What We Owe To The Anti-Vaxxers
The case for universalism in protecting the vulnerable.
Hundreds of millions of Americans are waiting in line. When they get to the front, they’ll find themselves peering out of the exit of the long tunnel that has been the global coronavirus pandemic. And as they step through to the other side, the number of fellow Americans joining them each day steadily rises. Eligibility for the COVID-19 vaccination has expanded to every adult in every state, and as the rate of vaccine dose administration accelerates, the US rapidly approaches the milestone of inoculating ~1% of the total population per day. At that pace, the herd immunity threshold could be reached by the end of May 2021.
Until then, those standing further down the immunization line remain in need of the protective measures in place shielding them from the deadly disease. Presently, their protection appears to remain a priority for elected officials. But some others will require protection indefinitely: those who will never get in line to begin with.
As is true with many diseases, there will always exist some number of people who remain non-immunized against illness as a matter of circumstance, individual health constraint, or personal choice. That basic reality, the impossibility of achieving 100% immunization, motivates the pursuit of herd immunity’s prize: the insulation of those remaining vulnerable people from the deadly virus through a critical mass of vaccinated people that break the chain of infection, safeguarding the non-immunized from threat.
It is within this pursuit that the noble ambition of cooperative society comes into view: the goal to eliminate, or greatly reduce, preventable suffering and preventable death. All of the collective sacrifices of the last year, from the economic to the interpersonal, evidence the desire to answer to that call.
But soon, as the pool of vaccinated people expands, the moral prompt that the pandemic presents to the collective will become something of a puzzle. The sheer randomness of a disease springing seemingly from nowhere, ravaging humanity and ending the lives of millions, had until now given the pandemic the weight of tragic accident, not unlike a natural disaster. Any death could be understood as an undeserved chance misfortune; the cold injustice of chaos. In pre-vaccine world, all vulnerable people are victims of circumstance. But in post-vaccine world, the imperiled are freely choosing that status. At least, the majority of them are. And so, an element of blame enters the picture.
Will the introduction of that element alter the collective action taken, and the collective sacrifice offered, to protect the vulnerable? If some 35% of a community, for example, opts against the vaccine, should restaurants and businesses remain closed (or enforce safety measures) to protect those unguarded refusers? Or should they fully reopen, simply allowing any illness and death resulting from choice non-protection to continue unabated, the just fate for those knowingly choosing vulnerability? This latter line of reasoning, which flows from a theory of protection deservingness, can go a step further still: Wolfram Henn, a doctor on Germany’s Ethics Council, told Bild that vaccine refusers should forgo ICU beds and ventilators — life-saving measures — in the event of serious illness resulting from a COVID-19 infection.
As Henn correctly notes, some number of anti-vaxxers will undoubtedly contract a severe case of the disease. Another number of them will die. If protective measures are not collectively taken to insulate those people from danger, and are instead relaxed or eliminated completely, will their deaths be an injustice? Or will they be the lamentable — but just — penalty for anti-vaxxism?
Such a framework is uncomplicated, though uncomfortably grim: some people are deserving of having their deaths averted, and some are not — transforming public health into a thing that must be earned.
It’s a simple move, but one with frightening implications. To allow a theory of “deservingness” to invade the calculation of whose health matters is to allow the venue of public health to be repurposed into an arena for the administering of justice. It would recast public health shortcomings not as the outer edges of health outreach, formed by the failure of policy, but as the just and moral perimeter of deserved safety. You either deserve protection, or you don’t. Sickness, then, becomes a kind of punishment for moral failings.
If public health should be shaped by such an unforgiving and punitive approach, who then would decide what kinds of vulnerability are deserving of sympathy, and therefore collective action, and what kinds aren’t? Various types of vulnerability to COVID-19 exist that may fall onto the wrong side of a moral judgment, depending on the judge. For example, Florida Governor Ron DeSantis, when asked if vaccines would be distributed to prisoners, responded:
“You know, some of these states are vaccinating prisoners… They’re vaccinating drug addicts… [In Florida], there’s no way you’re going to get some prisoner a vaccine over a senior citizen.”
If one were to concede to a disciplinary dimension of public health, what might the verdict be for an Evangelical Christian — with conspiratorial views on vaccination — in the eyes of someone with a strong devotion to “believing in science”? Would the hesitance of some people of color to trust the healthcare industry, following a history of mistreatment, rouse the sympathies of a person who rejects the existence of systemic racism? What about the people operating with a dearth of information, such as the 7 million who are unaware that the vaccines are free? Is theirs a vulnerability sympathetic enough to merit the continuation of collective protective measures?
If the theory of health-deservingness muscles its way into public health considerations, the moral calculus that these Rorschach’s give rise to would ultimately decide who among us is thrown to the wolves.
Alternatively, if the principle priority were purely the prevention of sickness and fatalities, any notion of deservingness would be entirely irrelevant to the question of safety measure tactics. Vulnerable people would be deserving of protection because they are vulnerable, not because of any other moral estimation. Until the attainment of herd immunity, which would provide indirect protection even to vaccine resisters, there would be no difference in the protective choices made pre-vaccine world and post-vaccine world — if the aim really were to maximally minimize illness and death.
We might imagine asking a surgeon, treating a car accident victim, if their behavior and choices in the O.R. would be any different if given the knowledge that their patient was or was not at fault in the accident. When the guiding principle is the preservation of life, the surgeon’s answer is not much of a mystery.
For individuals, local governments, and policymakers, accepting a framework of health-deservingness would be to embrace a blithe abdication of duty, much like Germany’s ethicist Dr. Henn. They should aspire instead to follow the principle of minimizing preventable death and suffering as closely as a surgeon might follow their Hippocratic Oath.
From that principle, the universal protection of the vulnerable, flows a mandate — and that mandate is squarely fulfilled by the achievement of herd immunity. But it will be difficult to get there, even with the surge in vaccinations. Some 30% of adults say they will not get a COVID-19 vaccine. When taken together with those who cannot get the vaccine — because of their age or allergies, their status as pregnant or prisoner, or the contraction of COVID or chronic condition — the total achievable immunity level hovers around a meager 56% according to some commentators.
Some back-of-the-napkin arithmetic verifies that bleak estimate: the roughly 21% of the population 16 or younger (currently prohibited from vaccination), added to the 30% of the remaining 79% of adults that say they will refuse the vaccine, combine for a baseline of around 45% of the total population that will remain non-immunized. That’s before adding in the adults barred for health or circumstantial reasons.
(30% * 79%) + 21% = 44.7%
The challenge is escalated by both the far-right and emerging Republican anti-vaccination campaigns. That bloc of people rejecting immunization comprise the full gap between reaching herd immunity and the continuation of uncontrolled virus transmission. Short of expanding vaccine access to children, the solution is clear: the vaccine refusers must be convinced to take the vaccine.
Such a task would require reckoning with the diversity of reasons for vaccine hesitancy and refusal. It would require recognizing that many takers and refusers alike are completely oblivious to how the novel mRNA vaccines precisely work, yet the former group grants their blind trust, while the latter group does not, and investigating the underlying reasons for that faith differential. It would require navigating the tectonic fissures of social divisions to come to an understanding that the presence of trust in health interventions is often the constructed (and therefore changeable) outcome of social positioning.
The task is not insurmountable. There is some optimistic precedent for overcoming it, presciently recounted by Medicare For All advocate Tim Faust while touring his book, “Health Justice Now: Single Payer and What Comes Next”, in 2019. In Quebec, a modest group of just 53 social workers (called “vaccine counselors”) were deployed into neonatal units to counsel families following the delivery of their newborn child, in a kind of pilot program for improving child vaccination coverage. Through soothing vaccination anxieties, gently helping parents make informed choices, and being careful to avoid forcefulness, this group was able to increase the number of parents willing to immunize their children by an impressive 20%. What might the success figures be of a few hundred such counselors? Or a few million?
This is the type of work, referred to as “compassionate labor” by Faust, that is called on by a mandate to universally protect the vulnerable. This, and the recommendation to pay people to get vaccinated, emanate from an urgency to augment the net of protection until the whole is captured. It is a commitment to care, not to punishment, that will most directly address the needs of the herd and secure protection for all within it. Crossing the streams of public health and penal policy makes compassion conditional in place of making care universal and thus forecloses on the possibility of an egalitarian vision of health. It would accept a view in which justice is tied up in a theory of deservingness, instead of one that postulates justice as fairness — where justice is obtained when fairness and equality are present. That is ultimately what we owe to the antivaxxers — that which we owe to each other: fairness. And there, in the surrender to compassion, lies the key to realizing that ideal.
Originally published on my personal blog: Provider
