THE DECISION TO VACCINATE: THE RISK-BENEFIT ANALYSIS RE-ANALYSED
Policy makers say that the benefits of receiving COVID-19 vaccines continue to far outweigh the risks of vaccination in a pandemic.
This may be true from a societal / collective perspective.
Two Perspectives, the Common Good and Prudential Judgment
However, it is not as straightforward as taking the policy makers’ risk-benefit analysis (which is made at a societal / collective level) and blindly applying it to any and all individuals. An individual’s risk-benefit analysis involves many factors as well as uniquely customized weightage for each factor (which involves value judgments, which differs from person to person) as compared to the risk-benefit analysis at the societal / collective level.
Both perspectives are of course important – and both involve prudential judgment. But not grasping the distinction between the two puts us at risk of putting the collective interests (as the policy makers perceive it) over the legitimate interests and concerns of living, breathing individuals (and their families).
Seeking what’s good for the community does not mean just seeking what suits the majority (and herein lies the misconception that the common good = interests of the majority). The principle of the common good reminds us that every person matters. Hence, we need to strive for solutions that address the concerns of every person – for the good of every person and for the good of the whole person.
Proposed Framework of Factors for Risk-Benefit Analysis
Consider the following factors in Table 1 below, which are framed as open-ended questions / factors, and not assertions of fact, as part of a proposed framework for risk-benefit analysis in deciding whether to vaccinate. For each of these factors, the two columns (A and B) expresses the extreme ends of a wide spectrum for the purpose of discussions.
Important Note: I am a pro-vaccination, fully vaccinated, concerned citizen of Singapore. Everyone, especially those who are older and vulnerable, should seriously consider the option of getting vaccinated to protect themselves from serious Covid or death. Nothing in this article shall be construed as encouraging anyone to remain unvaccinated or to downplay the seriousness of Covid for those who are more vulnerable to it. Nevertheless, it is of utmost importance that any decision to vaccinate must be made voluntarily, free from any duress or coercion.
Table 1: Proposed Framework of Factors for Risk-Benefit Analysis
Table 1 Proposed Framework of factors for Risk-Benefit Analysis
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Insofar as most, if not all, of the above factors lean towards vaccination (Column A, in Green), the stronger the moral case for mandating vaccination. In contrast, even if some of the factors lean against vaccination (Column B, in Pink), the much weaker the moral case would be for mandatory vaccination.
There are four points to highlight from the above risk-benefit matrix.
Point 1, the concept of the unlucky draw. While the risk of a serious AE or death after vaccination is very low, for an individual who happens to be adversely affected this way, it is absolutely devastating to that person and his or her family members.
Is it not understandable for an individual to be slower to take up vaccination personally than it is for society to recommend vaccination generally?
Point 2, in a field of rapidly and ever-evolving science, what is unproven today may be proven in the future. Factors 4, 5, 6 and 7 above relate to this point.
Indeed, consent may only be effectively informed when the risks and benefits are completely understood. It is only possible to make a risk assessment only when all adverse effects are known, and the risks are quantified based on research findings (Sessa et al).
Are we there yet? If we are not, then there is little or no moral case for mandating vaccination.
The WHO’s 2nd edition 2019 updated framework (dated 16 April 2021) for causality assessment of an AE following immunization cites a poignant example (at p.42) of how causality can change:
“Causality can change when additional information becomes available either about the same case or about similar cases. For example, a case of narcolepsy after AS03 adjuvanted H1N1 influenza Pandemrix®️ vaccine may currently be classified as a likely vaccine product related AEFI, while the same case would have been classified as coincidental or indeterminate prior to establishing the association between narcolepsy and influenza vaccine in 2010 by scientific evidence.”
Point 3, it is critical how we as a society care for people if something catastrophic happens after vaccination. See Factors 2, 6 and 7 above which relate to the values or concepts of causality (establishing it), transparency / inquiry, and reparatory / indemnity. The lower we score on these factors, the lower the moral case for mandating vaccination.
It may well be that in time to come, it is proven clearly that there was no causal association between the vaccine and any given severe AE or death. On the other hand, if a causal association is subsequently established in the future, then those persons and their families will be vindicated. For the avoidance of doubt, the official position by the HSA is that thus far, no deaths have been attributed to the COVID-19 vaccines.
If we do right as a society in this regard, by showing that we are not afraid to ask the right and reasonable questions, and to journey together with the suffering until they arrive at proper closure (regardless of the outcome of the causality issue), it will in fact reduce vaccine hesitancy.
Point 4, insofar as some or many or all of the 10 Factors are debatable, there is no moral case for mandatory vaccination. It is not about whether you agree with the unvaccinated. Even I find myself disagreeing with the unvaccinated on many points. It is about whether the above questions / factors are debatable. And clearly, many are seriously debatable, which substantially reduces (and even eliminates) the moral case for mandating vaccination.
For the avoidance of doubt, I am not encouraging the unvaccinated to stay unvaccinated. I repeat the “Important Note” above. Rather, I am saying that there is an appreciable margin of uncertainty or sufficient arguable issues which point strongly against mandatory vaccination.
Four Implications Flowing from the Above Points
First, if there is no strong moral case for mandating vaccination, and vaccination must remain voluntary, then VDS stands on extremely weak grounds. See my earlier post here for the critique.
Second, even if vaccination is a moral duty (which is debatable, having regard to the above 10 Factors, applied using current and personal circumstances), it may not necessarily be a legal obligation. For example, some may argue that giving to the poor is a moral duty (especially on the part of the rich). But it is not a legal obligation.
Third, even if for argument’s sake, we assume that vaccination is a moral duty and that it should be elevated to a legal obligation, the consequences of not vaccinating should be measured and proportionate. VDS in its current form is wholly disproportionate and unreasonable.
Fourth, VDS as a form of coercion has already been imposed prior to any national and Parliamentary debate on whether vaccination is or should be a moral duty or a legal obligation. The cart has been placed before the horse. The party whip should be lifted for any discussion of these issues in Parliament - so that we avoid group-think, and that the people can truly be represented by its elected representatives and have their voices (and the nuances of this very complex issue) heard.
Why is This Relevant for the Vaccinated Majority?
If the vaccinated do not take their booster, they will lose their vaccinated status eventually, and may lose their jobs like some of the unvaccinated. The continued enjoyment of fundamental liberties as a citizen has been effectively made contingent on receiving the booster. The majority today could end up being in the minority.
Insofar as a vaccinated person gets the booster due to coercion, rather than based on a risk-benefit analysis and a personal prudential judgment pointing towards protection, it provides an insight into (and a personal experience of) how the unvaccinated feel.
For the sake of democracy and the future of Singapore, and in solidarity with every Singaporean which has been or will be coerced, speak up.
Dominic Chan
* Note: The above framework will be referred to for further articles which may discuss some of the Factors in greater detail.
[1] One relevant sub-factor (which straddles many of the Factors) is whether one has many dependants to look after in the event of severe Covid or death, versus in the event of vaccine injury or death.