Posted on May 6, 2020 at 9:32 AM
Written by Alberto Giubilini
Wellcome Centre for Ethics and Humanities – Oxford Uehiro Centre for Practical Ethics
University of Oxford
Lockdown measures to contain the spread of COVID-19 have so far been compulsory in most countries. In the same way, use of contact tracing apps should be compulsory once lockdown measures are relaxed. And in the same way, vaccination should be compulsory once the COVID-19 vaccine is available.
We can think of the lockdown as a form of ‘social immunization’, of contact tracing apps as a form of ‘technological immunization’, and of course of vaccination as pharmacological immunization. The same reasons that justify compulsory lockdown, also justify compulsion in the other two cases.
Justification of compulsory measures
The first thing to notice is that each way of addressing the pandemic and contain infection rates in a way that allows healthcare systems to cope is likely to involve some ethical cost. There is no cost-free way out of this situation. The real question is how large a cost we are and should be prepared to pay. Lockdowns entail limitations of basic freedoms and grave harm to individuals (e.g., job losses, mental health risks, etc). Contact-tracing apps entail the risk of some privacy infringement. Vaccination entails some infringement on bodily integrity. The good news is that the cost grows smaller as we slowly move forward from lockdown to vaccination.
If we accept compulsory measures when the cost is very large (lockdown), we should accept compulsory measures when the cost is vastly smaller (tracing apps and vaccination), other things being equal. The justification for compulsory measures is stronger, the less burdensome the requirements are, other things being equal. “Other things” in such cases are, for instance, the effectiveness of a policy or the way it satisfies some other ethical requirement, e.g. fairness.
Lockdown, contact tracing apps, and vaccination can be seen as the three milestones of the strategy to manage the pandemic by creating immunity at the collective level.
- Lockdown, or ‘social immunization’. Immunity at the collective level is built up by distancing everyone from everyone else (where the relevant ‘one’ is a household) – except for essential workers. Lockdown has been very effective at reducing contagion, as data and different studies show (see e.g. here and here). To be effective, this policy requires high compliance, although from a public health perspective we could in theory tolerate some free riders that go out and about while keeping safe distance from others, despite the rules. But of course, we do not do that for a number of very good reasons, including the high risks involved and fairness considerations. The lockdown is compulsory for everyone in many countries (with the exception of essential workers), and rightly so. It is not simply encouraged.
Ethical cost: strong limitation of basic freedoms for everyone. In normal times, this kind of restriction would be an unacceptable violation of fundamental rights. But these are not normal times. This is a public health emergency that is claiming a high toll on people. Temporarily suspending certain fundamental freedoms is justified for the sake of preventing vastly greater harm.
Because of all its costs, a lockdown like this is economically, psychologically, and ethically not sustainable for too long. Countries will now need to move to a ‘phase 2’, as some have already started (e.g., Italy and Spain), where some of measures will be eased. This is a risky move, as it might cause infection rates to go up again. But it is a necessary risk, given the large toll the lockdown is claiming. Of course, since we have to take the risk, we need to do all we reasonably and ethically can to minimize it. One way of minimizing the risk is the appropriate use of contact-tracing apps, assuming they will be effective.
- Contact-tracing apps, or ‘technological immunization’. Immunity at the collective level is created by distancing only those people who are more likely to be contagious, based on the information made available by the app. The app is only effective if enough people use it. For the one the UK Government is trialling on the Isle of Wight this week, the estimate is that at the very least 50% of people need to use it in order for it to be significantly effective. As with the lockdown, we can therefore tolerate some free riders. However, the more people use it, the more effective it becomes.
Ethical cost: depending on how one defines and ethically assesses privacy, there might be some small cost in term of privacy infringement. Even if small, it is a cost which many would probably consider unacceptable in normal times. But, again, these are not normal times. Temporarily suspending some privacy rights would prevent some much greater harm (in terms of economic loss, unemployment, mental health, etc., in case we need to return to the lockdown, and in terms of higher number of infections or deaths if we exit the lockdown without an effective contact tracing mechanism). At the moment, though, the UK as well as many other countries are planning to roll out the app on a merely voluntarily basis. They hope that enough people will use it.
The contact tracing app that the UK wants to roll out uses Bluetooth technology to detect and keep records of the other mobile phones your phone has been in close proximity with (see e.g. Ferretti et al. 2020). If you develop COVID-19 symptoms, you ‘inform’ the app, which in turn sends the information to these other mobile phones. People would thus be aware of having been exposed to the virus and could self-isolate.
Some people are concerned about privacy issues involved by the use of this app. As explained by the UK Government, however, data collected will only be used for the purpose of tracing potentially infected people during the pandemic in order to prevent them infecting others, and for understanding the way the virus spreads. Data will be deleted once no longer needed for the management of COVID-19. Each person will be assigned an identification number upon installation (ID), but no names or addresses will be recorded (except for the first part of the postcode, not even the full code). The installation ID will not be linked to any individual identified by name or other personal information. Whatever privacy infringement is involved here, if any at all, it would be very small. And simply framing the issue in terms of ‘human rights’ is not making the infringement any bigger.
Data might end up being used for research purposes, some worry. But this is a strange worry, given that more research on COVID-19 is desperately needed. But even in that case, unless someone wants to assign privacy some quasi-sacred value, the infringement is vastly smaller than the kind of right infringements and harms involved in the alternative scenarios.
We should not forget that we are assessing this scenario against the lockdown scenario, where everyone is confined in their homes, and against an alternative post-lockdown phase where vulnerable people are exposed to a higher risk of contagion without adequate contact tracing. The alleged privacy infringement is vastly smaller than other infringements in the alternative scenarios by the very same hierarchy of values democratic societies use to regulate their everyday life in normal times. In this hierarchy, privacy does not rank higher than right to life, to health, to effective healthcare, to safe employment, to mental health – all things that would be jeopardized without high enough collective immunity after the lockdown. We do not even need to rethink our hierarchy of values. We just need to acknowledge that these are not normal times.
- Vaccination, or pharmacological immunization. Immunity at the collective level is built up by vaccinating as many individuals as possible. The most promising vaccine candidate is the one developed and currently tested in Oxford (by the Jenner Institute and the Oxford Vaccine Group), but other candidates are being researched elsewhere. Like all other vaccines, it will be effective at creating immunity if enough people get vaccinated, though the threshold for herd immunity is at the moment uncertain. Even in this case, we can tolerate a small number of free riders. However, as with other vaccines, the more people get vaccinated, the better. Vaccine uptake might fall below herd immunity at any time (as happened for example in the UK with the MMR and other vaccines in recent years in the UK, where vaccination is not mandatory,). The risk will be high especially after travels resume and non-vaccinated people will be able to move across different communities.
Ethical cost: like all vaccinations, it entails some breach of bodily integrity, and some very small risk of side effects. Vaccines are not authorized until trials show they are safe enough. No vaccines have risks of side effects even remotely close to the risks of the diseases against which they protect, including the risks of death. The same will be true for the COVID-19 vaccine. Again, unless one thinks that bodily integrity is a quasi-sacred value, it is unreasonable to think that the breach of bodily integrity represented by injecting a vaccine through a thin needle or the small risks of vaccine side effects outweigh the harms of the virus and those of compulsory lockdown.
The University of Oxford has partnered with the biopharmaceutical company AstraZeneca to mass produce the vaccine, if the candidate being tested turns out to be safe and effective. Both the University and AstraZeneca have agreed not to profit from the commercialization of the vaccine until the pandemic lasts. The University of Oxford will reinvest any royalty it will receive from the vaccine after the pandemic into medical research and research on pandemic prevention.
When explicitly asked whether the vaccine will be compulsory during a press conference on 4 May, the UK Health Secretary Matt Hancock said that he hopes it will not be necessary, because he is confident enough people will want to use the vaccine. There will also be a question about whom should be prioritized in accessing the vaccine, after healthcare and other essential workers, given the likely initial limited availability of the vaccine (in a forthcoming paper, for instance, Julian Savulescu and I argue, on the basis of previous research, that if the vaccine will turn out to share some of the characteristics of the flu vaccine, there might be a case for prioritizing children in order to build up better collective immunity to protect the elderly). However, a compulsory policy will more likely ensure a higher vaccination uptake, provided it’s properly implemented. The ethical cost of compulsory vaccination is very small. As was the case with privacy, any ethical cost in terms of violation of bodily integrity is vastly smaller than the ethical costs all of us are already paying in terms of limitation of freedom, economic loss, mental health, and so on.
Having presented the benefits and costs of the three measures, it seems that there are strong ethical reasons to make the measures compulsory, in the same way as the lockdown has been compulsory. The ethical reasons are at least three.
First, in all the three cases, the higher the compliance, the more effective the policy at containing the spread of the virus and at minimizing the economic, psychological, and societal costs of this pandemic. Compulsion will likely make compliance higher than alternative policies. It is true that some people do not comply with legal requirements, but when that is the case, they would probably not comply with milder measures either. Recent mandatory vaccination policies, e.g in Italy, for instance, have proven very effective at increasing child vaccination uptake.
Second, in all three cases, not complying with the requirement would be an unfair form of freeriding on the efforts of others. Freeriding on important public goods – as collective immunity is – is not only unethical, but often prohibited by the law, and rightly so. Fairness is valuable not only intrinsically, but also instrumentally. As I have argued in a previous post and in some academic publications, free riding generates the so-called ‘problem of assurance’: people are more likely to comply with certain requirements if they can be relatively certain that other people are doing their fair share, too. The state can provide this reassurance through compulsory measures. We could tolerate some people to freeride on others being in lockdown, from a public health perspective. However, we are not doing it, and rightly so. The same should apply to contact tracing apps and to vaccination.
Third, the infringements involved would be much smaller than the ones we are already accepting in the case of compulsory lockdown. The benefits, though, will be much greater. Not only will we be increasing the chances of successfully containing the spread of the virus, as the lockdown is managing to do, but with increased safety and therefore increased liberty, the economy, social life, and mental wellbeing of people will dramatically improve, contrary to what is happening with the lockdown. Hence, the case for compulsory vaccination is even stronger.
All in all, in all three cases, the benefits of the compulsory measures would outweigh their costs.
Tracing apps for COVID-19 and the COVID-19 vaccine should be compulsory. This would be the most effective and most ethical way to slowly return to normal life. We have all made great sacrifices so far. Whatever we would be required to do from now on, it will likely be a much smaller sacrifice.