Alberto Giubilini

Public health policies often require individuals to make personal sacrifices for the sake of protecting other individuals or the community at large. Such requirements can be more or less demanding for individuals. This paper examines the implications of demandingness for public health ethics and policy. It focuses on three possible public health policies that pose requirements that are differently demanding: vaccination policies, policy to contain antimicrobial resistance, and quarantine and isolation policies. Assuming the validity of the ‘demandingness objection’ in ethics, we argue that states should try to pose requirements that individuals would have an independent moral obligation to fulfil, and therefore that are not too demanding. In such cases, coercive measures are ethically justified, especially if the interventions also entail some benefits to the individuals; this is, for example, the case of vaccination policies. When public health policies need to require individuals to do something that is too demanding to constitute an independent moral obligation, states have an obligation to either provide incentives to give individuals non-moral reasons to fulfil a certain requirement – as in the case of policies that limit antibiotic prescriptions – or to compensate individuals for being forced to do something that is too demanding to constitute an independent moral obligation – as in the case of quarantine and isolation policies.

We argue that individuals who have access to vaccines and for whom vaccination is not medically contraindicated have a moral obligation to contribute to the realisation of herd immunity by being vaccinated. Contrary to what some have claimed, we argue that this individual moral obligation exists in spite of the fact that each individual vaccination does not significantly affect vaccination coverage rates and therefore does not significantly contribute to herd immunity. Establishing the existence of a moral obligation to be vaccinated despite the negligible contribution each vaccination can make to the realisation of herd immunity is important because such moral obligation would strengthen the justification for coercive vaccination policies. We show that two types of arguments—namely a utilitarian argument based on Parfit’s Principle of Group Beneficence and a contractualist argument—can ground an individual moral obligation to be vaccinated, in spite of the imperceptible contribution that any single vaccination makes to vaccine coverage rates. We add a further argument for a moral obligation to be vaccinated that does not require embracing problematic comprehensive moral theories such as utilitarianism or contractualism. The argument is based on a “duty of easy rescue” applied to collectives, which grounds a collective moral obligation to realise herd immunity, and on a principle of fairness in the distribution of the burdens that must be borne to realise herd immunity.

Strategies to increase influenza vaccination rates have typically targeted healthcare professionals (HCPs) and individuals in various high-risk groups such as the elderly. We argue that they should (instead or as well) focus on increasing vaccination rates in children. Because children suffer higher influenza incidence rates than any other demographic group, and are major drivers of seasonal influenza epidemics, we argue that influenza vaccination strategies that serve to increase uptake rates in children are likely to be more effective in reducing influenza-related morbidity and mortality than those targeting HCPs or the elderly. This is true even though influenza-related morbidity and mortality amongst children are low, except in the very young. Further, we argue that there are no decisive reasons to suppose that children-focused strategies are less ethically acceptable than elderly or HCP-focused strategies.

We describe a form of moral artificial intelligence that could be used to improve human moral decision-making. We call it the “artificial moral advisor”. The AMA would implement a quasi-relativistic version of the “ideal observer” famously described by Roderick Firth. We describe similarities and differences between the AMA and Firth’s ideal observer. Like Firth’s ideal observer, the AMA is disinterested, dispassionate, and consistent in its judgments. Unlike Firth’s observer, the AMA is non-absolutist, because it would take into account the human agent’s own principles and values. We argue that the AMA would respect and indeed enhance individuals’ moral autonomy, help individuals achieve wide and a narrow reflective equilibrium, make up for the limitations of human moral psychology in a way that takes conservatives’ objections to human bioenhancement seriously, and implement the positive functions of intuitions and emotions in human morality without their downsides, such as biases and prejudices.

We address the issue of whether, why and under what conditions, quarantine and isolation are morally justified, with a particular focus on measures implemented in the developing world. We argue that the benefits of quarantine and isolation justify some level of coercion or compulsion by the state, but that the state should be able to provide the strongest justification possible for implementing such measures. While a constrained form of consequentialism might provide a justification for such public health interventions, we argue that a stronger justification is provided by a principle of State Enforced Easy Rescue: a state may permissibly compel individuals to engage in activities that entail a small cost to them but a large benefit to others, because individuals have a moral duty of easy rescue to engage in those activities. The principle of State Enforced Easy Rescue gives rise to an Obligation Enforcement Requirement: the state should create the conditions such that submitting to coercive or compulsive measures becomes a fundamental moral duty of individuals, i.e. a duty of easy rescue. When the state can create such conditions, it has the strongest justification possible for implementing coercive or compulsive measures, because individuals have a moral duty to temporarily relinquish the rights that such measures would infringe. Our argument has significant implications for how public health emergencies in the developing world should be tackled. Where isolation and quarantine measures are necessary, states or the international community have a moral obligation to provide certain benefits to those quarantined or isolated.

Antibiotic use in animal farming is one of the main drivers of antibiotic resistance both in animals and in humans. In this paper we propose that one feasible and fair way to address this problem is to tax animal products obtained with the use of antibiotics. We argue that such tax is supported both by deontological arguments, which are based on the duty individuals have to compensate society for the antibiotic resistance to which they are contributing through consumption of animal products obtained with the use of antibiotics; and a cost-benefit analysis of taxing such animal products and of using revenue from the tax to fund alternatives to use of antibiotics in animal farming. Finally, we argue that such a tax would be fair because individuals who consume animal products obtained with the use of antibiotics can be held morally responsible, i.e. blameworthy, for their contribution to antibiotic resistance, in spite of the fact that each individual contribution is imperceptible.

A lot of the language we use to refer to AI, including in healthcare, uses terminology that originally and literally applies to humans and human relationships. Such terminology includes both non-evaluative terms, like “learning,” “memory,” or “intelligence,” and evaluative terms, like “trust” or “responsibility.” In this article I focus on the latter type and the way it is applied specifically to the case of medical AI. Focusing on the discussion of “responsibility gaps” that, according to some, AI generates, I will suggest that such terminology is revealing of the nature of healthcare professional obligations and responsibility prior to and independently of the assessment of the use of AI tools in healthcare. The point I make is generalizable to AI as used and discussed more broadly: the language used to refer to AI often tells more about humans and human relationships than about AI itself and our relationship with it. In healthcare, whatever else AI will allow us to do, it can prompt us to reflect more thoroughly on professional responsibility and professional obligations.

This first chapter introduces some ethically relevant concepts that illustrate why we need an “ethics of vaccination”, such as “herd immunity”, “public good”, and “vaccine refusal”. It argues that the choice whether to vaccinate oneself or one’s children is by its own nature an “ethical” choice: it requires individuals to act not only or even not primarily to promote their self-interest but also or even primarily to contribute to an important public good like herd immunity. Besides, since herd immunity is an important public good, ethical questions arise also at the level of state action with regard to the obligations to implement vaccination policies, if necessary coercive ones, that allow to realize herd immunity.

The principle of least restrictive alternative (PLRA) states that policymakers have significant reason to implement the policy that is effective in achieving a certain result and that is least restrictive of individual liberty or autonomy. This chapter provides a ranking of vaccination policies, or an intervention ladder, on the basis of the PLRA, assessing the level of coercion of each type of policy. The ranking of vaccination policies I suggest, in order of increasing restrictiveness or coerciveness, is as follows: persuasion, nudging, financial incentives, disincentives (including withholding of financial benefits, taxation, and mandatory vaccination), and outright compulsion. Each type of policy suggestion is presented with a discussion of the level of restrictiveness or coerciveness involved and the potential effectiveness.

This chapter discusses the relation between collective, individual, and institutional responsibilities with regard to the realization of herd immunity from certain infectious diseases. The argument is put forth that there is a form of collective moral obligation to realize herd immunity, that there is a principle of fairness in the distribution of the burdens of collective obligations, and that such principle entails that each of us has the individual moral responsibility to make their fair contribution to herd immunity through vaccination. These individual moral obligations, in turn, entail a further individual obligation to support policies aimed at realizing herd immunity. The chapter concludes with a suggestion that the individual moral obligations to support such policies generate an institutional responsibility to implement them.

This chapter presents an argument for compulsory vaccination and against allowing non-medical vaccine exemptions. The argument is based on the idea that the proper aim of vaccination policies should be not only herd immunity but also a fair distribution of the burdens entailed by its realization. I argue that a fairness requirement need not and should not be constrained by a principle of liberty and a principle of least restrictive alternative. Indeed, I argue how compulsory vaccination is more successful than other types of vaccination policies at satisfying the principles of fairness, least restrictive alternative, and maximizing expected utility, once these principles have been properly understood.

This article suggests that the concept of global health – and to an extent the field that it designates ‐ is problematic in various ways. Within public health, the concept of the ‘public’ has been widely investigated. However, “global health” has been introduced in academic, policy, and public discussion with comparably lower level of conceptual, philosophical scrutiny. Thus, while public health ethics addresses the ethical and political issues that the different meanings of ‘public’ allow to identify, global health ethics tends to leave ethical and political issues raised by the concept of ‘global health’ implicit and insufficiently analysed. I will briefly present the debate around the ‘public’ in public health, describing some of the ethical and political questions that might arise, depending on what ‘public’ is taken to mean. I will then use this discussion as a conceptual map for an analogous analysis of the concept of ‘global’ in global health. I will discuss what dimensions ‘global’ adds to the concept of ‘public’. In the second part of the article, I will briefly introduce the philosophical debate on the concept of health, before suggesting that its cultural sensitivity makes it ill‐suited to be qualified as ‘global’. All in all, this article wants to bring to light the ethical implications that the terminology of ‘global health’ introduces in academic research and public policy that goes under that heading, as a first step towards better defining the ethical contours of this discipline.

Conscience is typically invoked in healthcare to defend a right to conscientious objection, that is, the refusal by healthcare professionals to perform certain activities in the name of personal moral or religious views. On this approach, freedom of conscience should be respected when the individual is operating in a professional capacity. Others would argue, however, that a conscientious professional is one who can set aside one’s own moral or religious views when they conflict with professional obligations. The debate on conscientious objection has by and large crystallised around these two positions, with compromise positions aiming at striking a balance between the two, for instance, by arguing for referral requirements by objecting healthcare professionals.In this article, I suggest that the debate on conscientious objection in healthcare could benefit from being reframed as a problem around demandingness rather than one about freedom of conscience and moral integrity. Being a professional, and a healthcare professional specifically, typically requires taking on additional burdens compared with non-professionals. For instance, healthcare professionals are expected to take on themselves higher risks than the rest of the population. However, it is also widely agreed that there are limits to the additional risks and burdens that healthcare professionals should be expected to take on themselves. Thus, a question worth exploring is whether, among the extra burdens that healthcare professionals should be expected to take on themselves as a matter of professional obligation, there is the burden of acting against one’s own conscience.

How should we regulate genome editing in the face of persistent substantive disagreement about the moral status of this technology and its applications? In this paper, we aim to contribute to resolving this question. We first present two diametrically opposed possible approaches to the regulation of genome editing. A first approach, which we refer to as “elitist,” is inspired by Joshua Greene’s work in moral psychology. It aims to derive at an abstract theoretical level what preferences people would have if they were committed to implementing public policies regulating genome editing in a context of ethical pluralism. The second approach, which we refer to as the democratic approach, defended by Francoise Baylis and Sheila Jasanoff et al., emphasizes the importance of including the public’s expressed attitudes in the regulation of genome editing. After pointing out a serious shortcoming with each of these approaches, we propose our own favored approach—the “enlightened democracy” approach—which attempts to combine the strengths of the elitist and democratic approaches while avoiding their weaknesses.

Some authors argue that it is permissible for clinicians to conscientiously provide abortion services because clinicians are already allowed to conscientiously refuse to provide certain services. Call this the symmetry thesis. We argue that on either of the two main understandings of the aim of the medical profession—what we will call “pathocentric” and “interest‐centric” views—conscientious refusal and conscientious provision are mutually exclusive. On pathocentric views, refusing to provide a service that takes away from a patient's health is professionally justified because there are compelling reasons, based on professional standards, to refuse to provide that service (e.g., it does not heal, and it is contrary to the goals of medicine). However, providing that same service is not professionally justified when providing that service would be contrary to the goals of medicine. Likewise, the thesis turns out false on interest‐centric views. Refusing to provide a service is not professionally justified when that service helps the patient fulfill her autonomous preferences because there are compelling reasons, based on professional standards, to provide that service (e.g., it helps her achieve her autonomous preferences, and it would be contrary to the goals of medicine to deny her that service). However, refusing to provide that same service is not professionally justified when refusing to provide that service would be contrary to the goals of medicine. As a result, on either of the two most plausible views on the goals of medicine, the symmetry thesis turns out false.

We discuss the relationship between expertise, expert authority, and trust in the case of vaccine research and policy, with a particular focus on COVID-19 vaccines. We argue that expert authority is not merely an epistemic notion, but entails being trusted by the relevant public and is valuable if it is accompanied by expert trustworthiness. Trustworthiness requires, among other things, being transparent, acknowledging uncertainty and expert disagreement (e.g., around vaccines’ effectiveness and safety), being willing to revise views in response to new evidence, and being clear about the values that underpin expert recommendations. We explore how failure to acknowledge expert disagreement and uncertainty can undermine trust in vaccination and public health experts, using expert recommendations around COVID-19 vaccines as a case study.

The debate around lockdowns as a response to the recent pandemic is typically framed in terms of a tension between freedom and health. However, on some views, protection of health or reduction of virus‐related risks can also contribute to freedom. Therefore, there might be no tension between freedom and health in public health restrictions. I argue that such views fail to appreciate the different understandings of freedom that are involved in the trade‐off between freedom and health. Grasping these distinctions would allow to appreciate why different people give more weight to different aspects of limitations of freedom, including whether certain options are made simply risky or impossible, whether limitations of freedom are posed intentionally or happen accidentally, whether risks are beyond a threshold of acceptability, and who gets to decide that. I provide a conceptual analysis of the relationship between different types of freedom, public health policies, viruses and diseases. As I argue, identifying what freedom‐based reasons count for and against different types of public health restrictions requires distinguishing between viruses and diseases, between lockdowns and other types of restrictive policies, and between risks posed by viruses and threats of penalties involved by restrictive policies.

I argue that appeals to conscience do not constitute reasons for granting healthcare professionals exemptions from providing services they consider immoral (e.g. abortion). My argument is based on a comparison between a type of objection that many people think should be granted, i.e. to abortion, and one that most people think should not be granted, i.e. to antibiotics. I argue that there is no principled reason in favour of conscientious objection qua conscientious that allows to treat these two cases differently. Therefore, I conclude that there is no principled reason for granting conscientious objection qua conscientious in healthcare. What matters for the purpose of justifying exemptions is not whether an objection is ‘conscientious’, but whether it is based on the principles and values informing the profession. I provide examples of acceptable forms of objection in healthcare.

Conscientious objection in healthcare is often granted by many legislations regulating morally controversial medical procedures, such as abortion or medical assistance in dying. However, there is virtually no protection of positive claims of conscience, that is, of requests by healthcare professionals to provide certain services that they conscientiously believe ought to be provided, but that are ruled out by institutional policies. Positive claims of conscience have received comparatively little attention in academic debates. Some think that negative and positive claims of conscience deserve equal protection in terms of measures that institutions ought to take to accommodate them. However, in this issue of The Journal of Clinical Ethics (JCE), Abram Brummett argues against this symmetry thesis. He suggests that the relevant distinction is not between negative and positive claims of conscience, but between negative and positive rights of conscience. He argues that conscientious refusals and positive claims of conscience are both already protected as negative rights of conscience, but that this does not require institutions to accommodate positive claims of conscience. In this article I will argue that both Brummett and the authors he criticizes share a wrong view about the existence of conscience rights in healthcare. I will argue that there is no right to conscientious objection in healthcare, whether positive or negative. Thus, contra Brummett, I argue that the question whether such rights are positive or negative is as irrelevant as the question whether the claims of conscience are positive or negative.

In this paper we analyse the notion of collective responsibility and the criteria for its application to different types of groups. We argue that most of the ways in which the notion of collective responsibility has been attributed to different types of groups actually refer to a form of responsibility that is not genuinely collective, but that boils down to some form of individual responsibility. We identify an intrinsically collective kind of responsibility and argue that it can be attributed to only one kind of group. We begin by setting two necessary and sufficient conditions for attribution of genuinely collective moral responsibility, asking whether these two conditions are satisfied in the case of different types of groups that have been taken to be bearers of moral responsibility: organized groups, groups with internal bonds of solidarity, groups that program individuals to act in a certain way, random collections of individuals, and individuals engaging in joint actions. Contrary to what various authors have maintained, we argue that only in the case of individuals engaging in joint actions is attribution of a genuinely collective form of moral responsibility warranted, i.e. only groups engaging in joint action satisfy the two conditions for attribution of genuinely collective moral responsibility.

In a paper recently published in this journal, Navin and Largent argue in favour of a type of policy to regulate non-medical exemptions from childhood vaccination which they call ‘Inconvenience’. This policy makes it burdensome for parents to obtain an exemption to child vaccination, for example, by requiring parents to attend immunization education sessions and to complete an application form to receive a waiver. Navin and Largent argue that this policy is preferable to ‘Eliminationism’, i.e. to policies that do not allow non-medical exemptions, because Inconvenience has been shown to maintain exemption rates low while not harming parents by forcing them to do something that goes against their beliefs. We argue that it is at least doubtful that Inconvenience is ethically preferable to Eliminationism: while the latter disregards the value of liberty, Inconvenience disregards the value of fairness in the distribution of the burdens entailed by the preservation of a public good like herd immunity. We propose a variant of Inconvenience, which we call ‘Contribution’, which we think is preferable to the versions of Inconvenience discussed by Navin and Largent in that it successfully strikes a balance between the values of parents’ liberty, fairness and expected utility.

Vaccine refusal occurs for a variety of reasons. In this article we examine vaccine refusals that are made on conscientious grounds; that is, for religious, moral, or philosophical reasons. We focus on two questions: first, whether people should be entitled to conscientiously object to vaccination against contagious diseases ; second, if so, to what constraints or requirements should conscientious objection to vaccination be subject. To address these questions, we consider an analogy between CO to vaccination and CO to military service. We argue that conscientious objectors to vaccination should make an appropriate contribution to society in lieu of being vaccinated. The contribution to be made will depend on the severity of the relevant disease, its morbidity, and also the likelihood that vaccine refusal will lead to harm. In particular, the contribution required will depend on whether the rate of CO in a given population threatens herd immunity to the disease in question: for severe or highly contagious diseases, if the population rate of CO becomes high enough to threaten herd immunity, the requirements for CO could become so onerous that CO, though in principle permissible, would be de facto impermissible.

The chapter presents an overview of the major lines of debate in the ethics of human enhancement. While permissive and restrictive positions on enhancement can be contrasted, the conservative camp (which is the focus of the book as a whole) is a specific subset of the latter. Although the restrictive but non-conservative position is outlined, most of the chapter is devoted to the themes and arguments of the conservative camp. To give a well-rounded account of the conservative position, the chapter begins with connections to the tradition of social conservatism, before moving to prominent themes in the conservative opposition to human enhancement. These include the charge of ‘playing God’, the appeal to intuition or emotion, human dignity, and the connection to eugenics. The final section of the chapter surveys some of the recent work in moral psychology that the human enhancement debate increasingly draws upon.

Cameron et al ’s1 ethical considerations about the ‘Dualism of Values’ in pandemic response emphasise the need to strike a fair balance between the interests of the less vulnerable to COVID-19 and the interests of the more vulnerable. Those considerations are at the basis of ethical defences of focused protection strategies.2 One example is the proposal put forward in the Great Barrington Declaration. It presented focused protection strategies as more ethical alternatives to lockdowns which would prevent lockdowns’ ‘irreparable damage, with the underprivileged disproportionately harmed’.3 Here we want to suggest that a version of Cameron et al ’s analysis can be applied to the case of vaccines to support a focused protection vaccination strategy. At this stage, we should limit vaccination to the vulnerable and not target children in COVID-19 vaccination strategies. We argue that, given the current state of knowledge about COVID-19, immunity and vaccines, it would be wrong to pose the costs and risks of vaccines on children for three reasons. First, they are unlikely to benefit from COVID-19 vaccination …

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Seven COVID-19 vaccines are now being distributed and administered around the world (figure correct at the time of submission), with more on the horizon. It is widely accepted that healthcare workers should have high priority. However, questions have been raised about what we ought to do if members of priority groups refuse vaccination. Using the case of influenza vaccination as a comparison, we know that coercive approaches to vaccination uptake effectively increase vaccination rates among healthcare workers and reduce patient morbidity if properly implemented. Using the principle of least restrictive alternative, we have developed an intervention ladder for COVID-19 vaccination policies among healthcare workers. We argue that healthcare workers refusing vaccination without a medical reason should be temporarily redeployed and, if their refusal persists after the redeployment period, eventually suspended, in order to reduce the risk to their colleagues and patients. This ‘conditional’ policy is a compromise between entirely voluntary or entirely mandatory policies for healthcare workers, and is consistent with healthcare workers’ established professional, legal and ethical obligations to their patients and to society at large.