We have seen that both a utilitarian and a contractualist approach can justify a moral obligation to be vaccinated (or to vaccinate one’s children) in spite of the negligible individual contribution to herd immunity, at least if non-vaccination constitutes a small additional risk of infecting others that can be prevented at a very small cost to individuals. One might reply, however, that appealing to utilitarianism or to contractualism is problematic because it requires accepting comprehensive moral theories to which many reasonable people do not subscribe. Both utilitarianism and contractualism are often considered very demanding theories. In fact, they would justify an obligation to be vaccinated even if the cost to individuals were not small, as long as the benefits to others of vaccination remain sufficiently large, and some may reject the theories on this basis. Thus, in this section we seek to offer a more ecumenical justification for a moral obligation to be vaccinated, one that renders it unnecessary to appeal to utilitarianism, contractualism, or any other contested, comprehensive moral doctrine. Our justification appeals to a duty of easy rescue applied to collectives that could be endorsed by proponents of a wide range of such doctrines.
Easy rescue, collective obligations, and the individual duty to be vaccinated
A duty of easy rescue is an almost uncontroversial requirement of morality, i.e. a requirement on which most reasonable people would agree, no matter what moral theory or moral view they subscribes to (with the exception, perhaps, of some libertarians). According to the duty of easy rescue, when I could do something that entails a small cost to me and a significant benefit to others, I have a moral duty to do it. Peter Singer provided perhaps the most famous characterization of the duty of easy rescue in his article Famine, affluence, and morality, through the well-known example of the child drowning in a pond. The case is analogous to all the cases in which an agent could easily avoid serious harm to someone else without significant personal costs. According to Singer,
“if I am walking past a shallow pond and see a child drowning in it, I ought to wade in and pull the child out. This will mean getting my clothes muddy, but this is insignificant, while the death of the child would presumably be a very bad thing” (Singer
1972, p. 231).
The duty of easy rescue as expressed by Singer’s example does not presuppose, nor does it support (though it is consistent with), a utilitarian morality. A formulation of the duty of easy rescue has been provided by Tim Scanlon, according to whom, “[i]f we can prevent something very bad from happening to someone by making a slight or even moderate sacrifice, it would be wrong not to do so” (Scanlon
1998, p. 224). Thus, both utilitarians (such as Peter Singer) and contractualists (such as Tim Scanlon) have endorsed a duty of easy rescue. This is not surprising: we have seen above that both a utilitarian and a contractualist ethical approach support a moral obligation to be vaccinated and to reduce the small additional risk of infecting others at least
as long as this comes at a small cost to individuals.
Now, considering the small cost to individuals of vaccination, being vaccinated is comparable to getting one’s clothes muddy in Singer’s example, or to donating one’s litre of water in Parfit’s example (or perhaps, one could plausibly argue, it is even less costly, given its benefits). However, the desirable outcome—namely herd immunity—cannot be realised individually. Herd immunity is a “collective effect”: it requires the contribution of a sufficiently large number of individuals to be realised. Accordingly, if there is a moral duty to realise herd immunity, such moral duty will arguably need to take a collective, rather than an individual form: no individual can realise herd immunity, in the same sense in which no individual can form a circle. Many would take this to imply that no individual can have a duty to realise such immunity, since ‘has a duty to’ implies ‘can’.
As is the case with individuals, one uncontroversial way to justify the collective moral responsibility to realise herd immunity is to say that such responsibility expresses a duty of easy rescue, and more precisely a collective duty of easy rescue: realising herd immunity would be a collective moral obligation if it came at a very small cost to the collective. We can express the principle at the basis of the collective duty of easy rescue in the case of herd immunity as follows:
If a collective could realise herd immunity, then this collective ought to realise herd immunity, provided that the collective cost is small and can distributed in such a way that the cost borne by each individual is also small (so that the collective cost is small under any plausible understanding of “collective” and that the collective duty is consistent with an individual duty of easy rescue)
It is not difficult to see how the principle grounds a collective moral duty to realise herd immunity: the small individual cost of vaccination entails that the cost to the collective of fulfilling its duty is also very small, because it merely consists of the aggregate individual small costs of vaccination, and there is no additional cost that the collective has to bear; at the same time, the benefits of realising herd immunity are very large. Therefore, there is the collective moral duty, grounded in a collective duty of easy rescue, to realise herd immunity. For the sake of consistency with the terminology used in the relevant literature, we will refer to this collective duty also with the terms “collective responsibility” and “collective obligation”: for the purpose of the present discussion, these terms are to be understood as synonymous.
Now, who exactly is the bearer of such responsibility? Is it borne by the collective as a unified agent? Is it somehow distributed across the individuals that comprise the collective? Or both? Here, we need to distinguish two questions: the first is a conceptual question: what does it mean to attribute moral responsibility to a loose collection of individuals—understood as a collection without a decisional procedure and an internal structure—like the individuals who together could realise herd immunity? The second question is instead genuinely ethical: what are the ethical implications of attribution of collective responsibility to loose collections of individuals for attribution of individual responsibility?
The debate on collective responsibility of loose collectives has focussed mainly on the former question, providing different answers (see e.g. Wringe
2016,
2010; Aas
2015; Pinkert
2014; Björnsson
2014; Collins
2013; Schwenkenbecher
2013; Lawford-Smith
2012; Isaacs
2011). To give just a quick overview of the types of concepts involved, the collective responsibility of loose collection has been conceived as a “joint” responsibility or duty (Pinkert
2014; Schwenkenbecher
2013), or as “shared” responsibility (Björnsson
2014), or as a “putative” collective responsibility (Isaacs
2011 and 2014), or as a form of responsibility attributed to a collective agent (Aas
2015), or as a form of responsibility that “supervenes” on individual responsibilities (Wringe
2016). However, we do not need to go into the details of each of these positions here, and therefore we are not going to provide a definition of each of these concepts. Rather, here we want to address directly the second, ethical question about what the attribution of a collective obligation to a loose collection of individuals implies, for an ethical point of view, in terms of attribution of individual responsibility.
We suggest that an ethical analysis of collective responsibility can allow the derivation from the existence of a collective duty of easy rescue of an individual
duty to contribute to the relevant collective outcome, which, in the case of a collective obligation to realise herd immunity, translates into an individual duty to be vaccinated (or to vaccinate one’s children). More in particular, the collective obligation to realise herd immunity implies a duty for each individual to contribute to herd immunity—and therefore to be vaccinated—on the basis of a principle of
fairness in the distribution of the burdens entailed by the collective moral obligation, or, as George Klosko put it, on the basis of a “just distribution of benefits and burdens” (Klosko
2004, p. 34). The burdens consist in people having to pay a visit to the doctor, receive an injection, incur the (very small) risk of side effects of the vaccine and of iatrogenic disease, and, for those who have reservations about the ethics of vaccination, overcome such reservations. A principle of fairness requires that such burdens be distributed fairly across individuals, and therefore that each individual take on herself a fair share of the burdens entailed by the collective obligation by being vaccinated, unless being vaccinated is too burdensome for the individual (we will consider these rare cases in “
High cost vaccinations”). This means that the type of collective responsibility that is entailed by the duty of collective easy rescue can be understood in a merely
distributive sense (Held
1970). We can take the notion of
distributive collective responsibility to indicate that
all members of a sufficiently large group have an individual obligation to
contribute to the realisation of a desirable collective effect, such as herd immunity, and that in virtue of a principle of fairness in the distribution of the burdens entailed by a collective obligation such individual obligation exists in spite of the fact that any individual’s contribution to coverage rates and to the realisation of herd immunity is imperceptible.
Notice that our argument is
not the same as the argument according to which the non-vaccinated would be impermissibly free-riding on herd immunity (Navin
2013, pp. 70–75,
2015, pp. 143–144; van den Hoven
2012; Dawson
2007, pp. 174–176), although the impermissibility of free-riding is an implication of our argument. To use once again George Klosko’s words, the problem is not so much that “[i]ndividuals who benefit from the cooperative efforts of others have obligations to cooperate as well” (Klosko
2004, p. 34), and therefore that individuals would violate a requirement of reciprocity. Rather, the unfairness implied by the decision not to contribute to herd immunity is, at a more fundamental level, the unfairness of failing to make one’s contribution to fulfilling a collective obligation that is ascribed to the collective of which we are part, i.e. the collective that can realise herd immunity from any disease. The conceptual distinction between the two types of unfairness also has significant practical implications. For example, suppose that in a given community there is herd immunity against measles but not against HPV. In such a context, the unfairness of free-riding on herd immunity implies that a person has a moral obligation to be vaccinated against measles, but not against HPV, given that in the case of HPV there is no herd immunity on which this person can free-ride. However, our argument based on the unfairness of failing to make one’s contribution to a collective good like herd immunity implies that a person has a moral obligation to be vaccinated against both, given that herd immunity against both measles and HPV is a valuable societal goal that that community has a moral obligation to realise or to preserve. Or consider the following:
2 sometimes, in polio outbreaks, healthy people who have been already vaccinated with the inactivated polio virus (IPV) are called to take the oral polio vaccine (OPV) as well in order to disseminate it in the benefit of the vulnerable: the attenuated vaccine virus in the OPV replicates in the intestine and is then excreted, which allows it to spread in the immediate community (WHO
2017). Thus, those taking OPV do not need vaccination for themselves at all if they have already been vaccinated with IPV; they only take OPV in order to benefit their community. Once again, while an argument based on the unfairness of free-riding would not imply that these healthy people have a moral obligation to take the OPV—because, being already vaccinated, they would not “benefit” from herd immunity (except in the broad sense in which everyone benefits from living in a society without polio)—our argument based on a fairness based obligation to make a contribution to a public good does imply that they have such a moral obligation, though it may be a weaker one to the extent that the benefit of the vaccination is smaller in such cases.
Also, our argument can be taken to have some implications for the issue of whether, in case of an infectious disease outbreak, those who refused vaccination for themselves or for their children for non medical reasons should be held accountable, or morally responsible, for the whole outbreak, i.e. even if they have not directly infected anyone or only infected a few people. The answer to this question depends on whether the notion of ‘accountability’ or ‘moral responsibility’ we are using presupposes causal responsibility. If we think that accountability or moral responsibility presuppose causal responsibility, i.e., that someone can be accountable, or morally responsible, for outcome x only if they are to some extent causally responsible for x, then of course a non-vaccinated individual is not accountable for the outbreak unless she infects so many people that the number of people infected by her is so great that it constitutes by itself an outbreak (which is unlikely), or unless the chain of infections that spread among the population can all be traced back to her as the one who started the contagion. However, if we think that accountability or moral responsibility do not presuppose causal responsibility, i.e. that someone can be held accountable, or morally responsible, for x even if she does not play any causal role in bringing about x, then our argument does imply that she is accountable, or morally responsible, for the outbreak, because she failed to fulfil her moral duty to make her fair contribution to the prevention of the contagion, regardless of whether her contribution would have made a difference. In the same way we can say, for example, that I am accountable or morally responsible for global warming if I engage in practices that involve unnecessary release of carbon emissions, even if the quantity of my carbon emissions does not make any difference to whether global warming occurs.
Let us address two possible objections to our arguments.
The first objection is that individuals have a right to bodily integrity, which includes a right not to have any external substance injected in their body. This right to bodily integrity could be thought to outweigh any moral obligation to be vaccinated. In this view, making one’s fair contribution to herd immunity would be morally different from making one’s contribution to any other collective or public good that does not involve the violation of individual rights to bodily integrity. A right to bodily integrity can be understood in either of two senses: either as a right not to undergo any invasive medical procedure without one’s consent or as a right not to have external substances introduced in one’s body without one’s consent. However, on either of these two understandings, this objection misconstrues the nature of the right to bodily integrity. The right to bodily integrity is normally understood—with reference to Hohfeld’s analysis of rights—as a claim-right held against others. It is a right that others not interfere with one’s body in certain ways, and perhaps also that they provide one with certain forms of assistance required for the minimal functioning of one’s body. Understood thus, the right to bodily integrity may imply that others are under a pro-tanto duty not to impose vaccination on an individual without their consent. However, the claim-right to bodily integrity held against others does not imply that one is under no moral duty to vaccinate oneself: having a claim right to non-x (e.g., to non-vaccination) is quite consistent with having a moral duty to x. In other words, if you have a right to bodily integrity, the right will entail that other people are under a duty not to force the vaccine on you. But it does not imply anything about what you morally ought to do. Thus, in principle, an appeal to the right to bodily integrity does not constitute a reason against the existence of a moral duty to be vaccinated. Of course, in practice, when vaccination is imposed by parents or medical professionals on children, children may possess a right to bodily integrity that is infringed by this imposition. However, it should be noted that, if the child is competent to consent, their valid consent could be obtained prior to vaccination, and this would prevent the vaccination from infringing the right to bodily integrity. In that case, the parents could still have an obligation to vaccinate their child, conditional on the child consenting to this. If consent cannot be obtained, then whether the pro-tanto duty not to impose vaccination that derives from a right to bodily integrity represents an all-things-considered duty not to vaccinate a child without their consent will depend on (I) how weighty the right is relative to the goods that can be achieved by forcible vaccination and the values that can be promoted (e.g., fairness), and (II) whether imposing vaccination involves bodily interference of the sort that infringes the right to bodily integrity, which remains to be established. Thus, parents might still be under a moral obligation to vaccinate their children even if this entails some violation of their right to bodily autonomy. In any case, even if the right to bodily autonomy is very weighty, it does not represent an argument against a duty to be vaccinated or to vaccinate one’s children, but only an argument against the enforcement of such duty.
The second objection is that, as Pinkert put it in his criticism of Wringe’s distributive notion of collective responsibility, moral obligations to
contribute to a collective outcome, without any further qualification, “imply that you ought to contribute even if not enough others contribute as well”; however, Pinkert continues, “it is implausible that one ought to perform such pointless actions” (Pinkert
2014, p. 189). Admittedly, our distributive notion of collective responsibility grounded in a principle of fairness implies that any individual has a moral obligation to contribute to herd immunity regardless of whether other members of the collective do their part, and therefore even if her contribution is pointless. Requiring everybody to be vaccinated regardless of how many people around them are vaccinated might sound implausible because a principle of utility conflicts with a principle of fairness: fairness would require to choose an option, namely vaccination, that has no utility net, and actually has a (small) cost for the individual. Our reply to this objection is twofold.
First, even if the act of vaccination is “pointless” as a contribution to herd immunity, it is not pointless on a utilitarian assessment. As we saw in the section on utilitarianism, it is simply not true that the utility net of any individual vaccination would be zero, given that any non-vaccinated person has a small chance of infecting others. Therefore, in this perspective, each individual vaccination is not pointless: vaccination might not be morally obligatory as a “contribution” to herd immunity, but it would still be morally required in order to minimize the risk of infecting others. In this sense, vaccination is different from the contribution to any other outcome that requires the imperceptible contribution of each of a large number of individuals, such as filling the water cart in Parfit’s example. There is a small chance that any vaccination would make a difference not qua “contribution” to herd immunity but in terms of infection prevention. Therefore, fairness does not conflict with expected utility: they both imply that individuals ought to be vaccinated. Moreover, another consideration in support of the idea that individual vaccination has positive expected utility and therefore that the moral obligation to be vaccinated can be supported on utilitarian grounds is that community efforts to cultivate herd immunity are often projects only of domestic politics; however, the fact that people in the globalized world travel at an unprecedented rate implies that exposure to vaccine-preventable diseases is only a plane trip away. Therefore, individual vaccination provides expected net utility given that, even when there is herd immunity, there still is vulnerability for individuals in the global context.
Second, fairness would still demand that any individual contributed to herd immunity even if the contribution, qua contribution to herd immunity, would be pointless. There are two possible scenarios here: either the individual contribution, qua contribution to herd immunity, is pointless and herd immunity exists, or the individual contribution, qua contribution to herd immunity, is pointless and herd immunity does not exist. In the first case, every individual would be under a moral obligation to be vaccinated to ensure that those who are vaccinated are not unfairly burdened, even if any contribution, qua contribution to herd immunity, is pointless. Compare the case of vaccination with the case of taxation: society would probably be able to tolerate a certain number of free-riders, who enjoy but do not contribute through their taxes to the maintainance of certain public goods; actually, overall utility would probably be maximized if a few individuals were allowed not to pay taxes, because, without their money, certain public goods, e.g., national defense or a good health care system, could still be guaranteed, and they would get to save some money. However, we are not inclined to tolerate tax evasion regardless of the impact that tax evasion has on the capacity of a state to provide certain public goods, because, at least where the vast majority of individuals do pay their own taxes, we expect all individuals to make their fair contribution: if I am under a moral or a legal obligation to pay my fair amount of taxes, we expect that everybody else is or should be, even if this would not maximize utility. The same considerations can be applied to the case of individuals’ fair contribution to the public good of herd immunity.
Consider now the second possible scenario—where any contribution qua contribution is pointless and herd immunity does not exist. Admittedly, in this case it is more difficult to argue that everybody has a fairness based moral obligation to be vaccinated. As Navin put it, “I have a duty of fairness to contribute to herd immunity only if most other members of my community act on the basis of this duty. If they do not, then herd immunity will not exist, and, therefore, I will not have a duty of fairness to contribute to it” (Navin
2015, p. 180). There are two possible replies here, the first of which is probably stronger than the second.
The first reply is that, as we have said above, in such cases considerations of fairness would be replaced by welfarist considerations or considerations of general beneficence: especially where vaccination rate is low, any non-vaccinated individual would significantly increase the risk that others be infected, so any individual would still have a duty to be vaccinated in order to minimize the risk of harming others.
Second, it is not so obvious that where too few people contribute to a public good and the public good is therefore not realised, there is no duty of fairness to nonetheless make one’s contribution. One could plausibly argue that even if most people around me did not pay their taxes, I would still have a moral duty to pay my fair share, on condition that what is considered fair is not determined by the fact that others do not make their fair contribution—for example, on condition that I am not requested to pay more taxes to compensate for the fact that many people around me do not pay theirs. This condition however does not apply to the case of vaccination, given that there is nothing more that any individual could do to contribute to herd immunity than to be vaccinated (or to vaccinate her children). Therefore, one could plausibly argue that I have a duty of fairness to be vaccinated even if few people around me are vaccinated in the same way as I have a duty of fairness to pay my fair (but no more than my fair) share of taxes even if many people around me do not. Admittedly, though, if such a moral duty existed, it would be quite a weak duty, and indeed it would be the weaker, the higher the number of people around me who fail to make their contribution. Also, the intuition that there is even a weak moral duty to make one’s contribution in such circumstances is probably not widely shared.
High cost vaccinations
Mark Navin holds that one’s contribution to herd immunity is fair when the cost is not only roughly the same for everyone, but also “reasonable”, i.e. not overdemanding (Navin
2015, p. 142). This restriction seems appropriate in light of a duty of (individual) easy rescue and to the extent that, generally speaking, the cost individuals
normally have to bear for being vaccinated is small.
But what kind of cost can be considered large enough to outweigh the moral duty to be vaccinated, i.e. to make vaccination supererogatory? One might suppose that it would make a difference whether an individual has health insurance (or is anyway covered by a national healthcare system). Without health insurance, any possible side effect of vaccination could potentially become a great burden. However, we need to consider that, as we said above, side effects of vaccines are very rare, and the most common of these rare side effects are not serious. Thus, the risks of vaccination for the uninsured remain very small, and indeed, though we cannot argue for this point here, we believe they are so small that they are insufficient to undermine the moral obligation to be vaccinated.
Admittedly, though, the cost of vaccination is not always small. Some people are too young or too old to be vaccinated, some people are allergic to vaccines, some people are immunosuppressed. Vaccination would be unsafe for these individuals, and therefore the cost to them of being vaccinated would not be small. Fortunately, our arguments do not imply that individuals have an obligation to undergo high cost vaccinations. Indeed, our requirement that the costs of fulfilling the collective duty to realise herd immunity must be distributed fairly could be invoked in support of the view that individuals need not undergo high cost vaccinations. Such high cost vaccinations would be unfair, since these individuals would be required to bear a greater share of the costs of realising herd immunity than others. As noted above, fairness requires that individuals bear similar costs.
Besides, our formulation of the collective duty of easy rescue requires that the costs for all individuals be small. This means that those for whom vaccination would represent a high cost will have to be excluded from the collective that is subject to the collective obligation, in order for the collective to fall under the duty in the first place.
It might be the case that some vaccinations entail high costs of a psychological nature, for example when parents have religion based objections to vaccines that use materials from cell lines derived from aborted foetuses or experience severe psychological distress worrying about potential vaccine complications for their vaccinated child. Perhaps in such cases fairness-based reasons are not strong enough to justify the existence of a duty to vaccinate, given that one might object that vaccinating in such cases is supererogatory. Now, it is not clear whether the moral significance of the psychological costs involved outweighs the strength of fairness-based reasons. But let’s assume, for the sake of argument, that it does. Even if that is the case, the problem is not so much with the fairness demand itself, but with what is demanded, namely vaccination. Exactly as is the case with pacifists’ exemptions from military duties, fairness would still demand that vaccine refusers make some alternative contribution to public health that could be considered equivalent to one’s contribution to herd immunity, as has recently been argued (Giubilini et al.
2017). The important point, for the purposes of the present discussion, is that individuals cannot simply escape a basic fairness demand to contribute to herd immunity; assuming for the sake of argument that for certain people for whom vaccination would entail a high psychological cost such demand of fairness does not translate into a moral obligation to vaccinate, fairness would still demand that these people make up, or compensate for their failure to vaccinate.