Julian Savulescu’s Posts

Mandatory Vaccination for Care Workers: Pro and Con

By Dominic Wilkinson and Julian Savulescu
An edited version of this was published in The  Conversation 

The UK government is set to announce that COVID-19 vaccination will become mandatory for staff in older adult care homes. Staff will be given 16 weeks to undergo vaccination; if they do not, they will face redeployment from frontline services or the loss of their job. The government may also extend the scheme to other healthcare workers.

It is crucial to achieve a high vaccine uptake amongst older adult care home staff due to the high mortality risk faced by residents. ONS Data suggest that there has been a 19.5% increase in excess deaths in care homes since the beginning of the pandemic, with COVID-19 accounting for 24.3% of all care home resident deaths.

According to SAGE, 80% of staff working in care homes with older adult residents (and 90% of the residents themselves) need to be vaccinated in order to confer a minimum level of protection to this vulnerable population. In mid-April, only 53% of older adult care homes in England were meeting these thresholds, whilst, as of the 10th June, 17% of adult care home workers in England have not had a single dose of the COVID-19 vaccine.

Mandating vaccination would increase vaccine uptake in care home workers, but would be a significant intrusion into individual freedom. Is it ethically justifiable?

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Care home staff vaccination – press release

Two (contrasting) perspectives on the news this morning about planned mandatory vaccination of care home workers.

Professor Julian Savulescu

“The proposal to make vaccination mandatory for care home workers is muddle-headed. Vaccination should be mandatory for the residents, not the workers. It is the residents who stand to gain most from being vaccinated.  Young care workers have little to gain personally from vaccination and there are now lethal risks, as well as uncertain long term consequences of novel vaccines. They have already risked their own lives during the pandemic. Some will be immune from past infection. Those remaining should be offered incentives, including financial incentives, to be vaccinated, not coerced. Vaccines like hepatitis and influenza may be mandatory, but they have been around for years and have established safety profiles.

“It’s too soon to be talking about mandates. We’re still researching rare but potentially serious side-effects that have been thrown up by national monitoring, for example a possible link between Pfizer and myocarditis. We don’t have the full picture on how well they prevent transmission. Public Health England data about how transmission is only available for the first dose and it is currently at up to 50%. Meanwhile the level of protection afforded to vaccinated individuals themselves is holding up very well in terms of hospitalisation and death even against the new variants. With the level of confidence we have encouragement to vaccinate is warranted, and incentives are warranted. Mandates should only be made on the basis of bulletproof safety and efficacy data, including transmission data.”

Prof Dominic Wilkinson & Dr Jonathan Pugh

“In the earlier phase of the pandemic, some of the most medically vulnerable members of our community, patients in care homes and acutely ill patients in hospitals, ended up catching coronavirus from those caring for them. Some patients and care home residents died from infections that they caught from their caregivers.”

“That is a tragic and distressing situation that we must do everything possible to avoid repeating.

First, we should ensure that all those who are high risk have access to vaccination. There are still approximately 10% of older adult care home residents who have not had a 2nd dose of the vaccine.

Second, those who work in the frontline with vulnerable high risk patients have an ethical obligation to take all reasonable measures to prevent spread of the vaccine to those they are caring for. They must follow guidance about the use of measures like hand washing and PPE. They should take part in lateral flow testing schemes. And they should be vaccinated.

In England, as of 10th June, 17% of adult care home workers have not had the COVID-19 vaccine.

There is a strong ethical case that care home workers (and NHS staff) who have not had the COVID vaccine should be redeployed to areas other than frontline care.
It would be ethical to make COVID vaccination (in the absence of a medical exemption) a condition of employment in the same way that hepatitis B vaccination is currently for some health professionals.

If vaccines are made mandatory for health care and care home workers, they should be able to choose from available vaccines. Every effort possible should be made to address any concerns that they have about the vaccines.”

Pfizer Jab Approved for Children, but First Other People need to be Vaccinated

Dominic Wilkinson, University of Oxford; Jonathan Pugh, University of Oxford, and Julian Savulescu, University of Oxford

Moderna and Pfizer have released data suggesting that their vaccines are well tolerated in adolescents and highly effective in preventing COVID-19. Canada, the US and the EU have already authorised the Pfizer vaccine in children as young as 12. And the UK has just approved the use of the Pfizer vaccine in children aged 12 to 15. But there may a case for holding out on an immediate rollout, for several reasons.

Whether a vaccine is beneficial for someone depends on three things: how likely they are to become seriously ill from the infection, how effective the vaccine is, and the risks of vaccination. Continue reading

Cross Post: Vaccine passports: why they are good for society

Written by Barbara Jacquelyn Sahakian, University of Cambridge; Christelle Langley, University of Cambridge,

and Julian Savulescu, University of Oxford

 

As more and more people get vaccinated, some governments are relying on “vaccine passports” as a way of reopening society. These passports are essentially certificates that show the holder has been immunised against COVID-19, which restaurants, pubs, bars, sports venues and others can use to grant them entry.

Israel currently operates a “green pass” system, which allows vaccinated people access to theatres, concert halls, indoor restaurants and bars. The UK government, had to roll back plans to trial vaccine passports after some of the venues involved experienced significant backlash against the proposals.

This is perhaps not surprising – vaccine passport schemes are controversial, with some arguing that they will reinforce inequalities. But there is an ethical case for using some form of certification of COVID status, as long as it is designed properly and as long as everyone has access to vaccines.

Let’s look at the ethics of vaccination and certification. Continue reading

Vaccine Nationalism: Striking the balance

Written by Owen Schaefer and Julian Savulescu

This is an updated cross-post of an article published in MediCine

On 2 February 2021, the Director-General of the World Health Organization, Dr Tedros Adhanom Ghebreyesus, issues a broadside against COVID-19 vaccine nationalism, calling it “morally indefensible” and “tantamount to medical malpractice at a global scale.” Rich countries representing 16% of the global population have snapped up 60% of the global supply of COVID-19 vaccines. [1] Meanwhile, India, which has only vaccinated 10% of its population, is facing a catastrophic COVID-19 surge.[2] And the COVAX facility – an international effort to get COVID-19 vaccines equitably distributed around the world – currently only projects capacity to offer vaccines amounting to about 3% of participating countries’ populations by mid-year.[3]

COVID-19 vaccine nationalism is not the exception to normal practice. In almost all matters, countries spend the vast majority of budgets on local needs, and only a small fraction of that foreign aid, even when the latter represents much greater need. But the fact that this is normal or expected does not amount to a moral defense.

Here, we explore a question of practical ethics: what is the appropriate extent to which a country can prioritize its own people over those in other countries in the securing of vaccines for COVID-19?

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Cross Post: End-of-Life Care: People Should Have the Option of General Anaesthesia as They Die

Written by Dominic Wilkinson and Julian Savulescu

Dying patients who are in pain are usually given an analgesic, such as morphine, to ease their final hours and days. And if an analgesic isn’t enough, they can be given a sedative – something to make them more relaxed and less distressed at the end of life. We have recently written about a third approach: using a general anaesthetic to ensure that the dying patient is completely unconscious. This has been described previously, but largely overlooked.

There are two situations when a general anaesthetic might be used in dying patients. The first is when other drugs have not worked and the patient is still distressed or in pain. The second is when a patient has only a short time to live and expresses a clear wish to be unconscious. Some dying patients just want to sleep. Continue reading

General Anaesthesia in End of Life Care – GAEL.

by Dominic Wilkinson @Neonatalethics

Our paper General anaesthesia in end-of-life care: extending the indications for anaesthesia beyond surgery has been published today in Anaesthesia. It is part of a series of work led by researcher Antony Takla, together with Julian Savulescu and Dominic Wilkinson. The recent paper is a collaboration with Professor Jaideep Pandit, Professor of Anaesthesia at Oxford.

 

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Press Release: Medical and ethical experts say ‘make general anaesthesia more widely available for dying patients’

General anaesthesia is widely used for surgery and diagnostic interventions, to ensure the patient is completely unconscious during these procedures. However, in a paper published in Anaesthesia (a journal of the Association of Anaesthetists) ethics and anaesthesia experts from the University of Oxford say that general anaesthesia should be more widely available for patients at the end of their lives.

Painkilling medications (analgesia) are commonly given to dying patients. But they may not be enough, leading to the use of continuous deep sedation (also known as “palliative” or “terminal” sedation).

“However, for some patients these common interventions are not enough. Other patients may express a clear desire to be completely unconscious as they die,” explains co-author Professor Julian Savulescu, Uehiro Chair of Practical Ethics, University of Oxford, UK. “Some dying patients just want to sleep. Patients have a right to be unconscious if they are dying. We have the medical means to provide this and we should.”

The authors make clear that their proposal is not about assisted dying, currently illegal in the UK. Instead, their focus is on options available to ensure that patients are comfortable at the end of their lives.

Put simply, some patients will want to be certain they are unconscious and unaware as their final moments arrive.

“The desire to be unconscious as a means of eliminating the experience of physical or mental suffering is understandable,” says co-author Jaideep Pandit, Professor of Anaesthesia at Oxford University Hospitals NHS Foundation Trust, UK. “Unconsciousness through general anaesthesia offers the highest chance of making sure that the patient is unaware of going through an adverse process.”

He adds that “although general anaesthesia in end-of-life care has been used and described in the UK since 1995, modern multidisciplinary guidelines will be needed before this can be offered more widely. Raising this issue now is important, especially in view of international trends showing increased use of general anaesthesia for dying patients.”

Informed consent will, say the authors, be crucial in helping patients understand implications of general anaesthesia for end-of-life care, and the other options they have to manage their final days.

“It is vital that patients are informed of all the legal options available to them to relieve suffering at the end of life. That includes analgesia, sedation and, potentially now, anaesthesia,” says co-author Professor Dominic Wilkinson, Director of Medical Ethics, Uehiro Centre for Practical Ethics at the University of Oxford, UK. “The risks and benefits of each should be explained. Patients should be free to choose the option, or combination of options, that best meet their values.”

In a separate survey of the general public, published recently in the journal PLOS One, Professors Wilkinson and Savulescu found a high level of support for access to deep sedation in dying patients. Some 88% of those surveyed said they would like the option of a general anaesthetic if they were dying. About two thirds (64%) said they would personally choose to have an anaesthetic at the end of life.

Professor Wilkinson adds “members of the general public appear to value the option of deep sleep and complete relief from pain if they were dying. Our previous research indicates that the public believes that patients should be given this choice.”

The authors counter any concerns that the use of general anaesthesia for end-of-life care could hasten death. Studies show no statistically significant difference in mean survival time between patients at the end of life who receive continuous deep sedation and those who do not. In several countries, propofol infusion as used for general anaesthesia has been continued for up to 14 days. “This stresses the point that the purpose of administering anaesthesia is not to hasten death but simply to achieve unconsciousness.” explains co- author Antony Takla, Research Associate at the Uehiro Centre for Practical Ethics, University of Oxford.

The authors believe the UK medical community should prepare for increased requests for general anaesthesia for end-of-life care, based on current trends in Western Europe and Scandinavia.

They conclude: “we have described a potential role for general anaesthesia in end-of-life care. This has, in reality, been available to UK patients since the 1990s, but is not commonly discussed or provided. There is a strong ethical case for making this option more widely available. This does not imply that existing palliative care practice is deficient. Indeed, we might see that general anaesthesia in end-of-life care is requested by, or suitable for, very few patients.”

“However, the number of patients involved should not alone determine whether this issue is regarded as ethically important. Even if complete unconsciousness is desired by only a few patients, there is a moral imperative for national anaesthesia, palliative care and nursing organisations to prepare for the possibility that general anaesthesia in end-of-life care may be requested by some patients, and to work collaboratively to develop clear protocols to address all of the practical, ethical and medicolegal issues concerned.”

Cross-Post: The Moral Status of Human-Monkey Chimeras

Written by Julian Savulescu and Julian Koplin 

This article was first published on Pursuit. Read the original article.

The 1968 classic Planet of the Apes tells the story of the Earth after a nuclear war destroys human civilisation. When three astronauts return to our planet after a long space voyage, they discover that humans have lost the power of verbal communication and live much like apes currently do.

Meanwhile, non-human primates have evolved speech and other human-like abilities, and are now running the earth with little regard for human life.

The astronaut George Taylor, played by Charlton Heston, is rendered temporarily mute when he is shot in the throat and captured. In one scene he is brought before the Apes, as he appears more intelligent than other humans.

He regains the power of speech, and his first words are: Take your stinking paws off me, you damned dirty ape.”

Planet of the Apes may be fiction, but this month the world’s first human-monkey lifeforms were created by Juan Carlos Belmonte at the Salk Institute for Biological Studies in the US, using private funding. Professor Belmonte and his group injected stem cells from the skin of a human foetus into a monkey embryo.

This part-human lifeform is called a chimera.

If implanted into a monkey uterus, the chimera could theoretically develop into a live-born animal that has cells from both a monkey and a human.

While it has been possible to make chimeras for more than 20 years using a different technique that involves fusing the embryos of two animals together, this technique has not been used in humans. It has been used to create novel animals like the geep – a fusion of a sheep and goat embryo.

Professor Belmonte used a different technique– called “blastocyst complementation” – which is more refined. It enables greater control over the number of human cells in the chimera.

But why is this research being done?

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Crosspost: Learning to live with COVID – the tough choices ahead

By Jonathan Pugh, Dominic Wilkinson and Julian Savulescu

This work was supported by the UKRI/ AHRC funded UK Ethics Accelerator project, grant number AH/V013947/1. The UK Ethics Accelerator project can be found at https://ukpandemicethics.org/

 

As mass vaccination continues to be rolled out, the UK is beginning to see encouraging signs that the number of COVID deaths is reducing, and that the vaccines may be reducing the transmission of coronavirus.

While this is very welcome news, a mass vaccination programme is unlikely to be enough to eliminate the virus, so we need to turn our thoughts towards the ethics of the long-term management of COVID-19.

One strategy would be to aim for the elimination of the virus within the UK. New Zealand successfully implemented an elimination strategy earlier in the pandemic and is now in a post-elimination stage.

An elimination strategy in the UK would require combining the mass vaccination programme with severe restrictions on international travel to stop new cases and variants of the virus being imported. However, the government has been reluctant to endorse an elimination strategy, given the importance of international trade to the UK economy.

One of the main alternatives to the elimination strategy is to treat coronavirus as endemic to the UK and to aim for long-term suppression of the virus to acceptable levels. But adopting a suppression strategy for the long term will require us to make a societal decision about the harms we are and are not willing to accept.

 

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