In our last blog post, we demystified the benefits and risks of the AstraZeneca vaccine.
Today, we will take a closer look into the ethical dilemma that politicians and public health advisors face in promoting the AstraZeneca vaccine, even when the benefits outweigh the risks.

The current situation: growing cases; low levels of fully vaccinated people

At the time of writing this article, over half of the country is under lockdown in a desperate effort to suppress the contagious Delta variant. Given the limited Pfizer vaccine supply, AstraZeneca seems to be the primary vaccine to immunise the population and allow Australia to return to some normalcy.
Indeed, the AstraZeneca vaccine is highly effective at protecting against symptomatic COVID-19. However, it has the severe, albeit rare, side effect of thrombosis with thrombocytopenia syndrome (TTS), which cause blood clots that may lead to hospitalisation and death.
Grappling with the risks and benefits of the AstraZeneca vaccine is a challenge faced by politicians and public health officials. For more information to contextualise the risks and benefits of the AstraZeneca vaccine, check out our previous blog post: ‘Is the AstraZeneca vaccine safe?’.
However, assuming there is a consensus amongst health advisors that the benefits of AstraZeneca outweigh the risks, there is still an ethical challenge facing politicians and public officials before about whether to encourage the use of AstraZeneca.

Framing the problem: the railway dilemma

The ethical challenge of the AstraZeneca vaccine is analogous to the railway dilemma.
Suppose there is a train charging down a track, on course to collide with and kill three people. There is no way to stop the train and move the three people to safety. It seems that their fate is sealed, that is, until you notice a lever beside you. You can divert the train onto a separate track and save the three people by pulling the lever. However, by doing so, the train will collide and kill one other individual instead. The question is, would you pull the lever to kill one individual to save the other three? What if, instead of three people saved, it was 300 or 3000?

The railway dilemma is analogous to the ethical challenge of the AstraZeneca vaccine. By allowing things to continue along their current course and not promoting the AstraZeneca vaccine to people under 60 years old, a more significant number of people will be hospitalised or die from COVID-19. However, by changing the health guidance, a smaller number of people might die from TTS instead.

While some may take a utilitarian approach and unequivocably pull the lever to save more people, others may find this simple arithmetic of comparing the number of lives saved insufficient to make this decision. Indeed, far fewer people may succumb to TTS with AstraZeneca than the number of people who will be hospitalised and die from COVID-19 as case numbers rise. Still, the people who will suffer from TTS will likely be different individuals from those who may end up being hospitalised or die from COVID-19. Therefore, changing the health guidance around the AstraZeneca vaccine for people under 60 years old is an active choice to change the course of events and bring severe ramifications to an innocent group of people to save a far greater number of other people.

Another perspective: the transplant lottery

There is another variant to the railway dilemma that further illuminates this moral challenge. Suppose you work in a hospital and are attending to three dying patients in desperate need of an organ transplant. One patient needs a heart transplant, another a lung transplant, and the final one needs a liver transplant. Unfortunately, there are no compatible hearts, lungs or livers available. It seems that all hope is lost. That is until you come up with an idea. You can save these three patients by sacrificing one random individual and transplanting their fully functioning and compatible heart, liver and lungs. You don’t want to be responsible for deciding who has this unlucky fate, so you create a ‘transplant lottery’ of everyone with compatible organs and choose a name at random. The unfortunate person selected will be sacrificed, but the three patients will be saved.

This reframed problem often presents a more significant ethical challenge, even for those who would not have hesitated in pulling the lever in the railway dilemma. Sacrificing a fully healthy adult for organ transplants violates the individual’s right to consent. Yet, this is in some respects, reflects the decision that the politicians and health officials must contend with: sacrificing a small group of innocent and healthy people to save a far greater number of potential COVID-19 patients.

A closer inspection of the hypothetical transplant lottery reveals one key difference with the AstraZeneca problem. In the case of AstraZeneca, people consent to the vaccination because they gain protection against COVID-19. In comparison, it is difficult to imagine people agreeing to the ‘transplant lottery’. However, in the same way that people gain protection from COVID-19 from the AstraZeneca vaccine, the hospital could similarly compensate those who enter the transplant lottery such that they consent with complete knowledge of the risks involved. Even when people willingly enter this transplant lottery because they perceive the benefits outweigh the risks, this problem is still ethically challenging.

While promoting the AstraZeneca vaccine for people under 60 years old may be less controversial than harvesting a healthy adult’s organs, politicians and public health advisors still have an ethical challenge on their hands. The inescapable reality is that Australia’s road to herd immunity will be determined by whether they can stomach the loss of a small number of innocent people to save countless more COVID-19 victims.

It is worth remembering that there are no risk-free choices for politicians, health advisors or indeed individuals. We each need to decide whether a vaccine with rare, albeit significant, side effects is better for us than taking our chances with COVID-19 while we wait for alternatives to be available (Which, by the way, aren’t entirely risk-free either). Finally, this is the main difference with the theoretical dilemmas raised in this article; every person involved (the entire Australian population) can make their own choices. This freedom of choice is what politicians are now relying on, encouraging people under 60 to make their own informed decision about the Astrazeneca vaccine, so they don’t have to make the hard decision to pull the lever.