The UK's Joint Committee on Vaccination and Immunisation recently recommended against vaccinating children under 16 against Covid, despite granting that "the benefits from vaccination are marginally greater than the potential known harms." (Of course, aggregated over a subpopulation of millions, even "marginal" improvements in risk profile can result in several saved lives and scores or hundreds fewer hospitalizations. And, as Deepti Gurdasani makes clear in this thread,* all the evidence should lead us to expect the "unknown" risks from Covid to outweigh those from the vaccine, so taking uncertainty into account should lead us to regard vaccination as all the more important.)
So what's behind the JCVI's verdict? They are at least admirably transparent:
In providing its advice, JCVI also recognises that in relation to childhood immunisation programmes, the UK public places a higher relative value on safety compared to benefits.
It's important to be clear on what this really means. Note that this is not invoking any kind of philosophically defensible harm/benefit asymmetry. (Many people think it's more important to reduce suffering than to promote happiness, but that's not what this is about.) Vaccines aren't to make you happy. The "benefits" they provide are specifically safety benefits, i.e. against other health risks. So what the JCVI is really saying is that they place higher value on protecting people from potential harms from vaccines than on protecting people from potential harms from COVID.
That is deeply messed up.
I just hope that greater philosophical clarity here will help people to see how messed up it is (and so change these institutions' values in future). Every time some dopey bureaucrat claims they're prioritizing "vaccine safety" over "benefits", they need to be met with the response: No, you're prioritizing safety from vaccines over safety from COVID.
That's clearly indefensible. We just need to make it clear that this is in fact what they are doing. Don't let them obscure the reality of status quo risks behind a weasel-word like "benefits". The choice isn't between "safety vs benefits", it's "safety [against lesser vaccine risks] vs safety [against greater covid risks]".
* = Thanks to Dan Fogal for the pointer.
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The Guardian has a good article on this:
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One risk raised by the JCVI was the chance of myocarditis, a form of heart inflammation, in children who receive the vaccine. While this is extremely rare, and children tend to recover quickly, there was uncertainty about any longer term effects, with further research needed, it said.
But Lawrence Young, a virologist from the University of Warwick said, the risk of developing myocarditis was “significantly higher for those youngsters who have contracted Covid-19 compared to those who have been vaccinated with the Pfizer jab”.
He added: “This is a very disappointing and worrying decision.”
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Not to mention this is forcing involuntary covid risks on the children to avoid voluntary vaccine risks, and that if you include the benefits to non-children who could be involuntarily infected by the unvaccinated children the net risk reduction grows massively. One might say that these deliberations try not to count protecting others, but kids are getting things like mask mandates imposed on them, with great costs, to protect others. If you include relief of those sorts of things the kids will be not marginally but greatly better off with access to vaccination.
ReplyDeleteThere's a separate medical magisterium issue where it's OK to require costly masks to stop kids from harming others with Covid, but not to permit beneficial vaccination (although admittedly part of that may be public health's general dismissal of hedonic costs).
Yes, absolutely.
DeleteI believe they're looking, as a separate question, whether there might be reasons to vaccinate children not to do with their own health; that's to say I believe this report was explicitly focused only on health benefits to children themselves and all other questions postponed. (And at least for now, children aren't wearing masks. I doubt that will change; the public mood is very much in favour of prioritising a return to normality for children even if that comes at some cost to others.)
DeleteGlad to hear of that respect in which the UK is treating kids better than the US does. And yeah, there's hope that the gov't may overrule JCVI on externalities grounds, but I gather that JCVI's verdict at least delays approval here, which seems unfortunate.
DeleteI especially agree with Carl that it's a major problem to be forcing the greater covid risk on kids. It'd be reasonable enough to refrain from *mandating* a vaccine because the net benefits were marginal, but to *ban* it for being marginally beneficial is just insane.
Just in case you're curious how events unfolded: Again, the decision above was looking only at reasons to vaccinate children based solely on benefits/risks to their health. But now we've also looked at the wider benefits to children - avoidance of disruption to their education - we are now set to offer all 12-15 year olds one jab of vaccine (interestingly one, not two like the rest of us). https://www.bbc.co.uk/news/health-58547659. I haven't seen the details of this recommendation but thought you might be interested.
DeleteBest,
Alex
That's good news, thanks! (From what I'd previously read, one jab did sound like the sweet spot for balancing covid-protection against the risk of side-effects.)
DeleteHi Richard,
ReplyDeleteI think you're overstating things here. First, I'd think the thing that they are responding to is not a harm/benefit asymmetry but a doing/allowing one. And they are surely right that many people endorse some distinction along those lines, so that it's worse to kill a child via vaccination than to allow them to die through inaction.
Second, note that what they are responding to is not the apparent *accuracy* of that distinction, but the fact that much of the UK public endorses it. The NHS is a public body and has to be responsive to public opinion to some degree. And as well as such intrinsic democratic reasons, there might also be pragmatic reasons to be responsive in this way to maintain public trust in their recommendations - we have very low rates of vacinne refusal, and this is perhaps a long-term benefit of the NHS maintaining this kind of trust.
Finally, for what it's worth, I doubt that you or I have the expertise to assess whether the unknown risks from COVID are greater or lesser than the unknown risks from the vaccine - I suspect that's a very complicated question involving a lot of guesswork about the underlying mechanisms in each case, and either way the risks are very small.
Hope you're well,
Alex
Hi Alex, good to hear from you!
DeleteI actually think that appeal to doing/allowing gets things backwards. It might be a reason against mandating vaccination, but not (I would think) a reason against allowing it. On the contrary, by coercively preventing parents from vaccinating their children, the government may now be morally responsible for killing those few children who die of Covid (if their parents would have vaccinated them in the absence of this state coercion).
That is, I think it's morally inaccurate to characterize a vaccination ban as "inaction" on the government's part. It is very heavy-handed action, that predictably harms the population, compared to a more liberal/"hands off" response of sharing the relevant data and allowing individuals to make their own decisions (in consultation with their doctor). The fact that familiar regulation is commonly seen as "inaction" is just another instance of how status quo bias distorts moral perception here.
re: public opinion, there'd be no point to having expert bodies if they deferred blindly to public opinion. When the latter is clearly mistaken, it's the responsibility of the experts to explain why. That holds for normative mistakes no less than empirical ones.
re: expertise, I'm deferring to Dr Gurdasani who argues pretty convincingly that this is a no-brainer:
"They have not factored in the cost of inaction to the risks posed by the virus- which we *know* has long-term effects in children, including neurological symptoms after infection (that in relatively young adults have been shown to be associated with structural brain changes)
Unknown long term effects from vaccine are very unlikely- most effects from vaccines are seen very early, and to my knowledge there is only one instance of a vaccine in which late effects were seen, and even these were rare.
For these theoretical possible future effects to outweigh benefits they would have to outweigh:
-known benefits in reduction of hospitalisation, PIMS, ICU admissions and deaths
-known benefits from reduction of long COVID
-unknown benefits from reduction of long COVID"
That said, I agree that the stakes are relatively low in this case. But the underlying normative principles have done a lot of damage, in my view, so it seems worth pointing out the error each time it recurs.
I don't know the processes here well enough (i.e. the exact remit of the JCVI), but it's not obvious to me that this is a ban on getting children vaccinated. The statement addresses the question of whether to universally offer the vaccine to all relevant children, but it's a separate question as to whether parents might get it done privately. In this case the matter seems a bit complicated because I don't *think* COVID vaccinations are available privately, but I think that has to do with supply issues rather than any principled objection (in general there are various interventions that are permitted privately but not funded by the NHS, obviously including ones that are perceived to be low-benefit). [An aside: there is also part of me that wonders about the political pressures on the JCVI. I wonder if in normal times they would rule against vaccination of this age group because although marginally beneficial it is not cost-effective, but perhaps that would be an unwelcome thing to say at this time.]
DeleteRe. public opinion: I absolutely agree that expert bodies should use their expertise, but that's consistent with making some concessions to public opinion where those opinions are widespread and the costs of following them are highly uncertain/contested, and anyway at worst only very small. Expert bodies should use their expertise, yes, but public bodies should also be accountable to the public.
Re. expertise: I can see you've found one expert saying one thing. The JCVI contains another larger (presumably, very distinguished) groups of experts who apparently say something else. No doubt we could find further experts saying other things. I just don't think I have the understanding of the underlying medicine to resolve this dispute by looking at what all these parties say, let alone by looking at just what one of those parties says.
Ah, I agree it would make a big difference if private vaccination is allowed! I'd assumed the situation was comparable to the FDA in the US, which regulates private as well as public provision of new medicines. But if I'm wrong about that, mea culpa!
Delete"JCVI contains... experts who apparently say something else"
What makes you think that? They say there's "considerable uncertainty" but nowhere assert (let alone argue) that there's positive reason to realistically expect that vaccine risks outweigh covid risks. It seems to me that everything they say is compatible with the disagreement being purely normative, not empirical at all.
(I mean, it's possible they disagree empirically. I just don't see any evidence of this. By contrast, it seems clear that they DO disagree normatively, and it's this that I'm interested in addressing at any rate. Happy to bracket the empirical issue if you find experts suggesting we should realistically expect vaccine risks to outweigh covid risks for kids.)
Again, I'm not on expert on the healthcare system here, but I believe it's the MHRA who approve drugs etc. and are the real counterpart to the FDA. It looks as though the MHRA have approved these vaccines for use in children, and they think the benefits of the vaccine outweigh the risks: https://www.gov.uk/government/news/the-mhra-concludes-positive-safety-profile-for-pfizerbiontech-vaccine-in-12-to-15-year-olds. That suggests that these will be available privately if the supply chain is favourable. It is a little hard to square this statement on safety with the advice from the JCVI: it's leaning me a bit further towards thinking the JCVI are really being moved by considerations of financial cost etc. - what they are really saying is that the benefits outweigh the risks by such a small margin, and with such uncertainty, that it's not worth expending time and money on this. But perhaps I'm being overcharitable and your interpretation of events is better.
DeleteAh, thanks for that important correction!
DeleteOn cost-effectiveness: it really wouldn't make sense to have an agency attempt to assess that without even considering the positive externalities (i.e. reducing spread of the virus to other, more vulnerable groups, and reducing risk of triggering economically damaging lockdowns, reducing risk of new variants emerging from unchecked spread, etc.). Given the cost of the pandemic, I can't imagine that there's any real question that vaccination is cost-effective all things considered.
Funny how they once justified banning much needed vaccine experiments on grounds that experimentation might cause vaccine hesitancy. Now the same people are trying to protect our minors from the vaccine? How are those prone to vaccine hesitancy meant to read this development?
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