The ethics of natural immunity exemptions to vaccine mandates: the Supreme Court petition.

The Supreme Court of the United States has recently been petitioned to revisit legal issues pertaining to the lawfulness of imposing a vaccine mandate on individuals with proof of natural immunity during the COVID-19 pandemic. While the petition accepts that the protection of public health during COVID-19 was an important governmental interest, the petitioners maintain that the imposition of a vaccine mandate on individuals with natural immunity was not 'substantially related' to accomplishing that purpose. In this short report, we outline how some of the petition's general arguments interact with points we raised in a 2022 article in this journal defending natural immunity exemptions, in light of new evidence. In particular, we reflect on new evidence pertaining to differences between vaccine-induced immunity, natural immunity, and so-called 'hybrid' immunity. We suggest that the nuanced nature of this evidence highlights the importance of making fine-grained judgements about proportionality and necessity when considering vaccine mandates. We conclude by claiming that if future pandemics necessitate the imposition of vaccine mandates, then those seeking to justify them should clearly articulate the relevance (and the evidence) for the comparative protection of vaccine-induced, natural, and hybrid immunity.

"More effective" is not necessarily "better": Some ethical considerations when influencing individual behaviour.

Chater & Loewenstein make a persuasive case for focusing behavioural research and policy making on s- rather than i-interventions. This commentary highlights some conceptual and ethical issues that need to be addressed before such reform can be embraced. These include the need to adjudicate between different conceptions of "effectiveness," and accounting for reasonable differences between how people weight different values.

The unnaturalistic fallacy: COVID-19 vaccine mandates should not discriminate against natural immunity.

COVID-19 vaccine requirements have generated significant debate. Here, we argue that, on the evidence available, such policies should have recognised proof of natural immunity as a sufficient basis for exemption to vaccination requirements. We begin by distinguishing our argument from two implausible claims about natural immunity: (1) natural immunity is superior to 'artificial' vaccine-induced immunity simply because it is 'natural' and (2) it is better to acquire immunity through natural infection than via vaccination. We then briefly survey the evidence base for the comparison between naturally acquired immunity and vaccine-induced immunity. While we clearly cannot settle the scientific debates on this point, we suggest that we lack clear and convincing scientific evidence that vaccine-induced immunity has a significantly higher protective effect than natural immunity. Since vaccine requirements represent a substantial infringement of individual liberty, as well as imposing other significant costs, they can only be justified if they are necessary for achieving a proportionate public health benefit. Without compelling evidence for the superiority of vaccine-induced immunity, it cannot be deemed necessary to require vaccination for those with natural immunity. Subjecting them to vaccine mandates is therefore not justified. We conclude by defending the standard of proof that this argument from necessity invokes, and address other pragmatic and practical considerations that may speak against natural immunity exemptions.

Broad Medical Uncertainty and the ethical obligation for openness.

This paper argues that there exists a collective epistemic state of 'Broad Medical Uncertainty' (BMU) regarding the effectiveness of many medical interventions. We outline the features of BMU, and describe some of the main contributing factors. These include flaws in medical research methodologies, bias in publication practices, financial and other conflicts of interest, and features of how evidence is translated into practice. These result in a significant degree of uncertainty regarding the effectiveness of many medical treatments and unduly optimistic beliefs about the benefit/harm profiles of such treatments. We argue for an ethical presumption in favour of openness regarding BMU as part of a 'Corrective Response'. We then consider some objections to this position (the 'Anti-Corrective Response'), including concerns that public honesty about flaws in medical research could undermine trust in healthcare institutions. We suggest that, as it stands, the Anti-Corrective Response is unconvincing.

Social Prescribing in National Health Service Primary Care: What Are the Ethical Considerations?

Policy Points Social prescribing is proposed as a way of improving patients' health and well-being by attending to their non-clinical needs. This is done by connecting patients with community assets (typically voluntary or charitable organizations) that provide social and personal support. In the United Kingdom, social prescribing is used to improve patient well-being and reduce use of National Health Service resources. Although social prescribing schemes hold promise, evidence of their effects and effectiveness is sparse. As more information on social prescribing is gathered, it will be important to consider the associated ethical issues for patients, clinicians, link workers, and community assets.

Prospective Intention-Based Lifestyle Contracts: mHealth Technology and Responsibility in Healthcare.

As the rising costs of lifestyle-related diseases place increasing strain on public healthcare systems, the individual's role in disease may be proposed as a healthcare rationing criterion. Literature thus far has largely focused on retrospective responsibility in healthcare. The concept of prospective responsibility, in the form of a lifestyle contract, warrants further investigation. The responsibilisation in healthcare debate also needs to take into account innovative developments in mobile health technology, such as wearable biometric devices and mobile apps, which may change how we hold others accountable for their lifestyles. Little is known about public attitudes towards lifestyle contracts and the use of mobile health technology to hold people responsible in the context of healthcare. This paper has two components. Firstly, it details empirical findings from a survey of 81 members of the United Kingdom general public on public attitudes towards individual responsibility and rationing healthcare, prospective and retrospective responsibility, and the acceptability of lifestyle contracts in the context of mobile health technology. Secondly, we draw on the empirical findings and propose a model of prospective intention-based lifestyle contracts, which is both more aligned with public intuitions and less ethically objectionable than more traditional, retrospective models of responsibility in healthcare.

Passport to freedom? Immunity passports for COVID-19.

The COVID-19 pandemic has led a number of countries to introduce restrictive 'lockdown' policies on their citizens in order to control infection spread. Immunity passports have been proposed as a way of easing the harms of such policies, and could be used in conjunction with other strategies for infection control. These passports would permit those who test positive for COVID-19 antibodies to return to some of their normal behaviours, such as travelling more freely and returning to work. The introduction of immunity passports raises a number of practical and ethical challenges. In this paper, we seek to review the challenges relating to various practical considerations, fairness issues, the risk to social cooperation and the impact on people's civil liberties. We make tentative recommendations for the ethical introduction of immunity passports.

Responsibility in healthcare across time and agents.

It is unclear whether someone's responsibility for developing a disease or maintaining his or her health should affect what healthcare he or she receives. While this dispute continues, we suggest that, if responsibility is to play a role in healthcare, the concept must be rethought in order to reflect the sense in which many health-related behaviours occur repeatedly over time and are the product of more than one agent. Most philosophical accounts of responsibility are synchronic and individualistic; we indicate here what paying more attention to the diachronic and dyadic aspects of responsibility might involve and what implications this could have for assessments of responsibility for health-related behaviour.

Irresponsibly Infertile? Obesity, Efficiency, and Exclusion from Treatment.

Many countries tightly ration access to publicly funded fertility treatments such as in vitro fertilisation (IVF). One basis for excluding people from access to IVF is their body mass index. In this paper, I consider a number of potential justifications for such a policy, based on claims about effectiveness and cost-efficiency, and reject these as unsupported by available evidence. I consider an alternative justification: that those whose subfertility results from avoidable behaviours for which they are responsible are less deserving of treatment. I ultimately stop short of endorsing or rejecting such a justification, though highlight some reasons for thinking it is unlikely to be practicable.

Resisting Moralisation in Health Promotion.

Health promotion efforts are commonly directed towards encouraging people to discard 'unhealthy' and adopt 'healthy' behaviours in order to tackle chronic disease. Typical targets for behaviour change interventions include diet, physical activity, smoking and alcohol consumption, sometimes described as 'lifestyle behaviours.' In this paper, I discuss how efforts to raise awareness of the impact of lifestyles on health, in seeking to communicate the (perceived) need for people to change their behaviour, can contribute to a climate of 'healthism' and promote the moralisation of people's lifestyles. I begin by summarising recent trends in health promotion and introducing the notion of healthism, as described by Robert Crawford in the 1980s. One aspect of healthism is moralisation, which I outline (alongside the related term moralism) and suggest is facilitated by efforts to promote health via information provision and educational strategies. I propose that perceived responsibility plays a role in mediating the tendency to moralise about health and behaviour. Since I argue that states ought to avoid direct and indirect moralisation of people's health-related behaviour, this suggests states must be cautious with regard to the use of responsibility-indicating interventions (including informational and educational campaigns) to promote health.

Social values and the corruption argument against financial incentives for healthy behaviour.

Financial incentives may provide a way of reducing the burden of chronic diseases by motivating people to adopt healthy behaviours. While it is still uncertain how effective such incentives could be for promoting health, some argue that, even if effective, there are ethical objections that preclude their use. One such argument is made by Michael Sandel, who suggests that monetary transactions can have a corrupting effect on the norms and values that ordinarily regulate exchange and behaviour in previously non-monetised contexts. In this paper, I outline Sandel's corruption argument and consider its validity in the context of health incentives. I distinguish between two forms of corruption that are implied by Sandel's argument: efficiency corruption and value corruption While Sandel's thought-provoking discussion provides a valuable contribution to debates about health policies generally and health incentives specifically, I suggest the force of his criticism of health incentives is limited: further empirical evidence and theoretical reasoning are required to support the suggestion that health incentives are an inappropriate tool for promoting health. While I do not find Sandel's corruption argument compelling, this only constitutes a partial defence of health incentives, since other criticisms relating to their use may prove more successful.

Moral responsibility for (un)healthy behaviour.

Combatting chronic, lifestyle-related disease has become a healthcare priority in the developed world. The role personal responsibility should play in healthcare provision has growing pertinence given the growing significance of individual lifestyle choices for health. Media reporting focussing on the 'bad behaviour' of individuals suffering lifestyle-related disease, and policies aimed at encouraging 'responsibilisation' in healthcare highlight the importance of understanding the scope of responsibility ascriptions in this context. Research into the social determinants of health and psychological mechanisms of health behaviour could undermine some commonly held and tacit assumptions about the moral responsibility of agents for the sorts of lifestyles they adopt. I use Philip Petit's conception of freedom as 'fitness to be held responsible' to consider the significance of some of this evidence for assessing the moral responsibility of agents. I propose that, in some cases, factors outside the agent's control may influence behaviour in such a way as to undermine her freedom along the three dimensions described by Pettit: freedom of action; a sense of identification with one's actions; and whether one's social position renders one vulnerable to pressure from more powerful others.

A Taxonomy of Non-honesty in Public Health Communication.

This paper discusses the ethics of public health communication. We argue that a number of commonplace tools of public health communication risk qualifying as non-honest and question whether or not using such tools is ethically justified. First, we introduce the concept of honesty and suggest some reasons for thinking it is morally desirable. We then describe a number of common ways in which public health communication presents information about health-promoting interventions. These include the omission of information about the magnitude of benefits people can expect from health-promoting interventions, and failure to report uncertainty associated with the outcomes of interventions. Next we outline some forms of behaviour which are generally recognised by philosophers as being non-honest, including deception, manipulation, and so on. Finally, we suggest that many of the public health communicative practices identified earlier share features with the non-honest behaviours described and suggest this warrants reflection upon whether such non-honesty is justified by the goals of public health communication.

Acceptability of financial incentives to improve health outcomes in UK and US samples.

In an online study conducted separately in the UK and the US, participants rated the acceptability and fairness of four interventions: two types of financial incentives (rewards and penalties) and two types of medical interventions (pills and injections). These were stated to be equally effective in improving outcomes in five contexts: (a) weight loss and (b) smoking cessation programmes, and adherence in treatment programmes for (c) drug addiction, (d) serious mental illness and (e) physiotherapy after surgery. Financial incentives (weekly rewards and penalties) were judged less acceptable and to be less fair than medical interventions (weekly pill or injection) across all five contexts. Context moderated the relative preference between rewards and penalties: participants from both countries favoured rewards over penalties in weight loss and treatment for serious mental illness. Only among US participants was this relative preference moderated by perceived responsibility of the target group. Overall, participants supported funding more strongly for interventions when they judged members of the target group to be less responsible for their condition, and vice versa. These results reveal a striking similarity in negative attitudes towards the use of financial incentives, rewards as well as penalties, in improving outcomes across a range of contexts, in the UK and the USA. The basis for such negative attitudes awaits further study.

The scientific and ethical feasibility of immunity passports.

There is much debate about the use of immunity passports in the response to the COVID-19 pandemic. Some have argued that immunity passports are unethical and impractical, pointing to uncertainties relating to COVID-19 immunity, issues with testing, perverse incentives, doubtful economic benefits, privacy concerns, and the risk of discriminatory effects. We first review the scientific feasibility of immunity passports. Considerable hurdles remain, but increasing understanding of the neutralising antibody response to COVID-19 might make identifying members of the community at low risk of contracting and transmitting COVID-19 possible. We respond to the ethical arguments against immunity passports and give the positive ethical arguments. First, a strong presumption should be in favour of preserving people's free movement if at all feasible. Second, failing to recognise the reduced infection threat immune individuals pose risks punishing people for low-risk behaviour. Finally, further individual and social benefits are likely to accrue from allowing people to engage in free movement. Challenges relating to the implementation of immunity passports ought to be met with targeted solutions so as to maximise their benefit.

Against Moral Responsibilisation of Health: Prudential Responsibility and Health Promotion.

In this article, we outline a novel approach to understanding the role of responsibility in health promotion. Efforts to tackle chronic disease have led to an emphasis on personal responsibility and the identification of ways in which people can 'take responsibility' for their health by avoiding risk factors such as smoking and over-eating. We argue that the extent to which agents can be considered responsible for their health-related behaviour is limited, and as such, state health promotion which assumes certain forms of moral responsibility should (in general) be avoided. This indicates that some approaches to health promotion ought not to be employed. We suggest, however, that another form of responsibility might be more appropriately identified. This is based on the claim that agents (in general) have prudential reasons to maintain their health, in order to pursue those things which make their lives go well-i.e. that maintenance of a certain level of health is (all-things-considered) rational for many agents, given their pleasures and plans. On this basis, we propose that agents have a self-regarding prudential responsibility to maintain their health. We outline the implications of a prudential responsibility approach to health promotion.

Designing and using incentives to support recruitment and retention in clinical trials: a scoping review and a checklist for design.

BACKGROUND: Recruitment and retention of participants are both critical for the success of trials, yet both remain significant problems. The use of incentives to target participants and trial staff has been proposed as one solution. The effects of incentives are complex and depend upon how they are designed, but these complexities are often overlooked. In this paper, we used a scoping review to 'map' the literature, with two aims: to develop a checklist on the design and use of incentives to support recruitment and retention in trials; and to identify key research topics for the future. METHODS: The scoping review drew on the existing economic theory of incentives and a structured review of the literature on the use of incentives in three healthcare settings: trials, pay for performance, and health behaviour change. We identified the design issues that need to be considered when introducing an incentive scheme to improve recruitment and retention in trials. We then reviewed both the theoretical and empirical evidence relating to each of these design issues. We synthesised the findings into a checklist to guide the design of interventions using incentives. RESULTS: The issues to consider when designing an incentive system were summarised into an eight-question checklist. The checklist covers: the current incentives and barriers operating in the system; who the incentive should be directed towards; what the incentive should be linked to; the form of incentive; the incentive size; the structure of the incentive system; the timing and frequency of incentive payouts; and the potential unintended consequences. We concluded the section on each design aspect by highlighting the gaps in the current evidence base. CONCLUSIONS: Our findings highlight how complex the design of incentive systems can be, and how crucial each design choice is to overall effectiveness. The most appropriate design choice will differ according to context, and we have aimed to provide context-specific advice. Whilst all design issues warrant further research, evidence is most needed on incentives directed at recruiters, optimal incentive size, and testing of different incentive structures, particularly exploring repeat arrangements with recruiters.