The gratifying news about advances in the development of a coronavirus vaccine by the pharmaceutical companies Moderna and Pfizer and the Israel Institute of Biological Research (IIBR) in Ness Ziona sparked excitement and expectation.
For the first time since the virus made its appears, we are feeling like there's light at the end of the tunnel. The vaccines appear to be a tool to reduce the danger of COVID-19, and possibly even eradicate it. The realization that the best minds in a number of countries are working on vaccines, and that vast resources have been invested in that work, is cause for us to be cautiously hopeful about a solution.
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However, the scientific breakthrough – like it almost always does – goes along with questions of morality, ethics, and law that must be clarified in the short time that remains before the vaccines arrive. Bringing the first vaccines to Israel could lead to two contradictory problems: a refusal to be vaccinated, as well as demand that outpaces the supply. These two issues go beyond strictly medical questions.
What will we do if large sectors of the population don't want or refuse to vaccinate their children? We will not be able to exempt them on the ground that it is their personal decision. Addressing a pandemic requires us to be responsible for each other – if a sufficient level of vaccination is not reached in a given society, the disease will stay with us. And as if that weren't enough. A person who doesn't get vaccinated could infect others, especially members of the most vulnerable groups, such as those who suffer from medical conditions that preclude them from getting vaccinated.
The issue of refusal to be vaccinated is thrown into sharper relief given that this vaccine is completely new, but the phenomenon is familiar. We've seen it with other diseases and other vaccines.
"We pediatricians, who deal with unwillingness to vaccinate children on a daily basis, have accumulated vast experience in overcoming opposition or hesitation to vaccines," says Professor Zachi Grossman, chairman of the Israel Pediatric Association.
"Naturally, this is a global problem, not a specifically Israeli one. Other countries are encountering this phenomenon, and they have adopted various solutions for childhood vaccinations. In the US, for example, a number of states have passed laws making childhood vaccinations mandatory, and anyone who is not vaccinated cannot attend preschool or school," Grossman says.
Damage to herd immunity
If that is the situation in the US, which holds individualism and personal liberty holy, is it any wonder that vaccines are mandatory in so many other advanced democracies?
"In countries like France, Germany, and Australia, childhood vaccinations are mandatory, and there are financial punishments and children who aren't vaccinated are not allowed into preschools," Grossman adds.
"The obligation isn't absolute, there are exceptions. In some states in the US the legislation has allowed 'outs' – parents can declare a medical, religious, or philosophical reason and be exempts. But that demands that they fill out a form and make some effort. The lawmakers wanted to make it difficult to refuse without putting up an insurmountable wall. It's a delicate balance between personal freedom and concern for public health."
The extent of exemptions varies from country to country, which allows us to examine how it affects the extent of illness.
"The more people who are exempted, the more spread of diseases like measles there is in that country," Grossman explains. "It's also important to stress that even when there is a large percentage of vaccinated citizens, even very high, like 95%, there could be 'pockets' of local opposition, and in those areas there will be outbreaks that will create an epidemic."
Grossman's concerns are backed up by statistics from the US, which demonstrate that every increase in the number of people refusing to be vaccinated detracts from herd immunity. In the case of measles, a 5% drop in vaccination rates leads to three times as many cases.
The severity of the COVID pandemic hints at the possibility that world leaders might require their citizens to be vaccinated. Three months ago, Australian Prime Minister Scott Morrison was quoted saying that his country would require vaccinations as widely as possible, with the goal being to vaccinate 95% of the population. Morrison's remarks caused a public storm, and the Australian health minister was forced to make it clear that the government would not force any Australian to be vaccinated.
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In Germany, a survey published in October showed that only 70% of population were willing to be vaccinated. Approximately half of respondents supported the idea of making COVID vaccinations mandatory, and 22% declared that they would not be vaccinated and said they opposed making the vaccine mandatory. Reasons behind the opposition to the vaccine included concern about the fact that, unlike regular vaccines, the COVID vaccine has no proven record of effectiveness. The response that the same could at one point have been said about all standard childhood vaccines appears not to have convinced about one-quarter of the German population.
Grossman explains that after the last measles outbreak in Israel, MKs in the 20th Knesset Yoel Hasson, Shuli Moallem-Rafaeli and Merav Ben-Ari authored a private member's bill that sought to establish a national vaccine policy and address the issue of vaccine reluctance. The bill was approved in a first reading, but the Knesset was then dissolved and three elections were held, and the legislation was stalled.
When asked if he thinks that forcing Israelis to be vaccinated against COVID-19 is the right thing to do, Grossman says, "I hope it won't take a law, although it's tempting to try. If we look at the global experience, it seems as if laws, when we take into account the exemptions they always include, give us more or less the same effect as good outreach calling for people to be vaccinated. Most countries believe in persuading the population. Passing laws about it opens the door to unending appeals and creates an appalling lack of trust, because people start resisting coercion and suspecting that if the law requires it – the vaccine might not be so successful or safe."
Q: What other tools can help Israel reach a high rate of vaccinations?
"What we need is persuasion based on a combination of full transparency, which presents the facts about the vaccine, and personal example from leaders and authority figures. Talking to a taxi driver who declared he would not be vaccinated, I asked him what could change his mind. He said, 'If the leaders get vaccinated, it will be persuasive.' In my opinion, we need a coordinated effort to convince the people who are reluctant, and pediatricians should lead it."
Grossman says that there is also great importance to the medical community adopting a cohesive stance, as it did during a recent polio outbreak. He says that former corona chief Professor Ronni Gamzu, who at the time was director-general of the Health Ministry, made sure that the entire health care system would express support for polio vaccinations. "But if there's a single doctor who publicly refuses to be vaccinated, it would have destructive ramifications," he warns.
Punishment vs. a clear and present danger
Virologist Anatoly Alstein of Russia's Gameleya Research Institute of Epidemiology and Microbiology, which developed the Russian COVID vaccine Sputnik V, tells Israel Hayom that the question of making the vaccine mandatory is irrelevant, because according to projections the rate of vaccination in Russia won't exceed half the population. The Russians were proud of being the first to announce a vaccine, but they warn that it cannot be used on pregnant women or nursing mothers, children or youths under 18; or people who suffer from chronic conditions. Its effect on the elderly is also unknown, because it was only tested on volunteers under age 65.
According to attorney Sara Frisch, a retired judge and a member of the ethics committee at Rabin Medical Center, "the basic principle in terms of values, morality, ethics, and also law is that a person is responsible for his or her body. A person's bodily autonomy is a guiding principle. So the Israeli law on patients' rights talks about not forcing medical treatment on someone, except in extreme conditions."
Q: Doesn't protecting the public from COVID comprise an extreme condition?
"Let's start by saying that we still haven't seen the vaccine, we don't know who built it, what the differences are between different vaccines, what works and what doesn't, what interests stand behind them. First, we need answers to all these questions. Therefore we still can't talk about coercion or obligation. If and when the day arrives, and I hope it will, that we have a clear vaccine with clear results without side effects or any other damage, we can ask the question about the value of autonomy vs. other values, like public health and the sanctity of life."
Q: Are there grounds to discuss mandatory vaccines?
"I think that we won't be able to make the vaccine mandatory. In general, the growing control over the lives of the citizens in a number of aspects is a little scary. However, there are clear risks of infection, and the disease is without a doubt serious and contagious, and we can't fall into the hands of the dangerous attitude of 'what will be will be.'"
"I believe that the public isn't opposed to the vaccine in principle, but rather has understandable concerns due to the lack of information and the zigzag in public orders and doctors' positions. The public saw the lack of answers, experienced the feeling that no one knew what the day would bring (at first doctors said no to masks, then yes) and feels that they aren't being brought in. Add the media that blows everything up, and you get a worldwide lack of leadership."
Q: When it comes to the opposite moral question of who should be vaccinated first, especially if there is a shortage, what should we do?
"The indication for prioritizing the vaccine should be solely based on medical considerations, not economic or anything else. Those who are weaker should be first, and it's very possible that is not just a matter of age. Based on the medical record, there are vulnerable populations and they should get priority for the vaccine. The parameters for prioritization should be transparent, and I think that the responsibility for determining them should rest with a system that includes, in addition to doctors, experts in ethics, public officials, and religious representatives. A good example of a system like that is the National Council of Bioethics in the Health Ministry."
