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Cameron et al’s1 ethical considerations about the ‘Dualism of Values’ in pandemic response emphasise the need to strike a fair balance between the interests of the less vulnerable to COVID-19 (most notably, their freedom) and the interests of the more vulnerable (most notably, their protection from COVID-19). Those considerations are at the basis of ethical defences of focused protection strategies.2 One example is the proposal put forward in the Great Barrington Declaration. It presented focused protection strategies as more ethical alternatives to lockdowns which would prevent lockdowns’ ‘irreparable damage, with the underprivileged disproportionately harmed’.3
Here we want to suggest that a version of Cameron et al’s analysis can be applied to the case of vaccines to support a focused protection vaccination strategy. At this stage, we should limit vaccination to the vulnerable and not target children (and possibly other young people) in COVID-19 vaccination strategies.
We argue that, given the current state of knowledge about COVID-19, immunity and vaccines, it would be wrong to pose the costs and risks of vaccines on children for three reasons. First, they are unlikely to benefit from COVID-19 vaccination directly. Second, the collective benefit would likely be very limited. Third, we have already imposed very large costs on children during this pandemic through indiscriminate restrictions, using them as mere means to others’ ends.
Cameron et al frame the ethical problem of pandemic restrictions mostly in terms of dualism between freedom and well-being. However, the cost of indiscriminate pandemic restrictions on young people is not only in terms of freedom. Restrictions such as lockdowns and school closure compromise important societal and public goods and the well-being and health of young generations.4
Thus, a fairer way to protect vulnerable groups is to adopt focused protection strategies targeted at them: the burdens on them would be justified by the benefit they receive in terms of protection from COVID-19, something that is not true for young people. How to implement these strategies (eg, through some form of state coercion or some incentivisation programme) is a question we are leaving open here.
The fact that focused protection entails a form of unequal treatment of different groups has often been used as a reason to rule this option out,5 often with very morally loaded language. For example, it has been called an ‘ageist and ableist statement’ and compared with a ‘genocide of the aged, the disabled and the sick’.6 And yet, equality and fairness are not the same thing and actually sometimes fairness ethically requires treating different individuals or groups differently.2 What matters, from an ethical point of view, is that the differential treatment is based not on arbitrary or irrelevant factors (which would make it discriminatory), but on morally relevant factors (eg, risks of COVID-19, individual benefit from restrictions, personal costs of restrictions, societal benefit and so on).
After vaccines: a focused protection vaccination strategy
A similar kind of argument can be made concerning COVID-19 vaccination policies.
The risks of COVID-19 for children and young people are minimal. For example, ‘[i]n the USA, UK, Italy, Germany, Spain, France and South Korea, deaths from COVID-19 in children remained rare up to February 2021 (ie, up to the time the study had available data about), at 0.17 per 100 000 population’.7 The long-term risks of the novel COVID-19 vaccines on a population of millions of children are at the moment unknown, given that the clinical trials involved a few thousands of subjects over a few months period. In spite of the relative uncertainty, the current COVID-19 vaccines are still very likely to be in the best interest of the elderly and more vulnerable, but not of children.
Vaccinating children would be a way of treating them as mere means to serve other people’s interests or some form of collective good. We already did this through indiscriminate lockdowns and other restrictions, such as school closure. Using children as means or even mere means in this way is not necessarily wrong, but it can only be justified if the cost imposed is sufficiently small and the benefit sufficiently large.7 Unfortunately, currently available COVID-19 vaccines do not meet either condition, given our current state of knowledge.
Not only would vaccinating children pose risks on them without any substantial direct benefit. Also, vaccinating children can only offer collective good if this reduces infection levels in the community. However, while COVID-19 vaccines almost certainly will provide long-term protection against severe disease and death, their infection blocking effects are incomplete and very likely to be transient. This means there is actually no collective benefit to trade off against individual harm to children, unless we perform mass vaccination on a regular basis, for example, annually. But this would compound the potential harms.
It is time to stop treating children and young people as mere means
During the pandemic, we have often treated children as mere means. The only reason why we have imposed this burden on children is to serve other people’s or broader societal interests. These measures have not been in the interest of children, nor where they intended to be. The burden on them has been vast and the benefit of lockdowns for the collective at the very least questionable.8 9 We should not make the same mistakes with vaccination policies.
Funding AG's work was funded by the Wellcome Trust through the grant WT 203132/Z/16/Z
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.