Gresham College Lectures

Would it be Right to Make Vaccination Mandatory?

January 20, 2023 Gresham College
Gresham College Lectures
Would it be Right to Make Vaccination Mandatory?
Show Notes Transcript

Vaccination against disease has saved countless lives, yet it remains a controversial topic because of concerns some hold about safety and potential harms. Should we be legally required to vaccinate ourselves and our children? How important is individual choice when balanced against saving lives? To what extent should vaccination of children be a matter for parents or the state?

This lecture considers the challenges we face in fighting disease while remaining a democratic, liberal society.


A lecture by Imogen Goold recorded on 16 January 2023 at Barnard's Inn Hall, London.

The transcript and downloadable versions of the lecture are available from the Gresham College website: https://www.gresham.ac.uk/watch-now/mandatory-vaccination

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(swooshing sounds)- Welcome, thanks very much coming today. I'm going to talk to you today, I'm Imogen Goold. I'm from the University of Oxford. I'm going to talk to you today about whether it would be right to make vaccination mandatory. Now this is in the second lecture in my series of three lectures on medical or on ethics' this term. And I wanted to talk first about the approach that I want to take and I think it's important to say at the outset that vaccination debates are emotive and I think it's really important as a society that we all think about how we speak to one another in these debates. And I don't think that we get anywhere by denigrating people's views. And I don't think we get anywhere by mocking people. And I certainly don't think you change anybody's mind by making fun of them or calling them stupid. So my attitude to this is, have an open mind and listen to people and start from a position of respect and thoughtfulness about what other people might think. So I've got my own views about vaccination, that's true, of course, but I'm really interested in your views. So I've left time at the end so you can ask me questions and tell me what you think as well. What I'm going to do today is try to present you with what I consider to be some trustworthy information. Some of that will tell you the vaccines have risks, some of it will talk about the benefits of vaccines. And I want to, in this conversation try to give you a framework for thinking about how we might arrive at a decision about what to do in terms of vaccination. What I don't want to do is delve into really detailed technical debates about diseases or every vaccine or some of the really vexed debates that have sort of dogged this area for a time. But what I have done, however, for those of you who want this sort of detailed information, I've put some links on my slides which you'll be able to access, and I've also put these in my transcript. The first is the Oxford Vaccine Knowledge Project. There's lots and lots of information about vaccinations, what they do, their benefits, their risks, and so on. People's attitudes, people's stories about their experiences of them. There's lots of data at Public Health England about what impacts vaccination has had, but I've also put in a series of, a link to a series of FOI requests where you can find out about the risks of vaccination. So in particular vaccine damage claims. So there's a really balanced picture is what I want to give you. So, what I want to do in this lecture is start by looking at some vaccine success stories, because I think it's important to think about why do we think vaccination is worth doing in the first place? And then I'll talk a bit about some of the things that we do vaccinate for. And then I'm going to explore the concerns that people have and the reasons people resist vaccination. And then I'll proceed to thinking about what are we to do and whether we should approach these by having vaccinations be made mandatory. So the best way to see what vaccination has done that's been a big success is to look at two big success stories from the 20th century. And the first of these with which you'll almost certainly be familiar, is smallpox. So smallpox is an incurable disease that has a fatality rate of 30%. And even if you survive it, you might be left with very severe scarring. So this was a scourge over the centuries, smallpox. Early efforts to control the disease, you'll be aware of these probably involved variolization. And then Edward Jenner developed his famous vaccine based on cowpox at the end of the 17th century, end of the 18th century. And what we can see is that the widespread use of that vaccine led to a really dramatic decline in cases of the disease. So what this shows you is this is the percentage of deaths caused by smallpox in London. And what you see is in nearly 20% of deaths were caused by smallpox at this time, right at the late, at the end of the the 18th century, many of those were children. The vaccine is introduced at around 1800, you see a drop. And then we see the point when the vaccine becomes mandatory in the mid 19th century here. So you see this even further further decline. So vaccination was made compulsory for smallpox in this country in 1853. And so it's really clear the vaccination in that case reduced deaths. It remained however, a disease that was endemic in many countries. It's estimated that nearly 300 to 500 million people died over the course of the 20th century. And the response to this worldwide was the smallpox eradication program, began in 1959 and by 1980 as an effect of this, smallpox was declared eradicated. Now this was done by the WHO working with local governments, working with lots of organizations, local healthcare workers. And the goal was widespread vaccination and it worked. Another major success story is polio. So some of you may be old enough to remember before the pre-polio vaccination days and how people felt about polio. Polio would sort of work its way through towns and villages and parents become very, very afraid if polio was going to break out. Now the reason for this is it is very contagious. It's spread through sneezing and coughing, unclean hands, and it's incurable. So it's still incurable. But we have therapies that we can use, ventilators and physical therapy. And the reason it's so dangerous is, it causes meningitis, but in particular it causes paralytic disease. So your muscles stop working. And the impact of this was that you would stop being able to breathe. So this is a really familiar image of a little boy in an iron lung. Iron lungs were developed in the early 20th century, but they became more available as we moved to the mid 20th century. And what it did was is it enabled them to breathe. So it kept them breathing while they could recover from their paralyzed muscles. So it saved lives. But it has a nearly 10% death rate, if you had paralytic disease. And even if you survived polio, you could be left with muscle pain, weakness. And you can still see people today who suffered polio when they were children. Mary Berry is a good example of someone you might have heard of who had polio and it left her with permanent curvature of her spine and one of her hands are still affected. So it had long-term impacts, as well as causing numerous deaths. And vaccines were the key thing that dealt with this. So two vaccines were developed in the 1950s. This is data from the United States, but what you can see here is there's an epidemic of polio that happens in sort of the early fifties, that's this big spike in cases. This is cases, this is deaths. The vaccines come in 1955 and we see this drop and it stays low. And in many countries polio have been declared polio free. So Europe's an area where we are polio free. And what we also see is the impact of vaccinations worldwide. So polio remained endemic in many other countries for a long time. And the polio eradication initiative began in 1988 and its goal was to eradicate polio elsewhere. So following in the footsteps of the smallpox program, a similar approach. This was led by the WHO working with the CDC and UNICEF and the Gates Foundation. And what has it done? Well, similarly, it's pursued programs of vaccination and the impact has been a huge reduction in cases of polio worldwide. So 1988 when it began, you can see there are 350,000 cases of polio a year. Now we're at less than 700 cases. And it's estimated to have prevented at least 2.2 million cases. So when you think about the fatality rates, you can see that that's a lot of deaths have also been prevented. So these are successes of vaccination, this is what it does. But these were big global diseases. They were really terrible diseases. What do we vaccinate for now? What I want to do is briefly take you through the schedule of vaccination but not spend a lot of time looking at it, but to think about what kinds of diseases we vaccinate against and why. So we vaccinate very young children for a lot of conditions, and this is in fact one of the concerns that people who have concerns of vaccination have, is that we give too many vaccinations too soon altogether. So, babies will be given these 8, 12 and 16 weeks, and there's a whole series of vaccinations and they protect against a lot of disease. So polio remains one, tetanus, whooping cough, rotavirus, pneumococcal infections, and meningococcal infections. We continue these through childhood. Some are boosters, some are other vaccinations. That's because some of them can't be given as early. So things like the MMR works better if you give it slightly later. Some are yearly, some are boosters. So this whole range of them that we give over the course of childhood. We also continue to vaccinate into adulthood. So obviously some people will have things like COVID vaccines or they have flu vaccines yearly. You'll have a tetanus booster. We also vaccinate people against whooping cough to protect babies. And as you get older, you might be offered things like a shingles vaccine and some immunocompromised people might be offered certain vaccines as well. So we continue to vaccinate throughout life and we do it for lots and lots of diseases. Now, I don't want to go through the whole schedule. What I want to do is pick out the four key reasons why we vaccinate. And the the reason to do this is that when we want to think about why should we vaccinate, how should we respond to concerns about vaccinations and whether we should make it mandatory, it's really important to understand why you're doing it in the first place because actually there are multiple reasons why we vaccinate and they differ by disease and they differ by who we give the vaccinations to. So the first reason is to protect vaccinated individuals from non-communicable diseases. So this is a really famous image of tetanus and this is what tetanus does to you when it's untreated. What it does is it causes really painful muscle spasms and they can be so strong that they can break your bones. It's why it's also called lock jaw. It locks your jaw up. It's incredibly painful and they last for weeks. And the way you get tetanus is not communicated from other people, but it actually, it's a bacteria that lives in soil, manure, dust. So that's why your worry would always have been getting, having it coming through a cut. Or it would be you pierce the skin with something that's got the bacteria on it. So, a rusty nail in your foot, that's a classic thing you would worry might give you tetanus. But tetanus is a disease that can be really easily prevented with a vaccine and that's why children are vaccinated against tetanus. Your protection against tetanus wanes over time and that's why you might have a booster. Now we can treat it to a degree, but if it's not treated quickly, it is really painful and really, really unpleasant. The other reason that we vaccinate people is probably the one that's most familiar and this is that we vaccinate against communicable diseases. So diseases that are spread between people. Now we spread diseases in all sorts of ways, coughing, showing bodily fluids, touching things and then touching them. And different diseases are more or less communicable. So measles is one of the most contagious diseases there is, that if you walk into a room and someone has measles, really high chance that you will catch measles from them. And what we, the reason we do this is to protect people against either severe illness or death or lifetime disability that can result from some of these diseases. So a really good example of one of these diseases is meningococcal disease. So, this is a picture of Charlotte Cleverley-Bisman. She's a little girl who became the face of vaccination in New Zealand for a while. And that's because she caught meningococcal disease when she was very young as a baby. And as a result of that she had to have all four limbs amputated. And that's because meningococcal diseases, infections cause all sorts of damage to your tissue and the treatment is to essentially amputate to prevent the spread of that damage into your body. It can also cause deafness, brain damage, nervous system problems and all sorts of things. It's a really terrible disease. It's rare, but when you get it, it's severe. And that's the thing to think about when you're thinking about diseases. Some happen to a lot of people but they aren't that severe. Some happen very rarely, but when they happen, they're catastrophically bad. And that's part of what we need to be doing when we're thinking about what to do, is having a sense of, what does this particular disease do and to how many people and to what level of severity? It's also happily though an example of a disease that's very well controlled by vaccination. So you can see the impact of the introduction of MenC and B on cases of meningococcal disease, a huge decline in cases. It is a disease that vaccination stops. The third reason that we vaccinate is to protect other people from contracting communicable diseases. And whooping cough is a really good example of this. Now of course the way people catch diseases from us, we should all be familiar with that, is that we spread it. And the way vaccinations stop that is it stops me having the disease. So it means I can't have it, so I don't pass it on. It also might reduce my symptoms. So some vaccinations just reduce your symptoms. You might still have it, but you have it less severely, so you are less likely to cough. You're less likely to spread bodily fluids in that way. And so people don't catch it from you. And that's partly how the COVID vaccine works. It reduces the severity so you are less likely to pass it on. You won't be ill for as long either. We can also use things like ring vaccination where you find a person who has the disease and you surround them with vaccinated people, you find all their contacts and you surround them with vaccinated people and it isolates the case and it doesn't spread any further. And that's one of the strategies that WHO now uses to deal with isolated cases of polio and it's what they also use to deal with cases of smallpox. What's also really crucial to understand is that some people can't be vaccinated. Very young children can't be vaccinated. And those with conditions that mean they might have adverse reactions. And also people who have weakened immune systems, these are all people who we would consider, ought to consider vulnerable. And we protect them from disease by vaccinating other people. So that's why whooping cough is a really good example. So we don't give the whooping cough vaccination until eight weeks. But very young babies are really vulnerable to whooping cough. And before vaccination began, there were thousands of cases every year and as many and sometimes thousands of, there were hundreds of thousands of cases and there were thousands of deaths. Now, we cannot protect them by vaccinating them. So what we do instead is we protect them by making sure the prevalence of whooping cough is very low. And we do that by vaccinating everybody else. So the less whooping cough there is circulating in the community, the more protected these babies will be. We also do this now by vaccinating pregnant women. So we make sure we offer whooping cough vaccinations to women who are having babies and other family members potentially because that means they also won't pass it on to their babies. And it gives these babies time to get old enough and make it to eight weeks essentially when they can have the vaccination and they can be protected. So this is an example of where vaccination is not just protecting the individual who's vaccinated, but it's protecting other people. And we know that it works. The NHS reports that babies born to women who are vaccinated at least a week before birth had a 91% reduction of risk of becoming ill with whooping cough in the first weeks of life, compared to babies whose mothers had not been vaccinated. So while whooping cough remains in our community, this is a way that we protect those very vulnerable members of our society. The fourth reason is similar, but it's subtly different and it also gives me an opportunity to talk about another disease that I think is really interesting and one that's important to talk about. And there are diseases which if you catch them they can harm your baby. So if you are, if a person is pregnant and they catch rubella, it can cause what's called rubella congenital rubella syndrome. Now, rubella itself is quite a mild disease in most cases. It can in rare cases lead to things like encephalitis and pneumonia and bronchitis, but generally it's rare. It's a bit of a rash, joint pain and some headache. But what's really problematic about rubella and one of the main reasons that we vaccinate against it is that if you catch it when you are pregnant, it can cause this syndrome in the unborn fetus. Now, the most common symptoms of congenital rubella syndrome are hearing loss, eye problems, heart problems. So babies can be born blind, they can be born deaf. It can also cause miscarriage, stillbirth, neurological problems and lots of other issues in unborn babies. So preventing rubella is as much or if not more about protecting fetuses in utero as it is about protecting people from getting rubella themselves. And this is another example where we can see the impact of vaccination. So this is the impact of vaccination on congenital rubella itself. And you can see when the vaccine is introduced, we see this huge drop in cases. So this is another beneficial thing that vaccines do. They protect us and they protect people around us. So they have both an individual benefit and they have a collective benefit and they benefit vulnerable people as well as people who are healthy. So we gain as a community when we reduce disease, partly because we ourselves are protected against it, but also we protect other people in our society. So given that, it seems like vaccinations seem like a really, really good thing to do and demonstrably they are very well accepted and highly regarded public health intervention. They're regarded as a very effective way of saving lives and reducing illness. However, people refuse them. So I think the first thing to think about then is to interrogate why do they refuse them? And in fact, there are a lot of reasons why people either refuse vaccinations or are hesitant about vaccinations. And it's not that this is new. So this is a really famous picture that came out just after Jenner's vaccination started to be used and it's making fun of the vaccination. It's suggesting that because it's based on cowpox, that people who have the vaccination will start to develop characteristics of cows. And this is actually one of the pieces of propaganda that relates to the anti-vaccination movement, which begins in the very early 20th century. And now there were protests in the United Kingdom and elsewhere throughout the 19th century, anti-vaccination leagues formed, and there was pressure to repeal the compulsory vaccination acts. And so it is not a new phenomenon for people to be concerned about vaccination. It's particularly interesting that this is a point when smallpox is causing hundreds of thousands of deaths and still people are resisting it. And so it's important to wonder why would they feel this way? And it's also important to wonder, not just so we can understand it, but so we can think about if we want to increase vaccination rates, we should listen to their concerns and see if some of them can be addressed. Now there is a lot of research about anti-vaccination views and I will try to give you the major strands of the views that we can identify and tease them out. And it's important to understand as well that some of these views interrelate. So they're not necessarily isolated. And when we look at them you can see that they contain both claims of about fact and they contain normative positions. And what I mean there is that people will make claims that they say are true of vaccination and they will also on the basis of those claims about vaccinations, may take particular normative positions, what they feel ought to happen. And this has implications for how we respond, because we should think partly about responding to the factual claims, but we need to also respond to the moral dimension. To say, well, even if this is true, we might not agree with your normative position about it. So we might say, yes, vaccines have risks, but I still don't agree that that's a good enough reason for you to opt out of having them. So these are distinct things that we can do when we respond to these concerns if we wish to. And I think it's really important to be clear about what it is that you are responding to. And this is also where people begin, and if you've ever seen an anti-vaccination kind of pile on, this is the bit where people will begin to make fun of people who take anti-vaccination perspectives because they will say you're wrong. And I think it's important actually to take pause and think about partly why does someone believe this to be true? Why do you think it's not true? And what you might respond with and how. Now I can't pretend to do justice to the range or the nuance of their arguments, but I shall do my best to give the strands of them. Now, one of these is that vaccinations are not risk free, that they can be harmful. Now I think it is true that very often when we are presented with, we're offered vaccinations, we will be told some of the risks. But if you go on the NH website, you will see that they do give you some of the risks. But if you want to see the more detailed, more severe risks, they are there. But you can drill down and find more cases. But because vaccinations are regarded as on balance worth any risk from a public health and community-wide perspective, the benefits hugely outweigh the risks at a community level, they are regarded as safe or sufficiently safe. That doesn't necessarily mean that they're risk free. And this is one of the arguments that people raise is that actually, vaccines can be dangerous. Now, when they say that, they may say it's because vaccines contain dangerous substances, substances they consider to be harmful. It may be that they think that vaccinations cause disease in the vaccinated individual. It might be that they think they will cause disease in people who come near them, so the idea of shedding. They may say that vaccinations cause dangerous side effects and that they might produce allergic reactions. Now some of these things are true, vaccines do have side effects, mostly in most cases those risks are very mild and they don't happen very often. But there are definitely reported major risks that are associated with all of these vaccinations. From blood clotting, anaphylaxis, fits and seizures, encephalitis, chronic arthritis. And in fact the OPV, the oral polio vaccine can in fact in some cases lead to paralytic polio. So it's not true that they are risk free. And so if you wanted to respond to this, you would think about whether the balance is right. There are risks, but is that risk benefit balance to such a degree that we shouldn't vaccinate? The public health view is no, nothing becomes a vaccination that is rolled out publicly unless the benefits outweigh the risks. Other concerns people might raise are that there are long-term risks that we just don't know about. So these are identified risks that somebody may not want to run. They may not feel it's personally right for them to run it. They might also say there's just limits to what we can know. Science hasn't caught up yet. They might say there are limits on safety trials. The ways we test vaccines just aren't good enough. And then the position that follows from this is that individuals should weigh these risks themselves. So an autonomy argument that will look out a bit more later and that then they may decide to refuse vaccination because they say the risk to themselves outweighs the benefits. Now it might be because they think the risks are generally so great that we shouldn't have vaccination, or it might be they think, I personally don't want to have the vaccination because my evaluation of this is that the risks to me aren't risks I want to run relative to the benefits. Now we know these risks exist. In fact, we know it to such degree that there is a thing called the Vaccine Damage Payment scheme. So in fact, the government runs a scheme that if you are severely disabled as a result of a vaccination, you will get a one-off tax-free payment of 120,000 pounds. It's recognizing the fact that we have rolled out a public health measure that is damaging potentially to some people. But what is also true is that over the course of 43 years, only 946 awards have been made. So yes, it is true that there is damage, but when there have been claims in actual fact, over the course of that many years, that is not a very large amount of claims. It's not a large amount of harms that are reported and regarded as having led to such severe damage relative to the levels of benefit that we see and the lives that we see saved. And so that's why on balance we can, we do recognize that there are risks, but on balance it is in favor of vaccination. It's also true that even though vaccines do have some risks, they go through very rigorous testing, they go through small initial trials, they go through larger trials, we review trial data and we ongoingly monitor them. So there is the yellow card scheme, where you can report an adverse reaction to a vaccine and that data is constantly maintained and evaluated as part of ongoingly reviewing vaccination. So the second argument, the second concern that people often raise when they want to, when they, that might leave them to not want to have a vaccination, it has to relate to the first one, right? They have risks, but also the diseases that they protect against aren't that severe. So this, I'm not sure if you can read it, this is a comment from a Reddit thread discussing vaccinations and she says,"Measles isn't dangerous. It's an integral part of childhood. How do you think people back in the 1700S survived?" Well, what we can actually see is lots of them didn't survive. That they died is partly true, but it's also true that many many people had measles and they did survive. I had measles as a child and it was mild and I'm absolutely fine. I was fine then and I'm still fine. So of course that is true. But what is also true is that some of these diseases are often mild but can be severe. But essentially the normative claim here is that if the disease isn't that severe and there are risks, that the balance tips in favor of them saying, well, it's not necessary for me to get vaccinated. Or, I don't want to run that particular risk because I don't think it's personally worth it. So again, there are some claims of fact in here and that leads to some normative arguments. Now, one of the ways you could respond to this is to interrogate each disease, which I don't intend to do here. But if we take two diseases that people do often say this about, we can look at whether this claim is true. So one of them is rubella. Yes, it is largely mild, sometimes it is severe, but almost invariably it isn't very severe. But we could also respond to that normatively to say, even though that disease will not be severe if you catch it, it has other implications for other people. So we come back to the reason why we vaccinate against rubella partly, which is to protect pregnant people. And so, the normative claim may not be the only normative position we need to consider when we think whether or not we should vaccinate and whether or not people should be required to vaccinate. And we'll come back to that later. But that's why it's important to understand the different reasons why we vaccinate and the particular concerns people have. The other way we could look at this is we could challenge the factual claim and say, actually measles is dangerous. So, measles can be mild, that is true. But we also know that there is a death rate to measles of between 0.1 and 0.3% of cases, even with good treatment now. So, sometimes measles leads to encephalitis, that can cause deafness, it can cause intellectual disability, can lead to pneumonia. And that is why there were thousands of deaths from measles in the past. And if any you've ever heard of the really famous story of Roald Dahl's daughter who died of measles. And he wrote a letter, a public letter afterwards to express what had happened because he was so, so distressed that his daughter went from well one day to essentially she died very soon after measles because of the impact that it had on her. The third argument is that we don't actually need vaccinations to reduce disease. And this is the idea that actually either the diseases are treatable, or if we're healthy enough that we can resist them. So the better way is not to put things into our body like vaccinations, but to think, well, I'm a healthy person, I eat well, I'm fit and so on and I can resist it. And we saw some of that in the public discourse around COVID vaccinations, is some people saying, well, I don't think I need it and my body will fight it off or will build natural resistance. And that is what people argue about a range of diseases. And some people even argue that you'll be more able to resist the disease. You'll be stronger if you naturally fight it off and develop natural resistance, and argue that is better than vaccine induced resistance. Now one of the ways we see this manifest is people pointing out that actually there are some diseases that declined without vaccination. So this is a good example, this is measles. So measles at vaccination isn't introduced until 1968, but you can see this really big decline in measles anyway. So it's declining before we hit the point when the vaccine's introduced. And by the time the MMR is introduced, it's very rare. Now one argument that people, so what we know is that Public Health England says that, well actually, we've prevented lots and lots of deaths from having the vaccination. But what other people argue is that it's not true. That it isn't true that the vaccine is necessary to reduce measles. So they're saying, well actually we don't need the vaccinations because the disease can be dealt with in other ways. Now, to some degree, this is actually true and it's partly true with measles. And the reason it's partly true is actually other things happened at that point. The reason measles declines in the 1940s and 1950s is because we develop antibiotics that are very good at treating the bacterial pneumonia that comes from having measles, which is a cause of death. We also see an increase in sanitation, an increase in nutrition. So actually people did get better at fighting off measles and also we got better at treating measles. These things are true. But what isn't true is that we don't need the vaccines. And the way I think about this is, this can all be true, but what is also true is that there is a set of deaths here that are deaths that happen even when all of that is true. So even with all of this treatment, there is still a death rate from measles. But what we also know is that when we eradicate measles, those deaths will be eliminated. So part of the question here is to interrogate the evidence really carefully. It's also to respect the fact that someone has looked at that data and in fact this person has looked at that data and he does make the arguments that I make about nutrition and sanitation. But someone can easily look at that data and think, do you know what? It does look like vaccines don't do this. And this is what I mean about being respectful and thoughtful when you're thinking about why somebody might resist vaccinations and taking seriously people's positions about this is that there may be an understandable basis. In fact they might also be right. It is true measles was reduced in this way, but it is also true that there remain vaccine preventable deaths. So what that does is it sets you up to think about the moral question, which is, what are the risks and the balances here? What are the risks and the benefits and what should we do in the face of those? Which is what we'll come to. The fourth reason that people resist vaccinations is mistrust. And there's a lot of reasons why people might mistrust the claim or mistrust pro vaccination policies from the government. One is they think that the information that they have is misleading or false. Another is the idea that there is some conspiracy. So this is another Reddit post where he's essentially saying,"Have we been poisoned from the very beginning? What makes us think big pharma only started harming us in the last three years? The rabbit hole goes deeper than that." So it's a classic conspiracy theory. And the idea is that they think that governments have agendas, harmful agendas. They also think that governments might be influenced by pharmaceutical companies. Now these are empirical claims, these ones, and they may be true, they may not be true. So, we can understand those claims, we may disagree with them and that is a different matter. It might be that somebody has access to information which is inaccurate. That's true. But the other things that are particularly, these are kind of small dimensions. The really interesting things are generalized mistrust of healthcare systems. So what you can see is that there are people who mistrust healthcare systems and they might have intelligible reasons for this. One is that they may have had problematic experiences in the healthcare system themselves. And so they may have a lack of trust in healthcare providers. Another is they might be a member of a group that has a history of mistreatment in healthcare systems. And so a really good example is the impact of the Tuskegee Syphilis Study on African-American people and the implications for those people's trust in the healthcare system, which were well-founded. And we see that still, that there are different groups that collectively have been failed and mistreated, and therefore they have a collective mistrust. And what I think we need to do when we think about this reason is partly the response to this is good data, but partly it's thinking about the reasons why somebody may mistrust systems and addressing those and working with those. The final reason is the idea that there are moral objections. So particular moral claims that people make about vaccines themselves. So not about the implications of vaccines so much, that they raise concerns. So one of these is they believe that it's problematic that they're made from human cell lines. A more popular one is that the cell lines that are used to manufacture some vaccines, so the AstraZeneca COVID vaccine is an example of this, are made from cell lines that are derived from aborted fetuses. And this is true, that that cell line is derived from a therapeutically aborted fetus from the 1970s. Some people have concerns about the use of animal products. So if you are vegan, you may have an understandable concern about a vaccine that's produced in a way that you think is morally problematic. Or you might have concerns about GMOs. So GMOs are used in the nasal flu vaccine. So there are a range of bases on which somebody may subscribe to a particular moral position, and then that makes it difficult for them to accept vaccinations because they're committed to a prior position. And in this situation, taking those ethical positions people might have seriously and understanding them is really important in the way that we respond to the reasons why they may be hesitant or objective to vaccinations. So the next question is think well, why do we need to do anything? It's really clear that vaccination is beneficial on balance, but why would we even consider whether we need to make vaccination mandatory? Why do we need to do anything at all? Well, what we see is sometimes there is a drop off in vaccination rates. And when that happens we see harms to people. So, good examples are recent measles outbreaks that I'll talk to you about in a moment. The WHO has named vaccine hesitancy as one of the top 10 global threats to health. So it is considered to be a real problem. We also need to think about the fact that when vaccine rates drop to a particular level, vulnerable people may be harmed. People may be harmed themselves because they get the disease and other people may be harmed if the disease is passed onto them by unvaccinated people when they themselves can't be vaccinated. And we can see what this looks like when we have a drop in vaccination rates. Now this is data from Public Health Wales as they've been trying to explore why they had recent outbreaks of measles. And what's really clear from their data is that the cases, this has confirmed cases of measles in Wales, and what they did was is they look at the year of of birth of the children who, or the people who are experiencing measles. And what you can see is that it tracks with when people, when there was a reduction in uptake of the MMR in the wake of concerns about its association with autism. So there's a direct correlation there, whether it's causal, it's not what I'm saying. But what they were saying is there is a correlation that many of the children and people who had measles were from the period when there was a drop in vaccination uptake. And so what we can see is that when vaccination levels decrease, we may see an increase in disease. So we lose the benefits. And there are arguments that we need to hit particular levels. So what is sometimes called herd immunity, it's probably better to think of it as collective protection, that we need to hit a certain level to enable us all to be protected. And that the vulnerable people can tolerate not being vaccinated because enough of us are vaccinated to protect them. So the question is what should we do? Well, it's a difficult one and there are a lot of different ways into thinking about this question. And I think the first thing to do is to think about what kinds of principles and values might be at stake and then I'm going to unpack some of them. So one of those is the idea of autonomy. Another is parental responsibility for children. So not only are people making individual decisions, they're also making decisions on behalf of other people. So particularly children and whether or not the risks and benefits are right in relation to their child. We might also, and I think rightly should think that there are questions of beneficence in whether we ought to protect vulnerable people. So not thinking about what do I want to do, but rather what ought I to do for the sake of other people? We could think about it in terms of ethic of care. We could think about it in terms of beneficence. We might also wonder whether we ought to be paternalistic, protect people from themselves. And we need to think about the relationship between state and individuals and what is the right role for government? And what is it the government could or should do? Now there are different ethical frameworks for which you might think about this. You might think that respect for autonomy should be the dominant value and we start from that as a position. And that's one of the ways I'll think about this in a moment. You might be a utilitarian, you might think, well actually what we need to do is look at which is the strategy that gets us to the best overall benefits. But another way to think about it is in terms of the concept of fairness. And that's what I'll also look at in a moment. And when we do this, we also need to weave in ideas about proportionality and the right role of the law in relation to citizens. And the question of just because someone ought morally to do something doesn't mean it's right for the law to make them to do it necessarily. It might be, but it might not. So the way I'm going to do this is I'm going to look first at autonomy. I'm going to look at it through the lens of autonomy first and then I'll look at it through the idea of fairness. So starting with autonomy, this is the kind of claim that people will make, is that it's my choice. And what they're doing there is they're asserting that autonomy should be the driving value here, that this is the big one and that this should be the starting point. And so therefore it's my body, it's my choice. And that's invoking a particular aspect of autonomy, the idea of bodily integrity. That you shouldn't put things into my body without my permission. And this is often invokes quite a strong autonomy argument, that there are lots of ways in which our autonomy is constrained, but constraints on our body integrity, invasions that are particularly egregious. So if you start from this position, your question will be, well, when can we justify overriding someone's autonomy? And the answer would be, well when you might think paternalistically, you might think to do good for other people. But the big question you'd be asking is, what is a sufficient amount of vaccination to achieve our goals, would be part of that question. And actually that's a really difficult question to answer. You might just mean herd immunity. You might mean enough to be protective. You might mean no vaccine preventable deaths are tolerable. So there's different ways to answer that question. You might say any death that happens, that could have been prevented by vaccination, where the vaccination is safe, is a death that is wrong and it shouldn't have happened. And if you thought that, your goal would be eradication. That's exactly what happened with smallpox. And so these are difficult questions partly 'cause as we saw there are different reasons to vaccinate for different diseases. Some are just individually protective, tetanus. Some protect both ourselves and other people. And some really are more about protecting others rather than ourselves. And that should play into your thinking about when you think overriding autonomy is legitimate. So if it's a vaccination that's really protective of the individual, so tetanus, then you would really be saying we should override your autonomous position for more beneficent or paternalistic reasons. And so you would pause there. It is a less good reason to override autonomy when somebody says to you, well I personally disagree with your evaluation of what should be done for me. I will bear that risk because the risk only applies to me. That's quite different if you're trying to protect vulnerable people, 'cause that implicates other values. And so you might have stronger reasons to override autonomy. And the way you might ground those is that we might have obligations to protect the vulnerable, or we might have collective obligations, or there might be some idea of social contract. That we all participate collectively in this project of eradicating disease for our own benefit, for the benefit of those around us. And if that's the case, then you might say, well this is a reason to override some people's autonomy in relation to vaccination. The third way to think about this is that some diseases however are more severe than others and that might shift the position here. And some are also diseases that can be easily prevented and some aren't. So something like smallpox was a very difficult disease to prevent being carried to other people and it was severe. So that seemed to be stronger reasons, fairly strong reasons and demonstrably regarded sufficiently strong reasons to move towards overriding autonomy. But that might be quite different for something like the HPV vaccination, which protects against human papillomavirus. Now that is a condition that's only passed on really through intimate skin to skin contact. So sexual relations. And so it's only going to be passed between sexually active teens and adults for one thing. And also you can be regularly screened, you can detect whether you have it. And so it is much less problematic from a contagion perspective. And so that might shift the way you think about it. So that's kind of your background to it. Then you might think, well, alright if I have some reservations about overriding people's autonomy, I might think, are there other ways to get to the same goal or at least sufficiently close to it? And there are lots of ways that we can increase vaccination uptake. and I've arranged them in order of in terms of how autonomy affecting they are. So you could start with public health campaigns, education campaigns, they could be compulsory, they could be in schools. So you just try to build knowledge. And what you're doing there is you're addressing one of the things that I raised earlier about people's resistance to vaccinations. It might be that you think some people have false information, they're in error, or their perception of the risks and benefits is skewed. And therefore you would think those are good things to do because they will address that problem. You might think you could go so far as nudging. So that is sort of doing things that push people into or sort of move them towards it without them noticing it. So a good example of a nudge is when you stand at the crossing on a road and the sign that shows you whether you can cross or not is actually you have to turn in the direction that the traffic is coming towards you to look at that and it makes you look to see if cars are coming. That's a nudge. You could move up to incentives and I'll talk about some of these in a moment, all the way through to it's compulsory before you can access education, you can't get to services, fines and incarceration. So when we think about these, think about the reasons why people were resisting in the first place. Vaccines are risky, the disease aren't that severe. Vaccines aren't necessary, mistrust and moral reasons. And when you evaluate these strategies, you need to think about that, because some of them may work better than others depending on the reason. And different strategies work better for different diseases in different groups, and some of them might be counterproductive as well. So if you think that mistrust of health systems is a real, is a big reason, then forcing people to do things, is probably not going to be very helpful, is it? Because it might make people more concerned or it will lead to polarization or entrenching of positions because the very organization they don't trust is now not taking their concerns seriously and forcing them to do something. That is not a particularly trust building way to behave. So you might instead think, well the way to address that concern is to build trust. And we don't do that by forcing things on people. We do that by talking to them, listen to their concerns. And that's why we would use things like GP to do that. And that's why there are high profile campaigns where famous people and people who work in communities are used to help build that trust and bring people into the system. There are other strategies you could use. So you might actually respond to some of the concerns. So one of those would be the moral concerns about animal products or using fetal cell based cell lines. You could just stop doing that and actually then you would bring in people who had those concerns if this were possible. But the key thing is that you need to be sensitive to the social and psychological elements of these and recognize that vaccination is an emotive topic and you don't necessarily solve it with blunt tools. So you have to start with belief. But the question is, what if that's not enough? Well then the next position that you would consider is the idea of the principle of the least restrictive alternative. And this is a public health principle, which is the idea that you should presume that autonomy is very important and that then when you're choosing between policies, as long as they're equal in all other respects, you pick the one that least restricts liberty. That's your way of thinking, that's your goal. And so then what you would do, is you would only move to mandatory vaccination, if it was really the only way to achieve the same goal. And that's why working out what is sufficient and what your goal is is really important. Now, if you had got to the position where you thought even in the face of a particular disease with particular severity in particular prevalence, that mandatory vaccination is beginning to seem like it needs to be, that's what we need to achieve the goal, then the next way to think about it is to think, well, if I've got to that point where I'm considering it's on the table, I need to think about the pros and cons. Now the pros of mandatory vaccination are quite clear, you will promote the interests of vaccinated people, you protect vulnerable third parties, fulfills our obligations to protect vulnerable children. And which the state regards as its obligation, it's quite clearly reflected in the law, prevents free-riding, which we'll talk about in a moment, and it shares the burden fairly. But the cons are partly this infringement of liberty, but also the concern that mandatory vaccination might contribute to social and political polarization. That if you think that people are resistant, forcing them to do something that they resist is a way to make them even more unhappy. And that might be problematic. It might discourage people from participating in healthcare systems. So if you already didn't trust a healthcare system, or you thought if you move into that healthcare system, someone will try to make you have a vaccination that you think is wrong, that might make you think, well I will opt out of the healthcare system altogether. And that might be particularly problematic if you have children being opted out. What you don't want is families not bringing their children to the doctor or to hospital systems for fear that they'll be forced to have a vaccination.'Cause that might be a really bad impact. You will reduce trust and you will also fail to respect value pluralism. And all of these things might be problematic. So that needs to bear on your thinking. You might also think about, well, when we talk about mandatory vaccination, there are lots of different ways in which you can encourage people through mandatory mechanisms to have vaccination. And these have varying degrees of severity on liberty as well. So the top level is going to be forceful vaccination. Now that is highly liberty restricting, it's going to have extremely problematic psychological implications for people. There's no real examples of this. It infringes bodily integrity and demonstrably regarded as something that's really not, shouldn't be on the table. Similarly, incarceration. But there are examples of criminalization. So there are examples at that end of the spectrum. But there are things that are problematic with things like criminalizing failure to vaccinate, is that it has this expressive force. That what it does is it says that this person is bad, it puts them in a category of wrongdoer and it's shaming. And that has social consequences as well as polarizing consequences. You could use levers, financial levers like fines, withdrawing benefits. That's the approach in Australia, No Jab, No Pay. So you can't access particular financial benefits unless you've had vac- your children have vaccinations. Fines are used in countries like Italy. They do work in the sense that there has been uptake. And what is interesting is there's lots of reports that show that they haven't really caused the kind of backlash that you might worry about. The other one that's popular is the idea of exclusion from services. And this I think is possibly one of the most palatable. It's the idea that you can't access social goods, like education or access to particular jobs, or particular settings unless you also participate in the social good of vaccinations. So in one sense it's more intelligible because it is actually, it is about the thing that the person is free-riding on. Another is it's only about removing somebody from the place where they might create the risk. So it's about keeping people who've decided not to be vaccinated, not have their children vaccinated, out of the space where they can cause harm. It's protective of the vulnerable. So in that sense, you might think there's a difference between the different ways to be mandatory and that might matter. The final thing I want to talk about is the idea of fairness instead as a different way of thinking about this. And what this means is the idea that it is unfair for people to take the benefits of vaccination programs but not take on the risks. So the free rider-problem is an element of this. Now one of you might just think it's just a bit irritating, Free-riding might be a bit tedious and you might think it's just wrong in that sense, but actually it's a bit more than that. What it's doing is it's putting the burdens on other people. And so if those burdens come to bear so that you suffer an injury or your child suffers an injury, they have been harmed, partly because that harm hasn't happened to someone else, but also because we haven't collectively removed this disease.'Cause if you think the ultimate goal is eradication, then that won't happen. It's also the case that we see there's correlations between affluence and not vaccinating in some context. And what that means is actually some people are opting out and the burden is left on those who are potentially less able to bear it because they have less good healthcare and they might face other barriers and burdens. It also can undermine the collective benefit. The idea that we need to get vaccines to a particular level to all achieve the benefit and opting out of that can be problematic. And so this is the theory of Alberto Gibellini and he argues that actually fairness is the key thing here. It's not just about balancing liberty and utility, but actually we should think of fairness as a goal and fairness as an end. So the goal should not just be to achieve enough vaccination, it should to be achieved fairly. And he says fairness is important instrumentally. What it means is you get a fair distribution of risks, but what that does is it increases reasons to comply. So if you know everybody else has to do it, it seems worth doing it if you do it as well, because you know everybody else will have to do it. So you don't have that problem of feeling like, well I should opt out as well. And it has psychological and social benefits that you think everybody will participate, so it's worth doing. So you have less problems with people not wanting to cooperate and it doesn't appear to actually backfire precisely for that reason. You might also as Gibellini argued, say that actually the collective benefit we all take actually creates an obligation honest, that because we take this benefit, we have some sense of obligation as well. The final thing to think about is that if you move to a mandatory model, you would have to think about, there may still be reasons that people have for not wanting to have vaccinations that are legitimate, or that you think need to be respected, or that would avoid the backfiring problem. And one of those will be people who have medical health reasons. So someone who is immunocompromised, someone has allergic reactions, they would need exemptions. But you would also, unless you had taken a particularly hard line position, want to accept that there should be space for conscientious objection so that you could still respect some degree of value pluralism. You could still respect people's reasons. You would want to do this in tandem with things like education programs and building trust and so on. But this would be the way, if you had concerns about moving to some sort of mandatory system, this can ameliorate those concerns. All right. Thank you very much.(audience applauds)