Vaccine refusal/ hesitancy- the ethical standpoint regarding the COVID-19 pandemic

Rechazo/ vacilación ante vacunas - el punto de vista ético en la pandemia por COVID-19

ABSTRACT

Objective:

To reflect about vaccine hesitancy from ethical and bioethical perspectives.

Methodology:

Reflective study through the analysis of bibliographic research carried out from December 2020 to May 2021 in the data banks SciELO, PubMed, Direção Geral da Saúde, and Ordem dos Enfermeiros.

Results:

Vaccination aims at collective protection. The effects desirable in the individual do not have the same ethical value in the collective, leading to cost-benefit imbalances. The insufficiency of principlist Bioethics leads us to use other moral values, such as responsibility, solidarity, and social justice, to reflect on problems related to vaccination.

Conclusion:

In ethics there are no perfect solutions, and they depend on the context. Group immunity is one of the most discussed issues in a pandemic. Equitable distribution and the principle of justice are reflected daily in the nursing profession.

Keywords:
Vaccination refusal; COVID-19; Ethics; Bioethics; Social justice

RESUMEN

Objetivo:

Reflexionar sobre vacilación vacunal desde una perspectiva ética y bioética.

Metodología:

Estudio reflexivo con análisis de fuentes bibliográficas, realizado desde diciembre 2020 a mayo 2021 en las bases de datos SciELO, PubMed Central, Direção Geral da Saúde y Ordem dos Enfermeiros.

Resultados:

La vacunación visa la protección colectiva. Los efectos deseables en individuos no tienen el mismo valor ético que en el colectivo, generando desequilibrios costo-beneficio. La insuficiencia de la bioética principialista nos lleva a utilizar otros valores morales, como responsabilidad, solidaridad y justicia social, para reflexionar sobre los problemas relacionados con la vacunación.

Conclusión:

En ética no hay soluciones perfectas, pues dependen del contexto. La inmunidad de rebaño es un tema muy discutido en una pandemia. La distribución equitativa y el principio de justicia se reflejan a diario en la profesión de enfermería.

Palabras clave:
Negativa a la vacunación; COVID-19; Ética; Bioética; Justicia social

RESUMO

Objetivo:

Refletir e atualizar conhecimentos sobre hesitação vacinal numa perspetiva ética e bioética.

Metodologia:

Estudo reflexivo pela leitura e análise de pesquisa bibliográfica entre Dezembro 2020 a Maio 2021 nas bases de dados SciELO, PubMed Central, Direção Geral da Saúde e da Ordem dos Enfermeiros.

Resultados:

A vacinação visa proteção coletiva. Os efeitos desejáveis no indivíduo não possuem o mesmo valor ético no coletivo, levando a desequilíbrios custo/benefício. A insuficiência da bioética principialista, conduzem-nos ao uso de outros valores morais, como a responsabilidade, solidariedade e justiça social, para a reflexão dos problemas relacionados com a vacinação.

Conclusão:

Em ética não há soluções perfeitas e estas dependem do contexto. A imunidade de grupo é uma das questões mais discutidas em pandemia. A distribuição equitativa e o princípio da justiça, refletem-se diariamente na profissão de enfermagem.

Palavras-chave:
Recusa de vacinação; COVID-19; Ética; Bioética; Justiça social

INTRODUCTION

Vaccination is one of the fields where nursing excels, and during the pandemic, it has become a focus of action. In this article, we seek to reflect on this subject, which has become increasingly present in society and is currently a challenge for nurses, both in direct care and in management. The ethical dilemma related to vaccine hesitancy/refusal raises questions about whether vaccination should be mandatory, which must deal with collective and individual freedom, equity, social justice, and human rights. These issues became more relevant in recent times due to the pandemic, the creation of new vaccines, the vaccines that are already part of the Portuguese National Plan of Vaccination (PNV), and the fact that this ethical dilemma has existed for as long as vaccines themselves have. This article will focus on the COVID-19 vaccine.

In regard to the state of the art, vaccine hesitancy/refusal is a phenomenon as old as vaccination itself. There are countless examples in scientific literature about vaccine hesitancy/refusal before COVID-19. Although vaccination is one of the most effective public health interventions, nurses are often presented with children that were not vaccination. This may be why, in 2019, the World Health Organization (WHO) classified vaccine hesitancy as one of the 10 main threats to world health. At this time, we were far from imagining that, one year later, a pandemic would be ravaging the world. Indeed, the most effective and positive way to deal with pandemics is to vaccinate1. Therefore, the fantastic role different vaccines have taken cannot be denied; nonetheless, despite being safe, they are not entirely risk-free. Therefore, it must be recognized that Portuguese nurses were essential for the successful vaccination of the population of the country since 1965. In addition to ethical concerns regarding vaccination, there are now, with the emergence of COVID-19 vaccinations, new ethical issues. Some of these are related with the degree of risk the new vaccines pose to the community, while others are related to how much can individual rights be restricted. However, regarding the degree of risk, it should be considered that, while there was a single exceptional death caused by a vaccine, the number of deaths in unvaccinated individuals is vastly different1. In the current context of COVID-19, the question that triggers the reflection present in this work emerged: What are the consequences of the COVID-19 vaccination campaign on vaccine hesitancy/refusal? The goal of this article is to reflect and uncover new knowledge about vaccine hesitancy from an ethical and bioethical standpoint. This is a theoretical and reflective study carried out through the reading, analysis, and reflection about different bibliographical sources, at a point in time where the topic of vaccination is more discussed than ever, leading to ethical matters inherent to it.

METHODS

Reflective study carried out through a bibliographical research carried out from December 2020 to May 2021 in the data banks SciELO, PubMed Central, and those from the Portuguese General Health Administration and Order of Nurses, in the context of Portuguese Primary Health Care. Articles were selected and read as long as they were available in full and written in Portuguese, Spanish, French, or English. The articles were associated with the descriptors Vaccine Refusal, COVID-19, Ethics, Bioethics, and Social Justice, and the most recent articles possible were included. Articles were excluded when the text was not available in full. The reflection is organized in topics: The Principle of Justice; the Thin Lines between Beneficence and Non-Maleficence in Mass Vaccination; and Individual Freedom versus Collective Responsibility. These topics were addressed according with an analysis of mass vaccination from a bioethical principlist standpoint, enabling its discussion and the inferences carried out by the author during considerations about clinical practice for nursing.

RESULTS AND DISCUSSION

Mass vaccination, with a safe and effective vaccine against COVID-19, led to an extraordinary social and economic agitation around the world. Nearly one year after the pandemic, our hopes of overcoming COVID-19 largely depend on vaccines. This unprecedented global vaccination campaign is much more complex than any other before it, presenting new challenges that must be overcome for it to be successful. Although vaccines are a promising solution for the COVID-19 pandemic, their development is only part of the answer. The generalized acceptance of these vaccines is also essential and requires more than simply making safe and efficient vaccines available. Making vaccines widely available is a complex endeavor. Previous experiences suggest that this can be done with careful, proactive coordination, and clear communication2. At first, risk groups should hold priority for vaccination; then, as production issues are overcome, mass vaccination should take place, and the possibility of mandatory vaccination vs. voluntary vaccination will become a reality3. These new challenges raise unique ethical concerns about which we will reflect on this article. Vaccine hesitancy is the delayed acceptance or refusal of vaccination, despite the availability of vaccines. Our current situation, indeed, revolves around vaccine hesitancy/refusal, as COVID-19 vaccines become available; this seems to have been triggered by fast information and by the rapid development of new vaccines in this global emergency context. As a result, certain concepts become, once again, relevant, such as vaccine confidence or hesitancy, vaccines in a democracy, individual protection versus collective protection, and mass vaccination. It is also important to reflect on the fact that, when health resources - in this case, vaccines - are lacking, the principle of equality cannot be applied. As a result, in the case of COVID-19 vaccines, we must consider the principle of equity. Equity is the distributive justice, understood not as an equal distribution of resources, but as justice in regard to needs, especially in the distribution of risks and benefits throughout society. According with this principle, in the risk/benefit analysis there are at least two groups that must receive the first batch of vaccines available: health workers and health system users above 70 years old3. Vaccine hesitancy takes place in a continuum whose extremes are high demand for vaccination and complete refusal of vaccination, that is, no demand for vaccines that are available and provided. Nonetheless, demand and hesitation are not entirely congruent. An individual or community can accept vaccination with no hesitancy, despite not demanding vaccination or any specific vaccine2. Vaccine hesitancy is the delayed acceptance or refusal of vaccination, despite the availability of vaccine services. Vaccine hesitancy is complex and specific to the context. It varies according with time, place, and vaccines available, and it is influenced by factors such as complacency, convenience, and trust2. The new coronavirus makes headlines around the world and led to a pandemic, at a point in time when social network use is generalized, leading to a fast, worldwide exchange of information, misinformation, and easy comparisons. Trust on vaccines will depend on how fake news that foment conspiracy theories about COVID-19 and its vaccines evolve. These factors will affect trust/distrust levels in the population in regard to institutions and COVID-19 vaccines3. Since the beginning of this sanitary crises, we receive news of the optimism regarding the discovery of a vaccine, amid many uncertainties. As a result, discussions on whether vaccines should be mandatory began. Most ethical committees that were considered in this research are opposed to mandatory vaccinations1 ^- 3 ^, 4 ^, 5. The General Health Administration itself6 states that the COVID-19 vaccine is voluntary but strongly recommended, believing that people above 16 years of age who go to a place of vaccination and are adequately informed will consent receiving the vaccine. Vaccine hesitancy, however, is a complex emerging phenomenon. Mandatory vaccination could even worsen the vaccine hesitancy/refusal issue7 and is an ethically controversial decision, as it affects individual rights, including the right an individual has to make decisions about their own health. Ethical issues related to vaccine are specific, such as the vaccination of individuals with limited capacity of choosing, and without vaccines there are evident contradictions between individual and collective issues. One of the reasons why ethical dilemmas about vaccines persist may be the difficulties in showing, methodologically, that vaccines are definitively not a causal factor for disease. Therefore, a bioethical reflection about universal vaccination strategies is necessary. In the current context, from a bioethical perspective, and considering the relationship between nurse and user, I decided to use the principlist approach. Principlism is one of the several, most used forms of bioethical expression8. The principlist approach was first introduced by the Belmont Report (1979)8, which included basic principles for the solution of ethical problems that emerged in research with human beings. In the same year Beauchamp & Childress8, presented bioethics from the same perspective, based on the four prima facie (non-absolute) principles: 1) respect for autonomy; 2) non-maleficence; 3) beneficence; 4) justice. These authors attempted to associate the principles enshrined in medical ethics for the relationship with the patient (beneficence and non-maleficence) with two other principles that had not been included up to that point (autonomy and justice). The principle of beneficence has a long tradition in Hippocratic medical ethics ⁽ 8. The principle of non-maleficence is associated with the maxim primum non nocere (above all, do not harm)8. The principle of autonomy is based on the presuppositions according to which a democratic society and individuals in equal conditions are pre-requisite for moral differences to coexist8. The principle of justice is more intimately tied to the role of organized bioethical social movements, and with the actions of society as opinion leaders8. Here, I use an approach of bioethics that is more closely related with the social dimension of health, which considers, in its moral reflections, the fragility and vulnerability of groups or social segments as a hegemonic, broad, and politicized epistemological proposition9. The ethical aspects of collective health decisions are quite interesting, since, in certain situations, the interests of the population as a whole are opposed to the interests of individuals. In collective contexts, small risks are considered to be balanced by the benefits of the immunization of the population. Therefore, an individual accepts the occasional adverse effect for the good of the population as a whole. The principle of respecting the autonomy of the individual allows one to reject a treatment, and, therefore, to reject vaccination. Therefore, it is clear that the individual has the right to choose not to be vaccinated3. The bioethical principle considered is that of respect for individual autonomy and freedom, respect for one’s capability of making a decision. An especially interesting aspect is that of the opportunity cost of each health intervention5. Opportunity cost is an expression used when we refer to the introduction of a new health service that consumes resources and delays other health interventions, as resources available are limited. Some authors7 ⁾ state that, if we are to be coherent, health interventions financed with public resources should undergo opportunity cost analysis, if one is to act in accordance with the justice and equity ethical principles. These principles should be applied to the new vaccines, since they are financed by millions of Euro from public funds. As a result, we must consider the issue of equity, since different population groups are not equally likely to be infected or to develop complications due to the infection. On January 13, 2021, the news outlet "Observador" reported on the case of an elderly woman from a Spanish nursing home who was not capable of deciding for herself whether to be vaccinated. The daughter of said woman was opposed to vaccination while the nursing home was in favor. When the case was brought to justice, court decided that the woman should be vaccinated, determining that it was urgent to vaccinate an elderly woman during the pandemic. According with the judge, who decided in favor of the nursing home, the infection numbers indicated that this urgency was notorious, as there was a high number of deaths, which made it urgent to protect the woman. Vaccination in Spain is voluntary; however, several nursing homes are asking the courts to force their residents who cannot decide to be vaccinated, despite family opposition7. From a bioethical standpoint, the collective value may be more important here and, without a doubt, the context of a pandemic is the essential factor that leads to the decision of the judge, since the WHO and the scientific community form a consensus according with which, in the context of a pandemic, collective value is more important than individual value, even in countries where vaccination is not mandatory. In this concrete case, the principle of justice could also be invoked, since the daughter refused vaccinating her disabled mother, eventually justifying this opposition to the vaccine based on the fact that her mother was in a group of vaccinated people (considering that the residents of the home were vaccinated) and not considering that her mother could endanger the group immunity (that is, a collective right). She would reap benefits from the situation without contributing to it. Vaccination is also not mandatory in Portugal8, except in the case of tetanus and diphtheria vaccines. The Decree-Law No. 44.198, from 1962, which has so far not been revoked, establishes the conditions in which these vaccines are mandatory. In Portugal, the National Vaccination Plan is voluntary, as only the vaccines mentioned above are mandatory according with legislation. COVID-19 vaccination is also voluntary. The most important action to meet vaccine hesitancy/refusal is health education, leading to health literacy enough for users to make free and informed decisions in a more inclusive context that would lead to more health gains10. From a bioethics standpoint, issues in regard to individual protection from the vaccine and logistic viability of a program of mass vaccination emerge; other factors, such as the duration of the protection provided, its cost, and herd immunity, are also addressed7. To minimize potential harm from a specific vaccine, only safe and effective vaccines are used, thus respecting the principle of non-maleficence. Vaccines should not only protect people from a specific disease, but also provide them benefits through herd immunity. From the perspective of human rights, vaccination promotes and protects collective health in an egalitarian manner.

The Principle of Justice

Distributive justice is often mentioned in bioethics. It relates to the fair sharing of expenses and benefits - on one hand, the equal distribution of cost and of benefits to society; on the other, the fair access to these resources11. In the case of Portugal, paradoxically, although there is equal access to vaccines, the costs of vaccination are not distributed equally; in the case of collective vaccination, specifically, a person is not likely to receive more benefits than another, since benefits cannot be allocated unjustly. Distributive justice requires fair allocation of scarce resources. In the context of the COVID-19 vaccine, circumstances are exceptional, and the need is higher than the resources available. As a result, the making of decisions and the establishment of priorities become challenging from an ethical standpoint5. How can we distribute the vaccines against SARS-CoV-2 equally? Should we prioritize the most vulnerable groups of people or those more likely to disseminate the disease? This is challenging because we need substantially more vaccines than can be provided. In this case, the random selection of people could be more egalitarian. Considering that reaching herd immunity is one of the goals of the vaccination plan, how will geographical areas be distributed? Around the world, who receives the vaccine against COVID-19 earlier, who does later? Concerning their vulnerability, in emergency situations, poorer societies are more affected, because poverty decreases resilience. The usefulness of vaccination tends to be higher when it targets groups that are in a lower social position7. Foreign people and refugees should not be treated separately, and vaccination plans should include all those present in a given geographical area. It is important to highlight that health workers will receive indirect benefits as they are vaccinated. After all, not only they are under a higher risk of infection, they also have the moral obligation of vaccinating themselves to avoid the risk of infecting their patients. The principlist bioethics approach is focused on moral principles whose application would theoretically solve ethical health dilemmas: respect for autonomy, beneficence, non-maleficence, and justice.

The Thin Lines between Beneficence and Non-Maleficence in Mass Vaccination

Vaccination implies some degree of risk for the citizens. In the context of principlist bioethics, health workers must follow the ethical principle according to which they will not harm their patients (primum no nocere). Preventive activities aim to protect people against infectious diseases, respecting the principle according to which vaccination procedures are in accordance with the principle of beneficence. Since it is morally undesirable to cause harm, whether through the exposure to adverse effects from vaccination or from the disease acquired through lack of immunization, which moral principle should be considered when the risks and benefits of vaccination are distributed unequally among the population? Therefore, there are conflicts between the principles, which should lead us to reflect more on these issues.

Individual Freedom versus Collective Responsibility

The notion of autonomy in clinical practice is used to express the freedom of a subject to consent or refuse the treatment proposed by a health professional. In regard to public health, however, especially considering mass vaccination in epidemics, the autonomy of the individual is in conflict with the need for collective protection, since respecting individual autonomy would imply in a real risk for a community. In the context of mass vaccination programs, the right to autonomy is based on the social recognition of this principle. Considering that vaccines are not completely safe, respecting their autonomy means that the risks should not be imposed on individuals. There is a critical reason to evaluate arguments in favor or against the right to consent or refuse vaccination. After all, a refusal may lead to serious damage to people's health. Restrictions to individual rights in regard to vaccination plans are justified by two reasons: the benefits to the individual or the benefits to the collective. The better the vaccination coverage, the less likely the infectious agent is to spread, especially in vulnerable groups. In this context, it is undesirable for an individual to remain unvaccinated, since those who decide not to vaccinate are under more risk than those who choose vaccination. In this case, there is a tension between individual and collective interest, and autonomy loses value when compared to the goal of immunizing the collective. From a principlist standpoint, to respect the principle of autonomy, which gives the individual the option to take or not the vaccine, is to go against the principle of non-maleficence by putting the entire collective at risk. Nonetheless, this is only true when the individual makes the decision to refuse vaccination. Even in that case, it could be argued that, if an individual does not take the vaccine, it does not mean that they will necessarily do harm, but that this is a possibility.

This raises other questions, such as whether the model of the four principles of principlist bioethics is adequate to be adapted to the collective context as a tool to understand and discuss the moral conflicts that take place in collective actions. In this case, it could be more adequate to analyze the situation under the light of Utilitarian Theory, where the ends are considered more important than the means. It is necessary to define what are the conceptual tools that could be used in addressing these issues and causing positive impact on more vulnerable and disregarded groups of the population. In mass vaccination plans, which ultimately aim to provide collective protection, the ethical value of the desirable effects on the individual is not as high as that of the effects on the collective. As a result, there is no balance between individual cost-benefit and collective cost-benefit calculations. Considering the moral conflicts between individual and collective, this cost-benefit imbalance and the incapacity or insufficiency of principlist bioethics means that other values and moral principles are needed, such as responsibility, solidarity, and social justice, as tools for reflecting about ethical issues related to vaccination plans. Bioethics underwent significant conceptual changes when the United Nations for Education, Science and Cultural Organization (UNESCO) published, in 2005, the Universal Declaration of Bioethics and Human Rights. We should also not forget that the moral principle of protection is implied in the necessities of the State, who should protect its citizens against calamities, since citizens cannot protect themselves against everything and everyone and can become susceptible and even vulnerable in certain situations. In some countries, people are legally exempt from mandatory vaccination due to the ethics of freedom and autonomy. However, there are several examples throughout the world of places where, after vaccines stopped being mandatory, vaccination increased. Information seems to be the crucial factor that provides an ethical base for consensual vaccination. We know that many people seek information on the Internet. Another argument we analyzed here is related with the increase in the number of vaccines available, especially in regard to the new COVID-19 vaccine. It should be highlighted that health workers are in a privileged and ideal position to provide reliable information about vaccination and to have a positive influence towards adherence. Profound bioethical reflection could contribute for better universal immunization policies and allow all groups involved in this activity - that is, society in general - to come closer together, so every citizen has the information needed to make a cooperative individual decision12. Vaccination should be voluntary, as long as it is not critically necessary to avoid serious and concrete damage; vaccine hesitancy is a behavioral phenomenon influenced by several factors9. The reasons for the decline in the confidence on COVID-19 vaccines are also complex7, The future of immunization is closely related to the credibility of vaccines. In this regard, bioethics can contribute for reflection and debate, helping us to understand the complexity and conflicts of reality, respecting the rights of citizens. In any case, vaccination refusal is as old as vaccination itself, and the workers involved should see every situation as an opportunity to provide health education, thus increasing the capacity of the population and contributing to improve their level of health9.

CONCLUSION

Vaccination raises ethical questions. One of the most pertinent of them, in the context of a pandemic, is that of herd immunity, when the decision to vaccinate is individual, thus endangering public health. Ethical dilemmas may lead to extreme postures that, on one hand, harm individual autonomy and freedom and, on the other, harm the preservation of collective health. Both extreme situations should be avoided, and it is best to search for intermediary solutions. The nurse must explore the reasons why vaccine opposition takes place, in order to provide the Health Education necessary. The equal distribution of vaccine and the principle of justice are important, since the challenge to produce and distribute the vaccine globally will take months to be overcome. There is no perfect solution for the ethical dilemmas analyzed and solutions depend on context. Now, there is a greater focus on ethics in clinical practice due to COVID-19 vaccination campaigns. Ethics is one of the bases of nursing, and its analysis aims to improve the quality of nursing care and contribute for the creation of a fairer society. Through this reflection about ethical issues, I aim to contribute for the social valorization of the profession of nursing and for the advance of knowledge in nursing and health. In emergency situations, poorer societies are affected the most, due to the fact that poverty undermines resilience. The usefulness of vaccines, as a result, is higher when targeted at groups that are in worse social conditions. Vaccination plans should support all of those who live in the same geographical area. Nursing has the ethical responsibility of claiming for more social justice and worldwide equality for vaccination plans. We analyzed a topic that has received quite a lot of attention around the globe and is directly related to nurses, both in the direct provision of care and in regard to their managerial role. To contribute for the practice and improve the wellbeing of their populations, nurses should address social determinants of health in their daily practices, so they can take part in the development of national policies and strategies to promote health, such as mass vaccination campaigns against COVID-19. Reflecting on ethics, bioethics, and freedom in science is always difficult, but this topic should receive the attention of further studies to bring benefits for society as a whole.

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Edited by

Associated editor:

Rosana Maffacciolli

Editor-in-chief:

Maria da Graça Oliveira Crossetti

Publication Dates

• Publication in this collection
  15 Aug 2022
• Date of issue
  2022

History

• Received
  22 May 2021
• Accepted
  16 Nov 2021