all vaccinated people. Other nations have followed suit, including Britain, USA, Sweden, United Arab Emirates, Germany, France, and others.
The science surrounding boosters is controversial. Uncertainty exists, especially about the level of neutralizing antibodies needed to protect against COVID-19 . While the science continues to emerge, the ethics is clear: even if a third shots add significant protection against COVID-19, we should hold off on boosting for now.
The imperative to delay boosters gains ground from multiple sources. First, the spectacularly unfair distribution of vaccines around the globe violates our duty to the least well off. As of 6 October 2021, 77% of shots have gone to people in high-income and upper middle-income countries, while just 0.5% delivered to those in low-income countries. The striking divide between rich and poor is a problem of human making. Before vaccines were even shown effective, wealthy countries were hoarding them in a manner that bespeaks astonishing greed. In 2020, 44 bilateral deals between government and industry were struck, and an additional 12 were signed by March 2021. None of these advance market deals were structured to improve outcomes for low- and middle-income countries. Before making the well to do better off, we ought to bring everyone up to a threshold level of protection.
Yet it could be argued that pharmaceutical companies own the product of their labor and thus deserve whatever profit they reap. However this is a preposterous thing to say. In fact, science is a social product. The contributions made by big pharma are limited to the final, translational part of vaccine research and development. The public, principally governments, funds the science on which vaccines are based. Hefty public investments in the ten technologies employed in candidate COVID-19 vaccines contributed substantially to rapid vaccine development during the pandemic. Even if multinational drug companies deserve some profit, their profits are excessive, far more than other large companies. During a global health emergency, their proceeds cost us dearly.
From a utilitarian perspective, there is little to quibble with. If our goal is to save the most lives, current vaccine supplies should go to unvaccinated people. If our end is maximizing yield for each dose administered, it is also obvious that boosters make no sense — on the plausible assumption that getting vaccinated increases protection against severe disease and death by >80% (for 6 months minimum) and a booster gives a 10% increase (over a 6-month period), we should follow the Director-general’s good guidance.
Why then do prominent U.S. bioethicists defend boosters? Some appeal to “reasonable nationalism,” putting forth an influenza standard which holds that “when COVID-19 becomes more like a bad influenza season in terms of mortality, other health effects, and public health restrictions—then there is no longer an ethical justification for retaining vaccine doses for country residents.” Yet, this standard is anything but reasonable. What is ethically reasonable is what we have dubbed a fair-minded influenza standard: until COVID-19 resembles a bad influenza season, governments should work cooperatively, sharing vaccines. In other words, if the SARS-CoV-2 virus becomes a background condition of our lives, as scientist predict it will, then and only then does the world’s duty to help vaccinate the world recede.
A fair-minded influenza standard gains ethical backing from the principles noted. It also is in every nation’s self-interest. When the virus runs rampant, it “rolls the dice millions of times and some mutations produce fitter mutants,” potentially placing at risk the very protection vaccines afford. Our global interconnectivity, especially jet travel, collapses boundaries between ‘us’ and ‘them’ during the COVID-19 pandemic. In today’s world, even stubborn nationalism demands global solidarity.
Paper Author: Nancy S. Jecker, Ph.D. and Zohar Lederman, M.D., Ph.D.
Affiliations: Dr. Jecker is affiliated with the University of Washington School of Medicine, Department of Bioethics & Humanities; the University of Johannesburg, Department of Philosophy; and the Chinese University of Hong Kong, Center for Biomedical Ethics & Law. Dr. Lederman is affiliated with the Rambam Health Care Campus, Medical Ethics and Humanities Unit, Haifa, Israel.
Competing interests: None
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