Of Asymmetric Risk and the Ethics of Coercion

Proponents of the virtues of lockdowns seem to be stuck in a perpetual doom loop, unable to wean themselves off their comfort blanket of draconian restrictions, regardless of whether or not these are useful in controlling the spread of respiratory disease such as Covid-19.  Lockdowns are also ethically questionable: merely a tedious inconvenience to the ‘healthy wealthy’, they place a heavy – in some cases irreversible – burden on the poor, the young, the vulnerable and the old.  

Here in the UK, infections were decreasing well before the third national lockdown in January.  In terms of overall mortality, seasonal epidemics in neighbouring countries have been broadly similar.  Many claims have been made that vaccinations have been responsible for these abating epidemics (“the magic begins”), but this misses the point.  The clinical trials of the current crop of vaccines set out to prove that they make symptoms less deadly.  The vaccines (and indeed their clinical trials) were not designed to ‘stop the spread’, though it is hoped that they will.

Perhaps worried that this important topic was at risk of being seen as too mundane by the powers that be, the EU seems to have managed to create a public relations disaster of the most epic proportions, which has resulted in a nasty spat regarding the safety of the AstraZeneca vaccine.  There is no need to provide a detailed rundown here, but it is worth pulling out some of the salient facts and toning down both the ‘anti-vaxx’ and the ‘vaccine saviour’ rhetoric.  After all, we are all mortal: the sheer number of vaccinations means that some people’s appointment to meet their maker will – entirely coincidentally/by divine intervention – occur shortly after receiving their jab (and never the other way round, of course).

However, in some countries, use of the AZ vaccine has been temporarily suspended due to serious adverse impacts in seven individual cases “in temporal association” with the jab, all in people aged between 20 and 50, i.e. “not the population at high risk for a severe or even fatal Covid-19 course”.  This conclusion was reached by the Paul Ehrlich Institut, The German Federal Institute for Vaccines and Biomedicines – given they have been in this business since 1896, they can hardly be considered an anti-vaxx mouthpiece.  Their point is therefore highly rational: every medical intervention is a calculated risk between likely benefit and possible harms, both to the individual and the population at large.  

In the EU, the AZ vaccine is being administered under a what is known as a conditional marketing authorisation from the European Medicines Agency (EMA) while longitudinal data (long-term observation of the clinical trial cohorts) is gathered.  It is therefore only right and proper that possible serious side effects are carefully considered, and it is ethically entirely appropriate to pause a vaccination programme while salient data points are analysed in more detail.

Such a pause is not necessarily cause for alarm.  In fact, the AZ trial was briefly halted in 2020 when it emerged that two patients had suffered transverse myelitis.  Again, we should be pleased that serious side effects like this – which may have nothing to do with the vaccine – are investigated in meticulous detail, however much one might wish for a clinical trial to be successful.  Correlation does not imply causation, but when the data is fuzzy, care must be taken.  Anyone who has a problem with this should research the thalidomide tragedy, as well as numerous other medical reversals (the industry’s equivalent of a ‘reverse ferret’) that have occurred throughout history.  

So what happened next? Yesterday, Professor Pål André Holme, chief physician of Oslo University Hospital, announced the results of an investigation into three time-correlated cases of unexpected blood clots in patients (one of whom died) in Norway: “We have the reason.  Nothing but the [AZ] vaccine can explain why these individuals had this immune response”.  This was followed hours later by the EMA announcing its findings, namely that while “the vaccine may be associated with very rare cases of blood clots”, the “benefits of the vaccine … continue to outweigh the risk of side effects”.  

Given the hugely asymmetric risk profile of Covid-19 (the risk of severe outcomes is heavily skewed towards older generations), this is not an irrational verdict.  Individuals should be in the position to make their own decisions, and ‘at risk’ age groups may well wish to receive the vaccine if it is available, and others may wish not to.  This is fine.  The differential effect on the overall population, post epidemic, is not likely to be particularly impactful, especially given the high levels of immunity now present within various European populations.

In a similar vein, any minor delays to the UK vaccine supply are irrelevant.  Run any comparison you like, but every country that has had a Covid-19 epidemic is seeing mortality rates collapse (despite the SARS-CoV-2 virus remaining prevalent in these populations), in many cases to below seasonal trends.  This cannot be solely due to the vaccine rollout, for the obvious reason that these programmes have progressed at hugely varying rates.

An idea that has been floated – and has so far stubbornly failed to go away – is the concept of a vaccination certificate (or passport).  What would they actually achieve, apart from segregation according to a medical intervention that currently only has conditional authorisation for use? These passports could introduce an unethical pressure on an individual to get vaccinated, and most certainly would skew the concept of ‘informed consent’.  We would do well to steer well clear of such nonsense.  The UK’s Health Advisory & Recovery Team, an independent group of UK doctors, scientists, economists, psychologists and other academic experts, has just published a detailed dossier in which they flesh this out in more detail and think the same.  Hopefully HMG’s Covid-Status Certification Review – Call for Evidence (scheduled to close by 29 March) will also swiftly come to this conclusion and park the idea once and for all.

Given the high degree of population immunity, and the similarity of disease progression in countries and regions that have stringent lockdowns versus those without, it seems perverse for the cabinet office to be wasting time on such matters.  Surely the collective intellectual heft of Sir Humphrey’s grey matter could more usefully be deployed plotting the accelerated opening up of society, and all the health benefits that would bring.

Dr Alex Starling (@alexstarling77) is an advisor to and non-executive director of various early-stage technology companies.