Commentary J Med Ethics: first published as 10.1136/medethics-2021-107700 on 7 July 2021. Downloaded from ‘[i]n the USA, UK, Italy, Germany, Spain, A focused protection vaccination France and South Korea, deaths from COVID-19 in children remained rare up strategy: why we should not target to February 2021 (ie, up to the time the study had available data about), at 0.17 children with COVID-19 per 100 000 population’.7 The long-term risks of the novel COVID-19 vaccines on vaccination policies a population of millions of children are at the moment unknown, given that the 1 2 3 clinical trials involved a few thousands of Alberto Giubilini , Sunetra Gupta, Carl Heneghan subjects over a few months period. In spite of the relative uncertainty, the current COVID-19 vaccines are still very likely to be in the best interest of the elderly and Cameron et al’s1 ethical considerations BEFORE VACCINES more vulnerable, but not of children. about the ‘Dualism of Values’ in Cameron et al frame the ethical problem Vaccinating children would be a way of pandemic response emphasise the need of pandemic restrictions mostly in terms treating them as mere means to serve other to strike a fair balance between the of dualism between freedom and well- people’s interests or some form of collec- interests of the less vulnerable to being. However, the cost of indiscriminate tive good. We already did this through COVID-19 (most notably, their freedom) pandemic restrictions on young people is indiscriminate lockdowns and other and the interests of the more vulnerable not only in terms of freedom. Restrictions restrictions, such as school closure. Using (most notably, their protection from such as lockdowns and school closure children as means or even mere means in COVID-19). Those considerations are compromise important societal and public this way is not necessarily wrong, but it at the basis of ethical defences of focused goods and the well-being and health of can only be justified if the cost imposed protection strategies.2 One example is 4 young generations. is sufficiently small and the benefit suffi- the proposal put forward in the Great Thus, a fairer way to protect vulner- ciently large.7 Unfortunately, currently Barrington Declaration. It presented able groups is to adopt focused protection available COVID-19 vaccines do not meet focused protection strategies as more strategies targeted at them: the burdens either condition, given our current state of ethical alternatives to lockdowns which on them would be justified by the benefit knowledge. would prevent lockdowns’ ‘irreparable they receive in terms of protection from Not only would vaccinating children damage, with the underprivileged COVID-19, something that is not true pose risks on them without any substan- disproportionately harmed’.3 for young people. How to implement tial direct benefit. Also, vaccinating chil- Here we want to suggest that a these strategies (eg, through some form dren can only offer collective good if this version of Cameron et al’s analysis can of state coercion or some incentivisation reduces infection levels in the commu- be applied to the case of vaccines to programme) is a question we are leaving nity. However, while COVID-19 vaccines support a focused protection vaccina- open here. almost certainly will provide long-term tion strategy. At this stage, we should http://jme.bmj.com/ The fact that focused protection entails protection against severe disease and limit vaccination to the vulnerable and a form of unequal treatment of different death, their infection blocking effects are not target children (and possibly other groups has often been used as a reason incomplete and very likely to be transient. young people) in COVID-19 vaccina- 5 to rule this option out, often with very This means there is actually no collective tion strategies. morally loaded language. For example, it benefit to trade off against individual harm We argue that, given the current state has been called an ‘ageist and ableist state- to children, unless we perform mass vacci- of knowledge about COVID-19, immu- ment’ and compared with a ‘genocide of nation on a regular basis, for example, nity and vaccines, it would be wrong to 6 on September 29, 2021 by guest. Protected copyright. the aged, the disabled and the sick’. And annually. But this would compound the pose the costs and risks of vaccines on yet, equality and fairness are not the same potential harms. children for three reasons. First, they thing and actually sometimes fairness ethi- are unlikely to benefit from COVID-19 cally requires treating different individuals vaccination directly. Second, the collec- or groups differently.2 What matters, from IT IS TIME TO STOP TREATING CHILDREN tive benefit would likely be very limited. an ethical point of view, is that the differ- Third, we have already imposed very ential treatment is based not on arbitrary AND YOUNG PEOPLE AS MERE MEANS large costs on children during this or irrelevant factors (which would make During the pandemic, we have often pandemic through indiscriminate it discriminatory), but on morally relevant treated children as mere means. The only restrictions, using them as mere means factors (eg, risks of COVID-19, individual reason why we have imposed this burden to others’ ends. benefit from restrictions, personal costs of on children is to serve other people’s or restrictions, societal benefit and so on). broader societal interests. These measures have not been in the interest of children, 1Oxford Uehiro Centre for Practical Ethics, University of nor where they intended to be. The Oxford, Oxford, UK 2 burden on them has been vast and the Department of Zoology, University of Oxford, Oxford, AFTER VACCINES: A FOCUSED benefit of lockdowns for the collective at UK PROTECTION VACCINATION STRATEGY 8 9 3Centre for Evidence-Based Medicine, University of the very least questionable. We should Oxford, Oxford, UK A similar kind of argument can be made not make the same mistakes with vaccina- concerning COVID-19 vaccination tion policies. Correspondence to Dr Alberto Giubilini, Oxford policies. Uehiro Centre for Practical Ethics, University of Oxford, Oxford Ox1 1PT, UK; The risks of COVID-19 for children and Funding AG’s work was funded by the Wellcome Trust alberto. giubilini@philosophy. ox.ac. uk young people are minimal. For example, through the grant WT 203132/Z/16/Z
Giubilini A, et al. J Med Ethics Month 2021 Vol 0 No 0 1 Commentary J Med Ethics: first published as 10.1136/medethics-2021-107700 on 7 July 2021. Downloaded from Competing interests None declared. 4 Collateral Global. Week 2: young people, 2021. Available: https://collateralglobal.org/ article/newsletter- Patient consent for publication Not required. 2/ [Accessed 22 Jun 2021]. Provenance and peer review Not commissioned; 5 Lawrence DR, Harris J. Red herrings, circuit-breakers and ►► http://dx. doi. org/ 10. 1136/ medethics- 2020- 107104 internally peer reviewed. ageism in the COVID-19 debate. J Med Ethics 2021. This article is made freely available for use in J Med Ethics 2021;0:1–2. doi:10.1136/medethics-2020-107115. [Epub ahead of accordance with BMJ’s website terms and conditions doi:10.1136/medethics-2021-107700 print: 13 Jan 2021]. for the duration of the covid-19 pandemic or until 6 Klugman C. Why the ’herd mentality’ approach only otherwise determined by BMJ. You may use, download ORCID iD increases suffering, 2020. Available: http://www. and print the article for any lawful, non-commercial Alberto Giubilini http://orcid. org/0000- 0001-5163- bioethics.net/ 2020/10/ why-the- heard-mentality- purpose (including text and data mining) provided that 3017 approach-only- increases-suffering/ [Accessed 22 Jun all copyright notices and trade marks are retained. 2021]. 7 Bhopal SS, Bagaria J, Olabi B, et al. Children and young © Author(s) (or their employer(s)) 2021. No commercial people remain at low risk of COVID-19 mortality. Lancet re-use. See rights and permissions. Published by BMJ. REFERENCES Child Adolesc Health 2021;5(5):e12–13. Erratum in: 1 Cameron J, Williams B, Ragonnet R, et al. Ethics of Lancet Child Adolesc Health. selective restriction of liberty in a pandemic. J Med 8 Bendavid E, Oh C, Bhattacharya J, et al. Assessing Ethics 2021. doi:10.1136/medethics-2020-107104. [Epub ahead of print: 31 May 2021]. mandatory stay-at- home and business closure To cite Giubilini A, Gupta S, Heneghan C. J Med Ethics 2 Savulescu J, Cameron J. Why lockdown of the elderly is effects on the spread of COVID-19. Eur J Clin Invest Epub ahead of print: [please include Day Month Year]. not ageist and why levelling down equality is wrong. 2021;51(4):e13484. doi:10.1136/medethics-2021-107700 J Med Ethics 2020;46(11):717–21 http://www.ncbi.nlm. 9 Ragonnet Ret al. 2020, optimising social mixing nih.gov/ pubmed/32561661 strategies achieving COVID-19 herd immunity while Received 28 June 2021 3 Great Barrington Declaration. Available: https:// minimising mortality in six European countries. medRxiv Accepted 28 June 2021 gbdeclaration.org/ [Accessed 22 Jun 2021]. 2020. http://jme.bmj.com/ on September 29, 2021 by guest. Protected copyright.
2 Giubilini A, et al. J Med Ethics Month 2021 Vol 0 No 0