Vaccine mandates and bioethics
Just got back from a Rock Ethics Institute talk on vaccines. Arthur Caplan was arguing in favor of mandating influenza vaccination for hospital healthcare workers, among others.
Prof. Caplan is a good speaker, and covered the facts, context and motivation well. But it was a rather disappointing talk, and symptomatic of issues I've generally found with professional bioethics. Dr. Caplan's primary motivation seemed to be to change the world to match his personal preference for mandatory vaccination, rather than to study the actual problem and develop a practical decision or decision-process. He was pleasantly jovial with challenges, which kept things comfortable, but seemed to implicitly deny that this is a baby-splitting problem.
The Immunization policy problem is relatively simple to frame. First, there's some risk of getting sick, and there are some costs associated with that. There's also an opportunity to use a vaccine protocol, which incurs direct costs from the protocol, and additional chances for extra costs from side effects. There's usually uncertainty in both sets of risks. There's also heterogeneity among people -- the risks are different for different people. And there are externalities -- people's choices alter the risk profiles for those around them. People can choose to pay the costs of immunization if and when they want to, and institutions can choose to enforce additional costs anyplace in the process to favor any outcome they wish, including imposing additional costs on themselves.
There's allot of argument that goes on around the science of immunization concerning estimates of the risks and merits of immunizations (and certainly, there remains plenty of uncertainty around influenza). These are where the practical conversation needs to take place, for any policy -- you need to know the numbers. But for the moment, let's assume an ideal situation where we know everything we want to know. Then the choice of imposing a mandate becomes one of "Can we justify imposing additional costs X with chances Y on part of our comminity to gain benefits Z for our community as a whole?". And the practical question is how do we draw that line. When we know were we draw the line, the solution will be self-evident for which-ever disease and situation that confronts us.
Back to Prof. Caplan. The good professor did acknowledge that the mandates aren't necessarily right in all cases. But he refused to give any kind of criteria or number, saying every situation has to be handled on a case-by-case basis. In the ivory tower, I'm happy to agree with that -- the world's complicated and drawing hasty generalizations can be dangerous. However, in the practical world, our institutions have demonstrated a deep inability to balance complicated trade-offs. Nor does the legal system display dexterity in such matters.
Philosophy generally, and bioethics in the specific context, is useful for helping us develop frameworks within which we can find good decisions to hard problems based on our personal beliefs and cultural norms. A good way to do this is to walk through a proposed process and set up some straw men. And some people have tried. But doing this makes enemies -- it gives critics something with which to attack. That's what makes the field hard. When bioethicists punt on the issue, or choose advocacy over dialogue, I feel like they are abandoning us right back where we started and confusing the very issues they should be helping us manage.