Conscience and Vaccines: Lessons from Babylon 5 and COVID-19

Abstract

Babylon 5, like other great sci-fi franchises, touched on important ethical questions. Two ethical conundrums relating to the series’ main characters included providing life-saving treatment to a child against their parents’ wishes and potential involvement with a highly beneficial but morally dubious medication. I use these cases to discuss some aspects of the COVID-19 vaccines’ development and roll-out, demonstrating that people (be it patients or clinicians) might object to some vaccines due to reasonable ethics and safety-based concerns rather than due to an anti-vaxxer mind-set. I highlight that it would be disingenuous to lump these two groups of objections together for not all objections to specific vaccines are objections to vaccination in general. Rather, governments and pharmaceutical companies should seriously engage with the concerns of reasonable objectors to provide citizens with the appropriate products and ensure large vaccination uptake – in the case of COVID-19 this should include giving patients the choice of the product they will be inoculated with.

KEYWORDS:

• Vaccination
• conscience
• objection
• covid-19
• safety

You think it will always be like this Michael, little powers at the mercy of bigger powers, politics before morality, expediency before justice? – Commander Sinclair to Chief of Security Garibaldi; Babylon 5 episode Deathwalker, circa 40:55 minutes.

Dr Hernandez: You don’t disapprove of superstition if it’s your superstition.

Dr Franklin: Now what is that supposed to mean?

Dr Hernandez: They worship the Great Egg, your god is medicine. And you can do no wrong in his service. What’s the difference? -Babylon 5 episode Believers circa 12:50 minutes.

Introduction

The COVID-19 pandemic has had a large effect on societies in 2020 and 2021. Its virulent nature, and (when compared with the flu) higher burden on health and mortality (Xie et al. 2020), has led to the imposition of lockdown measures affecting people’s liberties, delayed the treatment of those with other medical problems and affected national economies – with many other effects on our day-to-day lives, especially on those who should be receiving social support. To help to alleviate this situation there has been a surge in COVID-19 research with the hope of developing effective and safe vaccines that would lead to the restoration of normal life.

COVID-19 also rekindled debates about vaccination across the world. Three aspects of these debates that I want to highlight are the plea of Australian Christian religious leaders for an ethical vaccine, a U.K. consultation on vaccine provision, and the Chinese military’s contribution to vaccine development – I will elaborate on these later. Firstly, I want to briefly introduce two episodes from the Babylon 5 sci-fi series (episode 9 ‘Deathwalker’ and episode 10 ‘Believers’ from the first season) that I will use to discuss the role of conscience (both of the patient and clinician) in deciding whether to participate in a treatment or not. One reason these Babylon 5 episodes are worth considering is that while Babylon 5 has been one of the more religiously literate sci-fi series (Greydanus 2017), the human command staff, including the chief medical officer (Dr Franklin), were not overtly religious (Babylon 5 1994). Moreover, the title space-station, Babylon 5, is a highly multicultural environment, making it a relatable setting to present-day pluralistic societies. In this paper I want to highlight that while religious literacy is important to understand some of the ethical problems that vaccination can present, despite what Magelssen et al. (2019) have found, conscientious objection in medicine can arise independently of religious motivation.

Fictional cases

In the episode Believers (Babylon 5 1994), a child of an alien species presents to the clinic with a life-threatening condition that can be easily treated with a simple surgical procedure. Yet, in that species’ religion it is held that making an incision on a person deprives them of their soul and, as such, surgery is only performed on food-animals. The parents were willing for the child to undergo any licit intervention, but refused surgery, even though they did not question its medical efficiency (importantly, the child agreed with the parents’ stance).¹ When the child’s health deteriorates Dr Franklin decides to ignore the parental refusal (and the station commander’s order not to operate) and performs the surgery. The parents are devastated and initially refused contact with the child. They then seemingly accept the child, make peace with Dr Franklin, and take the child for a special ceremony. Dr Franklin initially celebrates this as a success, but then realises that the child has been taken for a ritual killing. He runs to the parents’ room, but when he arrives the child is already dead. The parents comment that the child was dead since the time Dr Franklin performed the surgery and that they just ended the suffering of a ‘shell’.

I wish to highlight one dialogue from this episode, exploring the issue of a state’s medical interference in a pluralistic society:

Commander Sinclair: You believe you’re doing the right thing, don’t you? So do the parents. Who should I believe, you because we share the same beliefs or do we? / Dr Franklin: Commander, those parents are willing to see their son die because of their religion. Now you can’t expect me to sit here and do nothing. May God save us from false religion. / Commander Sinclair: What makes a religion false? If any religion is right, then maybe they all have to be right? /[…]/ Dr Franklin: I believe in saving lives. Without life, the question is meaningless. / Commander Sinclair: But life has to be more than just a pulsebeat.² What we hold sacred gives our lives meaning. What are we taking away from this child? / Dr Franklin: That’s a question we can worry about after the operation /[…]/ I thought I could depend on you. How can you deny me the permission to operate? / Commander Sinclair: If it were just me, I would have signed the order in the first place. But if the commander of Babylon 5 starts overruling individual beliefs just because they violate his own beliefs, we’ll be setting a dangerous precedent – it establishes that the concerns of other races will be set aside whenever it is convenient for Earth. /[…]/ I have to honour the beliefs of the parents otherwise Babylon 5’s charter will be compromised and the station’s ability to function as an independent meeting place for all the different races in the galaxy will be destroyed. Circa 26:52 minutes.³

The preceding episode, Deathwalker, dealt with the problem of the crew getting involved in an incident where a life prolonging serum could be popularised, despite the fact that its production would require sacrificing people’s lives to obtain one of its key components (Babylon 5 1994). The serum was developed by a war criminal who committed crimes against ‘sentience’. It was very effective against aging and preventing disease, but one of its essential components could not be synthesised, but needed to be extracted from living organisms.⁴ The episode highlighted the problems between justice calling for the punishing of Deathwalker on the one hand and that of utility of the discovery which could potentially save many people (though cause deaths as well). There was also a sense of tension between the government in control and the demands of those inhabiting the station. Though, admittedly, the debate surrounding the macabre manufacturing process did not feature as a central discussion point as it was revealed reasonably late in the episode, the clash between utilitarian considerations and those of justice are relevant to the COVID-19 vaccination debate.

Commentary on the cases

The Believers episode shows a particular form of moral distress that occurs when a patient (or their proxy) refuses a safe and efficacious treatment. More importantly, the refusal is due to a metaphysical belief (a consequence of which is that the surgery had an unacceptable side-effect) rather than due to some misunderstanding of the efficiency or biological safety of the intervention. Moreover, the parents were in general competent and caring, with no foul play suspected on their part – indeed they were happy to cooperate with an alternative treatment proposed by the Dr Franklin. Dr Franklin was torn between his duty to heal and to respect the consent process (as well as the family’s cultural background). The situation was particularly hard as the bestowal of clinical benefit was easily achieved via the proposed surgery and the reasons for the parents’ refusal to consent seemed arcane to the doctor. Moreover, Dr Franklin did not realise how seriously this belief was held and how severe the consequences of violating it would be. While one might not subscribe to a particular belief system, assuming that the system is coherent, one should still appreciate how it might affect the provision of medical care.

The Deathwalker episode outlines a situation in which the conflict is not between the station official and a citizen, but between the station staff and the Earth government (perhaps, since Deathwalker preceded Believers, this makes the doctor’s action in Believers more culpable as he did not reflect on the experience from Deathwalker). Here the protagonists are placed in a politically difficult position involving claims of vengeance and of great clinical benefit. The serum developed by the title character, Deathwalker, promises health and longevity, but at the cost of sacrificing other people’s lives. The case again involves clear clinical benefit, but at a moral cost that many would find repulsive.

I am not sure if these episodes were placed next to each other so as to juxtapose the clinical dilemmas or not – but they surely managed to achieve this. They both present cases of clinical interventions that provide clear medical benefit to those who would receive them. Yet, while the serum seems morally repugnant to many, the surgery seems to be such only to a minority. One treatment seems like it is radically in conflict with mainstream medical ethics (at least at first sight),⁵ the other seems largely uncontroversial. The two cases provide enlightening parallels to some aspects of the COVID-19 vaccine debate, but before I elaborate on this, it will briefly attend to some aspects of the debate on objections to vaccinations.

Vaccination and conscience

I wish to broadly categorise objections to specific vaccines as either safety based or ethics based⁶ (though strictly speaking, safety considerations do fall within the realm of ethical practice). Moreover, despite the fact that there is a misguided anti-vaccination movement (anti-vaxxers), fuelled infamously by Wakefield’s now retracted article about the MMR vaccine (Wakefield et al. 1998), I do not intend to deal here with objections based on disproven claims (such as that vaccines are generally unsafe or that they provide little benefits to individuals and society).

It seems to not be well-known that the term ‘conscientious objector’ first entered into English law via the nineteenth century vaccination opposition movement, and not in the context of opposition to military service (Wolfe and Sharp 2002). Of course, vaccine production standards where rather less stringent in the nineteenth century than they are now and being vaccinated (or having one’s children vaccinated) was riskier than now. Yet, even currently vaccination has some risk of side effects, occasionally defective batches might be produced, and some vaccines might be medically contraindicated to those suffering from certain medical conditions (Centers for Disease Control and Prevention 2020),⁷ allergies (indeed, people suffering from significant allergic reactions were warned not to take the Pfizer-BioNTech vaccine after two healthcare staff suffered allergic reactions after receiving the vaccine; Lovett 2020), those who are pregnant⁸ and some people might simply react badly to a vaccine for an unknown reason despite their by-and-large great safety profile.⁹ As such, vaccination safety concerns are not completely irrational, and might be exacerbated when those who provide vaccines are deemed to have political or economic motivations for doing it (Giubilini et al. 2018, McNeil et al. 2016, Australian Government: Department of Health 2015, Maglione et al. 2014, Pallansch and Sandhu 2006, Pierik, 2017).¹⁰ As Savulescu (2021, p. 79) states, the fact that ‘[v]accines are one of the greatest medical accomplishments and a corner-stone of public health’ does not change the fact that they, like everything else, do possess risk, and that ‘[p]erhaps the biggest challenge in the development of a vaccine for COVID-19 will be to be honest about the extent of those risks and convey the limitations of confidence in safety and efficacy relative to the evidence accrued’.

The ethics-based concerns can be both secular and religious in nature, with perhaps the most famous cases being vegans objecting to vaccines developed in hens’ eggs (a common production method for the influenza vaccine)¹¹ and Catholics raising objections to vaccines developed using cell lines of human foetal origin, such as HEK293.¹² Similar to the safety scenario, this is not per se an objection to vaccination overall and such objectors should not be labelled anti-vaxxers. They are only opposed to a specific production process (Pontifical Academy for Life 2005, Clarke et al. 2017, Iannelli, 2017), and could not be regarded as opposed to vaccination in general any more than those who oppose non-Fairtrade products or non-organic produce could be labelled as anti-traders or anti-agriculturists. Indeed, their objections might go beyond vaccination, and it is likely that vegans would also object to a range of medicines and medical equipment, such as dressings and surgical implants, that are manufactured using animal components (Rodger and Blackshaw 2019; Rodger 2021).¹³

It is therefore important to remember that there are legitimate safety concerns surrounding vaccination and that not all opposition to the use of specific vaccines can be equated with opposition to vaccination in general. Moreover, such objections could be made by both patients (or their parents) and clinicians. Indeed, if a product was unsafe, one could argue that a clinician supplying it, or a parent accepting it for one’s child, would be acting unethically if the vaccination risk was not proportional to the disease risk or if a safe alternative was available (or could be expected to be available in a short time). Such objections could be considered as instances of selective conscientious objection (Cowley 2019) – a concept developed by Smith (2015, 2018), though he insisted that ‘individualised claims of conscience’ were not predictable, but here (what differentiates them from anti-vaxxer rhetoric) they are predictable and are, at least conceptually, easy to address.¹⁴ As such, the view of conscience that I espouse here is that of a faculty that applies knowledge to decide upon the right course of action (Chalmers 2013, pp.137–138, commenting on Aquinas’ stance) – a faculty concerned as much with ‘lofty’ morals (e.g. to not co-operate with evil) and day-to-day practical matters (e.g. to provide safe healthcare). Consequently, what I note here will differ in many respects from the debate about healthcare practitioners’ right to conscientious objection in general to groups of interventions.

Vaccines in the light of Babylon 5

While perhaps the first impression is that both Babylon 5 episodes explore the issue of ethical objections (which are probably harder to appreciate for a lot of people than safety-based objections), I would argue that the Believers episode can be seen as discussing a safety concern, despite its cultural motivation. In Believers, the parents do not claim that surgery is per se an unethical practice (they say it is fine to perform it on animals), but that the side-effect of it (losing of one’s soul) is an unacceptable price to pay for health. As such, this episode highlights the fact that health is not regarded as the most important good by everyone,¹⁵ indeed this is an assumption that underlies a lot of the controversies surrounding medical interventions.¹⁶ We can be committed to something (e.g. health) without making it override other considerations¹⁷ (e.g. the ethical production process of healthcare products).

Believers explores objections from the perspective of the patient (or their proxy), while Deathwalker makes one reflect on whether a treatment should be developed at all. The juxtaposition of the two episodes also highlights that while officials can have strong ethical objections to a particular intervention, they can be unappreciative of patients’ commitments to their own beliefs and hierarchy of values. While not stated explicitly in Deathwalker, Dr Franklin would probably be passionate about the fact that we should not be sacrificing other people’s lives for our own longevity and health – acknowledging that medicine is subject to ethical constraints. Yet, despite living in a highly pluralistic environment, he failed to appreciate that others might regard a particular intervention as unethical due to its consequences and he was happy to carry out the intervention (with grave consequence). Though Deathwalker did not manage to hand over the serum to the Earth government, Earth government was quite keen on acquiring it and if it was successful it is likely that it would propagate it, and perhaps try to force Dr Franklin to administer it to people. Dr Franklin would most likely object to this (despite his commitment to the health and wellbeing of his patients), with his objection potentially not being any more comprehensible to a civil servant enforcing this policy than the parents’ objection to surgery was to Dr Franklin in the Believers episode. As such, these cases highlight that while we might be passionate about our own ethical beliefs, we can be quite dismissive of other people’s idiosyncrasies, even if they are similar to ours in philosophically relevant aspects.

Babylon 5, as a space station, was a cosmopolitan place: its inhabitants had a variety of world views, different physiological requirements and medical needs to which the station staff had to cater for. Multicultural countries are somewhat similar in this respect. In the UK this is reflected in the National Health Service (NHS) constitution, which principles state that the NHS’ services should be available to all irrespective of their background and that patients should be ‘at the heart of everything the NHS does’ and that it is accountable to those patients (Department of Health 2015). Moreover, the NHS’ values affirm that all patients count and nobody should be ‘excluded, discriminated against or left behind’ and that all the patients should be treated with compassion, respect and dignity (Department of Health 2015). Similarly, those developing vaccines and writing vaccination policies should take into account the specific medical requirements of various sectors of the population (e.g. those with allergies to specific ingredients) and should also cater to the range of moral beliefs held among their target populations and citizens (indeed for some vaccines vegan alternatives have been developed; Centers for Disease Control and Prevention 2017). Those in power should ensure that citizens have access to treatments they deem acceptable, for it would be odd for a secular and liberal state to cater for, and essentially enforce, only one moral outlook, considering that such a state limits itself from making judgements about the superiority of beliefs (including moral belief and judgements about which goods of life should be given a preference; MacIntyre 2013, p. 337, Oderberg 2017, Pruski 2019; Finnis 2011). As such, for a state to make a claim that health and efficiency should be pursued to the detriment of other goods, and valued over ethical commitments, seems untenable. Though, this does not mean that pluralism implies complete relativsim (Wilkinson 2020).

Ethical considerations are important in all our daily activities, ranging from the choice of products we buy to how we interact with others, and it would be odd to assume that it should be any different with regards to health.¹⁸ Indeed, this issue has been highlighted in the current debate surrounding the development of COVID-19 vaccines.

COVID-19 vaccines

The development of COVID-19 vaccines brought to attention both issues of safety and ethics, and in some instances both types of objections are interconnected. I wish to highlight three events relating to COVID-19 vaccines: a statement made by some Australian Christian leaders, a UK consultation on vaccination, and the development of a COVID-19 vaccine in China. I will argue that these cases point to reasonable objections that someone can hold despite the data demonstrating that these vaccines are in general safe and effective (see e.g. Pfizer 2020).

HEK293 and religious leaders

Australian Christian leaders from the Catholic, Orthodox and Anglican Churches have raised concerns regarding a deal struck between the Australian government and AstraZenaca which, in conjunction with Oxford University, developed a COVID-19 vaccine that is produced using the HEK293 cell line.¹⁹ Though this has been widely reported in the media (see e.g. Rachwani 2020), the nature of the concern seems to have been misrepresented (Bowling 2020). HEK293 is a cell line developed from a human foetal kidney (the acronym HEK refers to human embryonic kidney) most likely obtained from the remains of an elective abortion subject (van der Eb 2001).²⁰ Use of cell lines derived from human embryonic or foetal tissues and products derived from such cell lines has been debated among Catholic scholars, with an official statement made by the Vatican in 2005 (Wong 2006, Treloar 2019, Pontifical Academy for Life 2005, Watt 2020, Austriaco 2020) and in 2008 reaffirmed in Dignitas Personae (Congregation for the Doctrine of the Faith 2008). The provision and use of vaccines developed with such cells were deemed by Catholic Church authorities to be ‘very remote mediate material cooperation’ with evil (Pontifical Academy for Life 2005). This means that the healthcare staff and patients using such vaccines would be greatly removed in time or material connection from the evil act and would not share the intention of the associated evil, i.e. the original elective abortion (Pontifical Academy for Life 2005, Fisher 2012). In essence, the Church document meant that parents could let their children be vaccinated with such a product if there was a proportionately serious risk associated with them not getting the vaccination and there was no alternative available, but that Catholics could not use these cell lines in research. Importantly, it does not force the faithful to obtain such a vaccination for their children, but only permits it, and still states that ‘everyone has the duty to make known their disagreement and to ask that their healthcare system make other types of vaccines available’ (Congregation for the Doctrine of the Faith 2008, para.35).²¹ Indeed one instance showing the overall commitment of Catholics towards ensuring that appropriate vaccines will be available to the whole world population is that at least one priest-scientists is working on a COVID-19 vaccine that would be more accessible in poor countries and does not involve the use of such controversial cells lines (Picón 2021). Secondly, the UK and US bishops have highlighted that taking a vaccine can be viewed as an act of charity towards one's neighbour (Moth 2020; United States Conference of Catholic Bishops 2020).

Archbishop Fisher, one of the aforementioned Church leaders, himself a bioethicist who has written on the problem of cooperation with evil (Fisher 1994, 2012), clarified what he meant in the statement (Bowling 2020), i.e. that considering the fact that there are many COVID-19 vaccine trials underway (Gallagher 2020), offering an alternative to this product, which is seen as morally problematic to many, would seem to be the right thing to do. While the Church’s stance is ethics based,²² it seems that if a secular and liberal government could cater to this ethical view, it should at least do so to support compliance with vaccination, if not to also support its citizens’ religious freedom and cater to a variety of worldviews (see e.g. the aforementioned point about the commitment of the NHS to cater to the diversity of its patients). Of course, to a Catholic healthcare practitioner the dilemma resembles the Deathwalker scenario, though only one person had to die for all to receive the treatment (and the abortion did not happen specifically for this treatment to be developed)²³, and the healthcare worker too might feel moral distress from delivering such a tainted intervention. Moreover, many religious groups do not have a centralised body that could speak for the faithful (Rachwani 2020) and these might hold stronger ethical objections to the use of such a vaccine than the Catholic Church does.²⁴ Noteworthy, if vegans have made statements that taking a vaccine that has been tested on animals is not in agreement with their moral commitments (even if the final product does not contain animal-derived products; Newkey-Burden 2020, The Vegan Society 2020), it should not be surprising that those holding a pro-life outlook oppose vaccines developed on human foetal cell lines.

Of course, people could argue that a vaccine produced using HEK293 cells might be available sooner rather than others, that it might be more effective or that the Church should concentrate exclusively on promoting the public health response to COVID-19. But while it would make sense to choose the most efficient option from the ethically acceptable ones, concentrating solely on efficiency risks forgetting all the lessons we learned from tragic events of human experimentation and medical exploitation. The Church, or anyone else who might hold objections to some of the developed vaccines, can still promote health while carrying about ethics. Indeed, this is the same attitude we would want from a doctor – to care for patients without engaging in unethical practices, such as sourcing transplant organs from political prisoners – to heal us without harming others.

Temporary authorisation

Earlier during the COVID-19 pandemic, the UK government held a public consultation (GOV.UK 2020a) on whether a potential COVID-19 vaccine could be given temporary authorisation for use rather than going through the ‘usual marketing authorisation (product licensing) process’ ‘if there is a compelling case, on public health grounds, for using a vaccine before it is given a product licence, given the nature of the threat we face’ (GOV.UK 2020a). The consultation further highlighted that

A COVID-19 vaccine would only be authorised in this way if the UK’s licensing authority was satisfied that there is sufficient evidence to demonstrate the safety, quality and efficacy of the vaccine.²⁵ ‘Unlicensed’ does not mean ‘untested’: this temporary authorisation process exists to address the possibility that, in certain situations of public health need, the licensing authority may consider that the balance of risk and benefit to patients justifies the temporary supply of the relevant vaccine pending the issue of a product licence. (GOV.UK 2020a)

Such a temporary authorisation would mean that ‘key actors in the medicines supply chain cannot generally be sued in the civil courts for the consequences resulting from the use of an unlicensed product, or a new use of a licensed product, that a national licensing authority is recommending in order to deal with certain specific health threats’ (GOV.UK 2020a).

It does not seem unreasonable that given a certain magnitude of threat we might take a gamble in implementing a mitigating action that is likely to avert it but that has some risk attached to that action (Savulescu 2021). Yet, one can appreciate that the combination of ‘unlicensed’ and ‘cannot generally be sued in the civil courts for the consequences’ can cause some to worry. Those offered the vaccine would be excused if their assessment of the ‘balance of risk and benefit’ might be different than that of the UK’s licensing authority. Similarly, clinicians might not be keen to take-up such a product if their first concern is to do no harm. Moreover, public confidence has probably not been increased with the news that the White House (LaFraniere and Weiland 2020) has blocked attempts by regulators to enforce a robust standard for the licensing of a COVID-19 vaccine in the USA. It would be unreasonable to judge someone’s unfavourable safety assessment of a vaccine as subpar if the vaccine did not go through the usual process of licensing and safety validation (especially with respect to long-term side-effects). Such an expedited vaccine rollout might be the correct thing to do, but one should not claim that such a vaccine has been fully tested.

While antivaxxer-like general scepticism to vaccination should be viewed with suspicion, concerns about products that have been brought via an expedited route should not be treated with such suspicion given both the troubled (not so distant) history of medical product evaluation (Goldacre 2012) and long-term medical problems associated with two different H1N1 vaccines (Narcolepsy UK 2020, Fisher 2020).²⁶ At the time of the consultation, long-term safety data was simply not available for the Pfizer–BioNTech vaccine which ‘has completed only a few months of the two-year clinical-trial period that it will need to complete before it is approved to be sold freely on the market’ (Ledford et al. 2020). Some people might wish to have such long-term data available when making their informed consent decision on vaccination. This is not to doubt the genuineness of the safety assessment carried out by the UK authorities (Raine 2020),²⁷ but to simply recognise that people might wish to have more information before making a decision. Similarly, strongly highlighting that a vaccine has been tested can be misleading as for example the Pfizer-BioNTech vaccine has not been tested in such a way as to provide sufficient data on its safety in pregnant women (WHO 2021) – testing has its limitations and the public should know these. Mistrust is not created by healthy critique of something one generally supports, but by the creation of an atmosphere where any critique, even if justified, is viewed as a faux pas. In science, a healthy dose of justified scepticism should be viewed as a good thing and not as something that undermines trust in a procedure or product.

Ethics of trials

The last case I will highlight is that of China’s development of a vaccine with the aid of its military – a case presenting issues of both ethics and safety. First of all, when clear descriptions of the voluntariness of the military personnel’s, as subjects, in these studies is absent (Lewis 2020), one cannot be sure whether normal procedures of consent were respected. It does not necessarily follow that if soldiers can be sent into dangerous battle situations during war-time, they can be subjected to dangerous experiments during peace-time. This lack of complete information on the subjects’ consent status might also trigger suspicion about the completeness of the reported data, consequently casting a shadow over the vaccine's effectiveness and safety profile. Again, such a concern could be voiced by both patients receiving and clinicians administering the vaccine (and if the vaccine would be administered to those most at risk of COVID-19, high proportions of the patients would probably be clinicians themselves).

Objections to the use of such a vaccine mirror the situation presented in Deathwalker. The use of subjects who did not give informed consent is morally repugnant to most people,²⁸ indeed voluntary participation in clinical research was a key point highlighted by the Nuremberg Code (Judges of the American military tribunal 1947). Furthermore, there is a discussion about the scientific validity of past trials that were conducted without such consent, like those performed by the Nazis on their wartime prisoners (Post 1991, Moe 1984, Jewish Virtual Library N.D.). While such trials could still be conducted in a scientifically rigorous manner, such doubts mean that the uptake of such a vaccine could be low. One would certainly not give such a vaccine to one’s child or offer it to a patient if there was a suspicion of gross safety issues.

Discussion

The two Babylon 5 episodes highlight that objections to a treatment can be made on both ethical and safety grounds. These can be based on people’s ethical and metaphysical beliefs,or their prioritisation of goods of life that allows them to make a risk-benefit evaluation. What the juxtaposition of these episodes also revealed is that while we might hold fast to our beliefs we might be prompt to dismiss those of others, even if they are no more irrational than our own idiosyncrasies.

The opposition to some of the COVID-19 vaccines should not be merely dismissed as an anti-vaxxer delusion. Safety concerns for a promptly developed vaccine (when people are used to much longer developmental processes), that might not be licensed the usual way and without long-term data on side-effects (which if they occurred there would be a limit on the manufacturer’s liability) are not completely out of place – of course this is not to suspect that any foul play actually occurred or dismiss the possibility that they will be perfectly well-working vaccines. As to ethical concerns (problems with vaccines tested without the consent of the subjects or developed via a morally tainted cell line) they should be appreciated by political leaders, for it was not that long ago when medical atrocities were conducted on unwilling groups or when scandals arouse due to biological tissue being obtained without the people’s consent (Nice et al. 2019, Brandt 1978).

Safety and ethical concerns regarding specific vaccines should, as such, not be lumped together with anti-vaxxer objections, and then dismissed because we can dismiss the anti-vaxxer rhetoric – just because we can dismiss the weakest objection does not mean that we can dismiss all objections. Such an attitude would suggest a ban on scepticism in science, and would run counter to the spirit of rigorous inquiry, that the history of previous problems in medicine certainly warrants (Goldacre 2012). While a utilitarian outlook could call for the dismissal of other ethical concerns and (with the by-and-large well established safety and benefit profile of vaccines) also dismiss some speculative long-term concerns, given the NHS’ dedication to respect its diverse patient population (Department of Health 2015), the ends cannot justify all means.²⁹ As much as NHS commissioning (and government purchases) should take into account vegan staff and patients with regards to the delivery of flu vaccination, it should also consider the pro-life sector of the population with respect to COVID-19 vaccines. Some vaccines were produced without the use of these cell lines (though not the one discussed in the 'ethics of trials' section, as its development involved HEK293 cells), potentially including the GSK/Sanofi Pasteur and Valneva vaccines purchased by the UK government, but there is not sufficient information to confirm this (GOV.UK 2020b, Charlotte Lozier Institute 2020).

Finally, those administering the vaccine need to be aware of how it was developed, produced and tested, so as to be able to give this information to the patients. Patients who have strong beliefs regarding the ethics of the products they use require this information for giving informed consent.³⁰ A person worried about the long-term safety of a vaccine or a person holding strong pro-life views should be treated no differently with regards to vaccination than a vegan concerned that a vaccine might have been produced using hens eggs. It is not acceptable for a clinician to tell a patient to ‘either take it or not’, or to tell the patient to do their own research at home, especially if in most cases the patient is not told in advance what product will they be offered. When different products are available, clinicians should give patients the option to choose which vaccine they prefer,³¹ and where different products are not available, they should lobby for them to become available and so promote patient integrity (Pellegrino and Thomasma 1993).

Conclusion

While it is important that we promptly address the scourge of COVID-19, let the potential medicine not lead to another disaster by causing more scepticism about vaccination, which is overall a safe intervention and one of the main causes of a reduced infectious disease burden around the world. Rather than increasing the grounds for suspicion of vaccination, governments would do well to ensure that the vaccines sourced are ethically acceptable to the people and that their safety is adequately advertised. Moreover, when long-term safety data is not available, we should not be surprised when those who wish to have such information before giving consent to vaccination refuse to be inoculated. We facilitate patient choice in other areas of medicine despite the inefficiencies that result from this, as well as ensure patient safety and accept refusals from competent patients on whatever grounds they wish – why should it be different for vaccination? If people hand governments the solution³² to increased vaccination levels, perhaps it will pay off for governments to listen to the people (and fulfil their commitment to their diverse citizenry) and not claim that everyone who refuses a specific vaccine product is irrational. Catering to wide-ranging worldviews and respect for ethics were some of the foundations of the success of Babylon 5 as a space station – they might well be the foundations for a successful vaccination programme.

Acknowledgement

The author wishes to thank Xavier Symonds for comments on an earlier draft of this manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Michal Pruski

Michal Pruski is a registered Clinical Scientist. His academic background is in cellular neuroscience, bioethics and critical care. He currently works in clinical vascular ultrasound and the evaluation of healthcare interventions.

Notes

1 A real-world example would involve Jehovah’s Witness parents whose child requires a blood transfusion (Gamble and Pruski 2020).

2 This point is previously stated by the boy’s father who states that ‘[t]here are more important things in life than the next breath’ circa 17:26 minutes, and is later reiterated by the boy’s mother when Dr Franklin states that ‘[t]he child deserves a chance at life’ and she replies ‘[y]es, but without a spirit it isn’t life at all. You know that’ circa 31:06 minutes.

3 Another dialogue also highlighted the issue of state interference in a pluralistic society: Ambassador Delenn: Matters of the soul are very private, very personal to us. We have suffered the interference of others in this area, and are thus, ourselves, forbidden to intervene in matters such as this./ Parent: You are refusing because of your beliefs? We thought the Minbari were the most intelligent of all races. We are only trying to save our child./ Ambassador Delenn: That is also what Dr Franklin believes he is doing. Whose belief is correct and how do we prove it? No. On this issue the Minbari cannot take sides - circa 22:42 minutes.

4 Similarly to the youth serum from the Wachowskis’ ‘Jupiter Ascending’.

5 Some might argue that foetal cell transplants, e.g. for Parkinson's disease (Lindvall 2015), involve a similarly ethically problematic practice.

6 There can also be objection against compulsory vaccination, but here I only consider objections to specific vaccines. However, this is an important topic to consider in the COVID-19 debate, (especially in light of restrictive COVID-19 measures such as radical limitations on freedom of movement), as is the issue of the extent to which parents versus the state should be making decisions on behalf of children (see e.g. Pruski and Gamble 2019, Gamble and Pruski 2020 for a general discussion on this issue).

7 This means that if vaccination passports (Hern 2021, Ada Lovelace Institute 2021, Brown et al. 2020, Lawrie 2021) were to become a common reality, they would potentially increase inequality, for those who already are more burdened by having a medical conditions (and in some countries are protected by anti-discriminatory laws) would also be discriminated against in respect to travel. This should be something considered by those arguing for compulsory vaccination and the penalisation of those who choose not to be vaccinated, for they often advocate for such compulsory vaccination exactly to protect these vulnerable groups (Savulescu 2021). Of course, the matter of vaccination passports is subject to a plethora of other arguments as well, e.g. those relating to the efficiency of the process (Kofler and Baylis 2020). When Kofler and Baylis (2020) mention a ‘dystopian future’ in this context it also brings to mind Gattaca (1998).

8 This contraindication usually exists because a given vaccine might not have been tested on a sufficient population of pregnant women to confirm its safety, rather than because it has been shown to be dangerous if administered during pregnancy. Some vaccinations are, on the other hand, encouraged during pregnancy.

9 For cases of vaccination related compensations see Looker and Kelly (2011).

10 From an epistemological point of view, no medical professional can guarantee that a vaccination will have no adverse effect on a particular patient or that it will protect them effectively from the specified disease, the best they can do is give statistics on previously recorded effects (Flanagan-Klygis et al. 2005, Zimmerman 2006).

11 Even with respect to some COVID-19 vaccines there was debate ‘about pork or bovine gelatine used in some vaccines’ (Rachwani, 2020).

12 Though people can be vegan for religious reasons and at the core of the Catholic objection is a pro-life viewpoint that does not require a religious commitment.

13 Those holding strong pro-life views might object to such interventions as mentioned in footnote 5.

14 In Believers (circa 08:35 min.) Dr Franklin notes that ‘[y]ou never insult a patient’s beliefs! You work with them, you try to understand their concerns, you give them a reason to be on your side’, here the parents are already on the side of vaccination, one just has to address their concerns, and since they have most likely used vaccination before, these concerns should be realistic to address’.

15 See the earlier quoted dialogue between the Commander and Dr Franklin, and the parental replies to the doctor in footnote 2.

16 Additionally, there is no universally accepted denominator to balance the different goods of life (Finnis 2011).

17 This is also the case with respect to lockdown considerations (Pruski 2020).

18 Similarly, reproduction is not a value that trumps others for Catholics (as highlighted by their refusal of many assistive reproductive interventions) despite their reputation for having large families.

19 There are a lot vaccines that are predominantly or exclusively produced using cell lines derived from aborted human foetuses, e.g. the Rubella vaccine or the Hepatitis A vaccine (Treloar 2019).

20 Though van der Eb (2001) is probably the best formal account of how this cell line came to be, Austriaco (2020) notes that in private correspondence with the cell line’s creator, Professor Frank Graham stated that the exact origin of the foetal cells is unclear.

21 As such, the Catholic Bishops' Conference of England and Wales’ statement seems to correctly interpret the licitness of the Catholic faithful’s use of a COVID-19 vaccine developed from such cells, but ignores to exhort the faithful to lobby the government to provide what the Catholic Church would regard as ethical alternatives to such vaccines (Moth 2020). The American Catholic Bishops’ statement does state that the faithful should avoid using a vaccine produced using such cells (i.e. AstraZeneca) if an alternative is available that e.g. only used such cells in testing (i.e. Pfizer and Moderna vaccines; United States Conference of Catholic Bishops 2020).

22 Though as in Believers, the Church’s stance is also based on metaphysical assumptions about the personhood of the embryo from which the HEK293 cell line was developed.

23 Nevertheless, the public might have been more appreciative of the gravity of the matter if the kidney was not obtained from a foetus but e.g. from a political prisoner, or if the process of producing the cell line involved killing a born child, for the Catholic Church views the use of HEK293 as violating such same dignity (Congregation for the Doctrine of the Faith 2008).

24 See e.g. Brennan (2020) – a Protestant demonstrating a firmer stance. Indeed, it could be argued that unless such a firmer stance is taken, objections to the use of cell lines such as HEK293 will not be taken seriously.

25 It was rather unfortunate that while the Pfizer-BioNTech vaccine was advertised as safe and tested, soon after its roll-out guidance had to be changed because two healthcare workers had an allergic reaction after its administration (Lovett 2020). There have also been some concerns regarding this vaccine’s safety due to deaths reported among the elderly who have received it in Norway (Conifer 2021), though the link between these deaths and the vaccine has been dismissed (Taraldsen 2021). Similarly, the Oxford/AstraZeneca vaccine has been investigated with respect to links with disseminated intravascular coagulation, resulting in some changes in how that vaccine was offered to certain age groups and the term ’vaccine induced thrombosis and thrombocytopenia’ coming about (European Medicines Agency 2021, Triggle 2021, British Society for Haematology 2021). Issues surrounding blood clots were also brought to the public attention in relation to the Johnson & Johnson vaccine in the USA (BBC 2021).These incidents highlight both the precaution needed in how a vaccine’s safety is advertised when it is made available through an expedited approval route, but also that due vigilance is beening taken to continue the safety monitoring of the vaccines. Moreover, one needs to remember that the world-wide scale of these blood clot events (even if they were all due to the vaccines, which they might not have been) would still be magnitudes lower than the 10400 deaths that were likely averted in England alone due to vaccinations between December 2020 and March 2021 (Public Health England 2021).

26 The swine flu Pandremix vaccine was associated with a rise of narcolepsy that resulted in victim compensation being paid in the UK (Narcolepsy UK 2020). In 1976 a controversy resulted from Ford’s vaccination programme where compensations were made to those who developed Guillain-Barre syndrome following their vaccination (Fisher 2020). The Centers for Disease Control and Prevention notes that '[s]tudies suggest that it is more likely that a person will get GBS after getting the flu than after vaccination' (CDC 2020).

27 There should not be any suspicion in how quickly these vaccines have been developed as this is largely due to scientific progress and efficient management of the development and testing processes, rather than due to rushed work (Davis 2020). On the other hand, changing the vaccination schedule (Neville and Mancini 2020) did raise some criticism regarding the evidence basis behind this (Lintern 2021, Iacobucci and Mahase 2021). These criticisms did seem to be warranted and the data on single dose effectiveness might perhaps not have been as accurate as was thought originally (Beaumont 2021).

28 Though, to reiterate the point, this is largely how the Catholic Church views the development of the HEK293 cell line and other cell lines developed from samples taken from aborted foetuses.

29 Of course, some will wish to highlight the huge public impact of contagious disease outbreaks and their impact on other people’s lives. This issue is not the subject of this manuscript, but it is worth noting that we do not force patients to undergo treatments that will in the long run be most efficient for the economy, nor do we make it compulsory for HIV patients to take medication so as to reduce the chances of them accidentally passing on the virus to others.

30 See Rodger (2021) for a discussion of the relevant U.K. laws and guidance in relation to a parallel issue of the use of animal-derived components in medical products, and how this relates toissues of informed consent and respect for autonomy.

31 E.g. the Welsh Government website explicitly states that patients do not have a choice as to which COVID-19 vaccine they can receive (GOV.Wales 2021).

32 There is generally little discussion on how to address fears surrounding vaccination in a constructive way, as opposed to about how to enforce higher vaccination uptake (Berry et al. 2017, Black and Rappuoli 2010, Larson et al. 2011).