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• If..
  John Stone
  Published on: 26 March 2018
• The libertarian case reconsidered
  Ming-Jui Yeh
  Published on: 29 January 2018
• A devil's advocate outflanked by demons: Is it really time to stop talking to anti-vaxxers?
  Jacob M Kolman
  Published on: 18 December 2017

• Published on: 26 March 2018

  If..

  • John Stone, UK Editor AgeofAutism.com

  The article by Brennan [1], which has just been drawn to my attention, only exists in hypothetically perfect world in which medical evidence is always clear cut and bureaucracies beyond fallibility, bias, corruption or perhaps even scrutiny - it hinges like a lot of ethical investigations round the word "if". You could agree "y" if "x" (though I am not sure whether in this case it would be a libertarian argument as opposed to just an argument) but we do not have flawless bureaucracies making perfect decisions based on immutable scientific laws. Of course, a crucial argument relating to political liberty is just that bureaucracies are inevitably imperfect.

  While we could explore and criticize the basis of many such decisions (and despite huge institutional pressures many criticisms of vaccine products lie within mainstream scientific debate, for instance issues regarding influenza vaccination, HPV, aluminum adjuvants, mercury preservatives etc.) we are simply not talking about a branch of science which admits of such certainties. Nor are we dealing with just a few products. The US mandated schedule has perhaps dozens of products already, with hundreds in the pipeline which depend for their commercial viability on being licensed and mandated in their turn. Brennan does not engage with the problem that is not about one or two instances (for instance MMR vaccine is often cited) but an indefinitely large number products which could become c...

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  The article by Brennan [1], which has just been drawn to my attention, only exists in hypothetically perfect world in which medical evidence is always clear cut and bureaucracies beyond fallibility, bias, corruption or perhaps even scrutiny - it hinges like a lot of ethical investigations round the word "if". You could agree "y" if "x" (though I am not sure whether in this case it would be a libertarian argument as opposed to just an argument) but we do not have flawless bureaucracies making perfect decisions based on immutable scientific laws. Of course, a crucial argument relating to political liberty is just that bureaucracies are inevitably imperfect.

  While we could explore and criticize the basis of many such decisions (and despite huge institutional pressures many criticisms of vaccine products lie within mainstream scientific debate, for instance issues regarding influenza vaccination, HPV, aluminum adjuvants, mercury preservatives etc.) we are simply not talking about a branch of science which admits of such certainties. Nor are we dealing with just a few products. The US mandated schedule has perhaps dozens of products already, with hundreds in the pipeline which depend for their commercial viability on being licensed and mandated in their turn. Brennan does not engage with the problem that is not about one or two instances (for instance MMR vaccine is often cited) but an indefinitely large number products which could become compulsorily mandated for citizens by already existing bodies.

  Brennan weights the case by proposing on the one hand that we have reliable science and on the other hand a lady who has appeared in Playboy centerfolds, i.e. Jenny McCarthy, but of course the arguments against the perfection and safety of the program has often been taken up by scientific and medical professionals, and often against their professional interest. It is not a happy example for yet another reason. If we were to have reliable information about vaccine products (as opposed to Papal style declarations of infallibilty) scientists and doctors would need to listen respectfully to citizens about their experiences whether or not they had appeared in Playboy. For this purpose celebrities are just prominent members of the public. In the case of Jenny McCarthy she and her employers have been subject to professional intimidation lying well beyond the realms of dispassionate science [2]. The issue of false-flag "grass-roots" vaccine organizations has also recently been highlighted by Doshi [3]. Bureaucracies can maintain their record by socially repressive means against the public and Jenny McCarthy would be an example: this is what might happen to you if you stand up.

  It is not helpful - indeed highly misleading - to talk in abstract propositions: the truth here is messy and likely unpleasant.

  [1] Brennan J, 'A libertarian case for mandatory vaccination, BMJ Ethics', 11 July 2016 http://dx.doi.org/10.1136/medethics-2016-103486
  [2] Schneider S, 'Big Pharma’s faking a “grass-roots” campaign to keep Jenny McCarthy off “The View”", Notes from the Underground http://markcrispinmiller.com/2013/08/big-pharmas-faking-a-grass-roots-ca...
  [3] Doshi P, 'The unofficial vaccine educators: are CDC funded non-profits sufficiently independent?' BMJ 7 November 2017 http://www.bmj.com/content/359/bmj.j5104

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  Conflict of Interest:
  None declared.

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• Published on: 29 January 2018

  The libertarian case reconsidered

  • Ming-Jui Yeh, PhD Candidate Department of Health Policy and Management, Emory University

  Abstract
  Jason Brennan presents a justification for mandatory vaccination policy from a libertarian perspective. I reevaluate Brennan’s argument, focusing on the applicability and potential limit of the clean hands principle he proposed. I argue that the clean hands principle cannot tell us how to weight the degrees of risk of different collectively harmful activities; therefore, we could not distinguish the relative significance of coercive interventions that aim at stopping different kinds of collectively harmful activities. Using secondhand smoke prevention as an analogous policy example, I illustrate that many behaviors that suffice the five conditions could be qualified as collectively harmful activities. These activities are hence subject to coercive policies that are justified by the clean hands principle, including those obviously infringe individual rights and civil liberties and contradict with libertarianism. For libertarians, this implication of the clean hands principle might not be too comfortable to accept.

  Main Text
  Using David Gauthier’s strategy, Jason Brennan demonstrates that even starting with a theory “with strongly individualist and antigovernment premises” such as libertarianism, mandatory vaccination is justifiable (p.37).1 Drawing on one of his own works, Brennan argues that the clean hands principle requires a person not to participate in collectively harmful activities, and that libertarians should accept governments’ coercive...

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  Abstract
  Jason Brennan presents a justification for mandatory vaccination policy from a libertarian perspective. I reevaluate Brennan’s argument, focusing on the applicability and potential limit of the clean hands principle he proposed. I argue that the clean hands principle cannot tell us how to weight the degrees of risk of different collectively harmful activities; therefore, we could not distinguish the relative significance of coercive interventions that aim at stopping different kinds of collectively harmful activities. Using secondhand smoke prevention as an analogous policy example, I illustrate that many behaviors that suffice the five conditions could be qualified as collectively harmful activities. These activities are hence subject to coercive policies that are justified by the clean hands principle, including those obviously infringe individual rights and civil liberties and contradict with libertarianism. For libertarians, this implication of the clean hands principle might not be too comfortable to accept.

  Main Text
  Using David Gauthier’s strategy, Jason Brennan demonstrates that even starting with a theory “with strongly individualist and antigovernment premises” such as libertarianism, mandatory vaccination is justifiable (p.37).1 Drawing on one of his own works, Brennan argues that the clean hands principle requires a person not to participate in collectively harmful activities, and that libertarians should accept governments’ coercive interventions to enforce this requirement.2 Since the behavior of anti-vaxxers is a collective harmful activity, these anti-vaxxers “are imposing unacceptable and unjust risks on others.” Therefore, the governments could rightly coerce them to be vaccinated. Even libertarians should be comfortable with this policy recommendation. However, as I will show, there are several issues to be considered, especially for libertarians, if readers were to accept this conclusion.
  For the purpose of discussion, let us first recall the five conditions that constitute a collectively harmful activity. When a group of individuals 1. actively expose “themselves to potentially dangerous diseases,” and 2. actively do “things that have a high likelihood of spreading these diseases to others,” and 3. actively choose “not to take steps to reduce the risks they are imposing,” and 4. “are not epistemically justified in 3” for “they lack grounds for refusing to take precautions,” and 5. impose on others the risk that “cannot be justified as part of an equitable social system of risk-taking as it provides no advantage to others,” then this group of individuals perform a collectively harmful activity (p.41).1 Brennan suggests that under the circumstances that these five conditions present, governments’ coercive intervention to forbid individuals from participating in such activity is justifiable.
  The major issue is that the clean hands principle cannot tell us how to weight the degrees of risk of different collectively harmful activities; therefore, we could not distinguish the relative significance of coercive interventions that aim at stopping different collectively harmful activities. In the field of public health, many behaviors could be qualified as collectively harmful activities and hence be subject to the clean hands principle. In other words, many governments’ coercive interventions aim at these unhealthy behaviors could be easily justified even they might contradict with libertarianism.
  Take a common intervention policy – secondhand smoke prevention – for example. Is emission of tobacco smoke in places that expose others to secondhand smoke a collectively harmful activity done by smokers? Are these smokers imposing unacceptable and unjust risks on others? These smokers indeed expose themselves to potentially dangerous diseases (suppose we recognize the scientific evidence that exposure to tobacco smoke causes),3 such as lung cancer. Although they cannot literally spread lung cancer, they indeed have a high likelihood to spread secondhand smoke that causes lung cancer to others. When they emit the smoke in places where others present, they indeed actively choose not to take steps to reduce the risks they are imposing. So far, the smokers’ behavior has sufficed conditions 1 to 3. As for condition 4, considering the dominant propaganda on the health risks of tobacco, we could reasonably presume that most smokers already known the knowledge and hence lack grounds for refusing to take precautions (such as step to another place that on one present there). Lastly, those exposed to secondhand smoke are certainly not a part of an equitable social system of risk-taking, because there’s obviously no advantage could be obtained from inhaling secondhand smoke. Consequently, we establish an argument that emission of tobacco smoke to others is a collectively harmful activity done by smokers.
  Suppose the analogy is right, then we could confidently accept a policy proposal that governments should forbids every smoking behavior that might cause secondhand smoke. Actually, this is what people in public health have already done. In the 2003-adopted World Health Organization Framework Convention on Tobacco Control (FCTC), Article 8 “Protection from exposure to tobacco smoke” requires parties to protect people “from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places” through legislative efforts.4 In practice, many countries have implemented similar laws and regulations to forbid secondhand smoke in public places. Furthermore, in our inference of the five conditions above, they have nothing to do with whether the conditions present in a public or a private place. We could actually argue that secondhand smoke should be forbidden not only in public but also in private places. Therefore, we should accept a coercive intervention that regulate smoking behavior in even the most private and intimate places, even if we were libertarians. This conclusion obviously infringes many individual rights and civil liberties that libertarians believe should be protected against governments’ coercion.
  Some might argue that smokers’ spreading secondhand smoke is different from anti-vaxxers’ spreading infectious microbes, because infectious microbes are much more dangerous and fatal than tobacco smoke. However, I maintain that it is not so much a disanalogy; rather, it is just a matter of different degrees of risk. Different microbes cause different diseases and health outcomes to individuals. Some have longer latent, some have higher transmission rate, some cause higher mortality, some cause irreversible disability, and some are fatal only if the patient is exposed twice. The risks each microbe could cause are different. Suppose we consider secondhand smoke as a kind of microbe that have a long latent and cause fatal (and often painful and suffering in terms of life quality and finance) outcome – lung cancer, then it is no different from the others. What really different here is the degree of risk, depending on the measurement. The point is that the clean hands principle does not take the degree of risk into consideration. As long as the harms are caused by a collectively harmful activity, it is subject to governments’ coercive interventions.
  Note that the degree of risk I refer here is different from the assumption (C) of a valid intervention, which assumes that the target of a intervention will cause serious illnesses (therefore the intervention can protect against them) (p.37).1 This implies that as long as a collectively harmful activity would cause serious enough illnesses (let us tentatively neglect the definition of ‘enough’ and just suppose that lung cancer is a serious one), it could be the target of the intervention (secondhand smoke prevention policy), regardless of its degree of risk. Therefore, accompanied with the (A) effectiveness and (B) harmlessness assumptions, the intervention is valid and could be defended (p.37).1
  I take secondhand smoke prevention policy as an example to illustrate the applicability of the clean hands principle. From those related to individual-level life style (unhealthy behaviors) to community-level social determinants of health,5 in the field of public health, many more analogous examples could be easily proposed, and many coercive intervention policies could be defended accordingly. On this ground, it seems that the most radical public health advocates could march together with libertarians. I do not suggest that I am one of the public health advocates, but I figure that they would gratefully appreciate this conclusion, and I suspect that libertarians would be comfortable with it. Therefore, out of friendly intentions, I urge my libertarian peers to reconsider Brennan’s proposal.

  References
  1. Brennan J. A libertarian case for mandatory vaccination. Journal of Medical Ethics 2018;44(1):37-43. doi: 10.1136/medethics-2016-103486
  2. Brennan J. The ethics of voting. Princeton: Princeton University Press 2011.
  3. Öberg M, Jaakkola MS, Woodward A, et al. Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. The Lancet 2011;377(9760):139-46. doi: https://doi.org/10.1016/S0140-6736(10)61388-8
  4. World Health Organization Framework Convention on Tobacco Control. Geneva: World Health Assembly, 2003.
  5. Marmot M, Atkinson T, Bell J, et al. Fair Society Healthy Lives The Marmot Review Executive Summary. London: The Marmot Review, 2010.

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  Conflict of Interest:
  None declared.

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• Published on: 18 December 2017

  A devil's advocate outflanked by demons: Is it really time to stop talking to anti-vaxxers?

  • Jacob M Kolman, Senior research assistant

  Brennan offers an interesting strategy in "A libertarian case for mandatory vaccination," though in form it is the common "devil's advocate." The apparently least charitable bases for one's own position (in this case libertarian premises) are granted for the sake of argument; one's position is nevertheless found defensible (mandatory vaccination); and thus the harshest critics are answered without having to pay out a fu...

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  Brennan offers an interesting strategy in "A libertarian case for mandatory vaccination," though in form it is the common "devil's advocate." The apparently least charitable bases for one's own position (in this case libertarian premises) are granted for the sake of argument; one's position is nevertheless found defensible (mandatory vaccination); and thus the harshest critics are answered without having to pay out a full rebuttal. One need not endorse or condone the "devil" for this to work; it is not sophistry to pick your battles - if libertarianism is right, mandate vaccines; if it is wrong, mandate vaccines by a probably more obvious argument than if it is right. No commitment necessary.

  It should be noted, though, that Brennan's intended "devil" is clearly a pro-vaccine libertarian. The anti-vaxxer audience is lost by assumptions (A)-(D) that take for granted the efficacy, safety, and obviousness of vaccines, plus a quip about Jenny McCarthy.

  The damage here is not in directly insulting a particular reader (I would be suprised if many anti-vaxxers read the JME), but in what such disregard entails. For instance, the author briefly mentions that libertarians can tolerate government advertisement campaigns, but he does not feature this as a serious criticism, presumably because the anti- vaxxer is not only irrational, but unreachable. While it is true that any attempt to persuade a dogmatic believer can backfire and cause further polarization instead, this danger applies also when outreach is forsaken in favor of compulsion. It could be replied that, in the time it takes for outreach to work, we will fail to stop harm to others, but in the time it takes to debate each other about a mandate (and eventually to pass it), there will also be infected. Force is seen as efficacious only after diplomacy has been discarded.

  By disregarding the anti-vaxxer as an agent with potentially revisable beliefs, this article becomes about what "we" are to do about "them." "We" are very diverse (so some devil's advocacy is required), but "they" are demonized with words like "irrational," "stupid," and "self- destructive." "They" aren't invited to this article, where the "them- problem" is discussed and resolved (by government policy, no less). Liberals and libertarians should be the first to get chills, at which point Brennan also loses the very audience he attempts to court, who are particularly wary of government-enforced marginalization.

  So here is a "demon's advocate" portrait of an anti-vaxxer, based on close friends of mine who have not vaccinated their children (though I do not claim how far the portrait can be generalized): They are people. They are firm in belief, and when I finish talking to them, I do have feelings of frustration that one might express through name-calling (I have done so privately). However, they are not those names; they are concerned mothers and fathers who share many premises in common with me and probably with you - for instance, a high regard for the welfare of their children. Their premises diverge from mine on which sources of health information are most trustworthy, as we have both a different religious and educational upbringing, and they have felt (not unjustifiably) estranged from the mixture of impersonal, corporate, and politicized healthcare that differs strikingly from their intuitions on what "health" or "care" mean. They prefer personal relationships with small-town doctors who spend time taking their histories, and who typically engage in preventive, holistic, minimally pharmaceutical, and minimally invasive forms of care (primum nocere). Adverse events and side-effects are judged more heavily than potential gains in health or improvements in one's natural history, so most drug labels are off-putting and some minor maladies shrugged at; preferences sometimes align with what evidence-based medicine would prescribe and sometimes not. Drug and supplement companies who advertise as being all-natural, small-scale (non-PHARMA) businesses have taken the time to understand, magnify, and exploit some of these preferences to share information "that the FDA doesn't want you to know," along with conspiracy theories about FDA, Pharma, and government agendas (only marginally more far-fetched when compared to confirmed events like the Tuskegee or US Radiation studies, which, to use Brennan's phrase, "a minimal amount of research" can easily uncover for any American worried enough to look for it).

  If we are both clever and patient enough to derive government mandates from libertarianism, is our rhetorical distance from this portrait so much greater? Couldn't some of their own premises favoring preventive care and corporate transparency be used to expose the misinformation?

  *The opinions expressed in this letter are personal and do not necessarily represent the views of my institution

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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