Vaccine Skeptics are Pro-Vaccine: Moral Arguments Part 2

In this post I cover moral arguments vaccine skeptics make for non-medical exemptions. Skip to Part 3 if you’re just interested in the argument. In Part 1, I briefly make some general comments on the norms and practices for engaging vaccine skeptics and hesitants. In Part 2, quickly outline the strongest possible interpretation of medical ethics that favors non-medical exemptions. In most pro-vaccine groups and articles it doesn’t get enough attention, yet it is critical for engaging in an informed discussion of the ethics of vaccine policy with vaccine skeptics. Finally, in Part 3 I evaluate the most popular moral argument vaccine skeptics give for non-medical exemptions. [Go here for Part 1 of this series]

Part 1: Norms and Practices for Engagement with Anti-Vaxxers, Vaccine Skeptics, and Vaccine Hesitants

If I could criticize my past exchanges with opponents to vaccines I would say I lacked sufficient empathy. I was so focused on #FactsandLogic that I didn’t sufficiently engage in a way that acknowledged their full humanity. It took me a long time–too long–to come to terms with this.

Intelligence and knowledge are tools. And like any tool, depending on how you use them, they can be weaponized for destruction or they can help build and repair. In the skeptic community, too often we use them as a weapon rather than something with which to serve those who need them most. It’s very easy to convince ourselves that we are using our knowledge and intelligence to serve the public good when in fact we may be using it to feel better about ourselves, elevate ourselves above others, belittle, ridicule, or virtue signal. I know because I’ve been guilty of all of these things at some point.

Knowledge isn’t wisdom. And this is a time for wisdom. There is an additional public health crisis growing if we don’t reverse the course of public sentiment on vaccines. Future lives literally depend on the effectiveness of our communication strategies. The arguments are easy. All the science is on our side. The real challenge is figuring out how to maintain an empathic disposition while addressing the arguments–all while doing this in the most hostile environment for human communication ever created (i.e., online comments).

This is a massive challenge since even when we mean well, it’s so easy to misinterpret tone and intent in a text comment–especially between strangers. We will occasionally screw this up but it doesn’t preclude us from aspiring to meet this challenge. It’s doubly hard when everything we care about is under attack–i.e., public health, institutions of higher learning, epistemic norms, science, and expertise.

Empathy and personal relationships, not facts and logic, are our primary advantage in the information war. Active online pro-vax groups will likely always be a minority and at a strategic disadvantage. Ethically, we won’t stoop to misleading propaganda, outright lies, or rely on the aid of Russian and other disinformation bots. We are no match for those forces on their terms. But we have something propagandists don’t have. We have personal relationships with the people who have fallen prey to these forces. The pro-vax movement needs to appropriately value, nurture, and protect this advantage. Trust and reputation–not facts and logic–are the only thing that reliably open people to new information.

In a later post, I’ll offer more practical advice but for now here are a few quick tips:

1. If you’re in an agitated state, step away from the keyboard! Don’t engage with someone online. You’ll damage the personal relationship and further opportunities for communication.
2. As I’ve emphasized before, always begin in agreement. Acknowledge concerns. Don’t dismiss them out of hand–regardless of their merits. For them, they are legitimate. Dismissing them off the bat–even if they are misguided–shows a lack of concern for their humanity and harms the relationship as well as trust.
3. Before engaging with someone in your personal network, reflect on the relative value of the relationship and their views on vaccines. No genuine friendships are worth losing over someone’s views on vaccines. Let this guide your interaction.
4. Changing people’s views is a long-term process. Almost never will someone change their views in a single interaction (those familiar with Bayesian reasoning should understand why). Go in with the intent to plant seeds. You will never in a single interaction drastically reconfigure a vast edifice of deeply-held mutually reinforcing beliefs someone has accumulated–on any issue.

Part 2: Contemporary Medical Ethics, The Principle of Autonomy, and Vaccine Policy

A young mother goes to the hospital to give birth. During the delivery, through no one’s fault, she develops internal bleeding (postpartum hemorrhage). Without a blood transfusion, she will die. The hospital staff prepare the blood transfusion but the young mother tells them to stop. As a devout Jehovah’s Witness she believes God prohibits blood transfusions. In fact, she signed a form prior to delivering the baby stating that she would deny any blood transfusions. The woman passes out from blood loss. Is it permissible for the hospital staff to give her blood and save her life?

In contemporary medical ethics–especially in the US of A–the principle of autonomy reigns supreme. The principle of autonomy expresses the right of individuals to decide what is done or not done to their body. This principle connects with other important values such as respect for persons and dignity. At least in the West, respect and dignity require allowing individuals to make self-regarding choices according to their own values–regardless of how misguided we think they are.

In practice, the principle of autonomy is secured through informed consent. That is, for any treatment to be applied to a patient, they must freely and voluntarily consent (things get tricky for mentally incompetent patients and emergency situations, but let’s stick with standard cases). Without consent, no treatment may be legitimately applied–even if it means the patient will die. Or, in cases of passive euthanasia, especially when the patient will die. So, in the above case, the medical staff are ethically (and legally) prohibited from applying treatment since it would violate patient autonomy.

If the principle of autonomy morally prohibits medical practitioners from applying treatments to save a patient’s life, it certainly seems to apply to choices regarding vaccines. And this is something that I don’t think pro-vaccine people take seriously enough. On this interpretation, we violate the fundamental principles of medical ethics when we require healthy people to get vaccinated against their will even if we think they refuse for bad reasons (I’ll qualify this later).

Think about the case of the Jehovah’s Witness. The practice stems from an esoteric interpretation of a few biblical passages that no other Christian denomination interpret that way. From most people’s point of view, it’s an unintelligible reason to forgo life-saving treatment. But again, respect for autonomy and dignity protect the right of each individual to make important life decisions according to their own values.

Now, the astute reader will have identified an important disanalogy between the Jehovah’s Witness case and that of vaccines. The Jehovah’s witness case is a purely self-regarding choice (well, sort of–her family will be affected). But vaccines are different in that they also involve community health (i.e., public welfare) and children’s welfare rights.

Whenever a situation involves two or more moral values, there’s potential for conflict between them, and trade offs will be required. Both legally and ethically, Courts and ethicists have generally weighed community health and parens patriae (the idea that the state has legal authority on issues involving children’s welfare) over the principle of autonomy when it comes to vaccines.

In this article, however, I want to make the strongest case possible for vaccine skeptics. I want to assume that we are all monomaniacs (i.e., creatures who care only about one value). The public good is a fantasy and parents have full and absolute rights over their children. If parents want to employ their children in coal mines, the state can’t stop them. Individual and parental rights are the only value.

What does this mean for those of us who are pro-vaccine? It means at least two things: First, if we want to reduce vaccine hesitancy and increase compliance rates, we need to find a way to get people to do it voluntarily. This means, primarily, changing people’s beliefs. But also it also means showing how their own reasons lead to different conclusions than they originally thought.

Most objections to vaccines are fundamentally grounded in mistaken beliefs about relative risk. It’s been shown that opponents to vaccines systematically overestimate small risks. If we can correct these beliefs, voluntary vaccination follows logically. Getting vaccinated exposes one’s health to fewer risks relative to not getting vaccinated. If your decisions are based on what’s best for your or your children’s health, the choice is straightforward when it’s framed in the context of relative rather than absolute risk.

These are empirical concerns and I will address them in subsequent posts. However, for now, as before, let’s begin in agreement. Let’s grant the vaccine skeptic every. single. one. of their premises and see whether non-medical exemptions (NMEs) are morally justified.

Part 3: The Main Moral Argument

In 18 states, parents may exempt their children from regular vaccinations for (and this will shock you) non-medical reasons. This policy is in addition to religious exemptions. Children with NMEs are still permitted to attend public schools.

The argument supporting NMEs centers on the duty of nonmaleficence (it’s morally impermissible to subject someone to harm or risk of harm) and the principle of autonomy/informed consent (it’s morally impermissible to subject someone to medical treatment without their informed voluntary consent). [see my first post on this topic] The claim is typically goes something like this:

The state (through policy) doesn’t have the right to subject me or my child to risk of harm without my voluntary informed consent.

Let’s begin in agreement. This means, I will hold off for a later post the issue of relative risk.

Moving on. There is nothing obviously wrong with the above moral precept. But what policy follows from it? Vaccines do in fact carry risks. They are small–especially when compared to the diseases they protect against. Nevertheless, they do carry risks and so it follows from the above principle that the state cannot mandate immunizations without parental consent. [For this post, I’m setting aside issues involving parens patriae in which the state asserts authority over child welfare.]

Recall that children with NMEs may still attend public schools. But what about those children who attend public schools that have medical exemptions? Doesn’t this policy subject those children to risk without voluntary informed consent? If we universally apply the moral rule, allowing children with NMEs to attend schools with children that have medical exemptions subjects those children (ME) to risk without their voluntary consent. It follows, that such a policy is morally illegitimate for exactly the same reason that vaccine skeptics use to justify NMEs.

In fact, this was the reasoning followed by the Mississippi Supreme Court in Brown v. Stone when they struck down religious exemptions. The Court argued that the statutory religious exemption violated the Equal Protection Clause of the Fourteenth Amendment because it would

require the great body of school children to be vaccinated and at the same time expose them to the hazard of associating in school with children exempted under the religious exemption who had not been immunized (378 So.2d at 223).

Consistent reasoning requires that children with NMEs may only attend schools where parents of children with medical exemptions have given voluntary consent.

One might reply that NMEs represent a small portion of the population. For example, depending on the state, 1-6% of kindergarteners have NMEs for the MMR vaccine. This raises two issues. The first having to do with the moral principle itself. The second having to do with the way the world is.

All policy exposes some groups to some risk, just as having no policy does. No reasonable person thinks that all policies–no matter how minuscule the risk–require informed consent. A proper application of the principle requires working out the threshold for risk before informed voluntary consent is required. Part of the problem, as applied to the vaccine issue, seems to be the propensity of vaccine skeptics to asymmetrically misjudge (i.e., overestimate) risk.

But let’s set that aside. We begin in agreement. We are unconditionally granting all of the vaccine skeptics’ premises and assuming all of the following are true:

1. The level of risk imposed by vaccines surpasses the threshold required for informed consent.
2. When only around 1-6% of the population have NMEs, the level of risk to children with medical exemptions is below the threshold required for informed consent. (To help the vaccine skeptic I will ignore that this rate does not include religious exemptions.)
3. Therefore, children with NMEs may go to schools without the consent of parents of children with medical exemptions. (I’m also setting aside the cost to public health of undermining herd immunity–which I will cover next post).

This reasoning fails because it assumes NMEs are evenly distributed throughout the population. People with similar beliefs and values cluster together. For examples, in some counties NME rates are as high as 26% for the MMR vaccine. School-based outbreaks have been associated with high exemption rates and a recent survey of schools reported substantial intrastate variability in implementation of exemptions: In California, for the pertussis vaccine there are 50 large clusters of school districts where the immunization rate for kindergarteners is below 50% and about the same number of districts have 51-75% immunization rates (edsource.org, 2019).

Furthermore, a meta-analysis found that

Findings from 42 studies suggest that exemption rates are increasing and occur in clusters; most exemptors questioned vaccine safety, although some exempted out of convenience. Easier state-level exemption procedures increase exemption rates and both individual and community disease risk. 

Wang et. al.

[See here for more evidence of clustering and its relationship to outbreaks of vaccine preventable diseases.]

The evidence above suggests that, despite single digit state-level NME rates, clustering is common. Also, outbreaks occur where NMEs are clustered. Children with medical exemptions living in these counties or attending such schools will be subject to substantial risk without their voluntary informed consent. So, even if we grant every premise vaccine skeptics’ assume, the current NME policy is not justified by their own lights. It violates the very principle upon which it is grounded.

Recall also, that throughout this entire argument we have not contested the weighing of competing moral interests such as public health and the state’s interest in children’s welfare. I’ll address this in the next post…so stay tuned!

Conclusion

The first rule of vaccine debate skool is don’t be cruel. Be cool. Appropriately value our main tool: the personal relationships we have with people who are vaccine skeptics or hesitants.

The second rule is to think of interactions as exercises in seed-planting. You’re not going to overturn deeply held interconnected belief systems in a single interaction. No one gives up deeply held views overnight–on any issue. Be patient.

The third rule is don’t engage when you’re in a mindset that prevents you from empathizing and regulating your emotions.

The final rule is to always begin in agreement. Remember that all vaccine skeptics are actually pro-vaccine. They just don’t know it yet. Every substantial premise they hold, when reasoned from correctly, supports immunization. Our foundational moral beliefs do not differ substantially so it’s no problem to begin in agreement. And it fosters goodwill.

In the next post, I’ll address the final moral argument which revolves around collective action problems.

If you are a vaccine skeptic, thank you for reading. Please comment below what your top three main concerns are regarding vaccines. I will do my best to address them in subsequent posts.