Bioethics During the Pandemic


With Eric Meslin and Vardit Ravitsky





Vardit Ravistky: For the last six months, hundreds of millions of people have lined up for vaccination against COVID-19, an operation accompanied by worries, scares, occasional shortages and a blizzard of scientific studies. For Eric Meslin, President of the Council of Canadian Academies and 2020 Pierre Elliott Trudeau Foundation Mentor, the main issue though is what does the speed of vaccine development and deployment mean for the future of dynamic interplay among scientific, political, and ethical considerations. 


Eric Meslin: I think we all were caught by the surprise with the speed of the development of the vaccine, the speed with which the vaccine was reviewed by federal regulators and the speed with which the vaccines were being manufactured. This was unprecedented. And I don't think that word can be used enough or shouted out loudly enough, unprecedented. Even the bioethics community, who is often quite conservative in offering cautions and careful analysis of the design and conduct of research involving human participants were, if not warning, then certainly expressing concern to try and tamp down exuberant expectation about the vaccine. And yet, as you say, already a year later, we're not talking about will there ever be a vaccine? Which of the five, six or seven our best, which ones have high efficacy, safety? So it's an absolutely fascinating, almost mind bogglingly fast discussion that we have now found ourselves in a year later. I think what that's raised, though, are a set of revisiting of old ethics questions about the ethical issues that come up when you design and conduct vaccine research in particular. Remember, we still don't have an HIV vaccine almost 40 years after that disease faced us. So I think what it's done is two things. One is it's caused us to rethink what fast and speedy mean in relation to ethical and careful. And it's also done some really interesting sort of mind games on the public and on politicians about what the proper role should be and what the set of issues are that should be considered. 


Vardit Ravistky: So tell me more about how you see the interplay of science and politics or policies and what this fast evolution of policy based on crazy fast science does to the public.


Eric Meslin: Your Freudian slip when you say policies or politics, I think was not so Freudian. I think you actually nailed where some of the that dilemma is. And I don't want to keep coming back to how awesome that science is. I'm certainly a fan and a great supporter of great science. And it's just so important that we remember that this might have been fast in one way, but the vaccine development came after very impressive, long standing, well-established, good science science that was done in the laboratory. Science that was done many years ago, important genomic science, important epidemiologic science. So let's not leave aside that this crazy fast science didn't just emerge whole cloth by the snap of a finger. For those who understand how science and policy works, that science doesn't tell you what to do. Science gives you the facts, and it's up to policymakers to decide how to interpret and use them. I can say that I have a certain sympathy, but I'm also a little frustrated, that even our best and most trustworthy politicians have a hard time explaining fast moving science. We're at the moment where a vaccine is regarded as seventy nine percent effective, and the rest of the message might be lost. Effective at doing what? Preventing people from being admitted to hospital or dying, which is very different from preventing the infection so that the nuance of the science is often lost in the communication strategy of even our most articulate politicians when our politicians are less articulate. It's even more difficult. And that's why it's not surprising that you have frustration at the level of the public. Here in Ontario, we have a different set of issues than they do in Alberta or Saskatchewan or or Nova Scotia around availability of vaccine. So I think one of the triangulation problems is there is science which provides incomplete data in real time that may change over the course of weeks or months. That automatically triggers different kinds of policy responses or recommendations from public health authorities, which automatically triggers responses by the public. And it can get very messy and very frustrating. And I think that's what we what we see one year on, despite the, as we've said before, the phenomenal science that got us to this point.


Vardit Ravistky: So I loved how you recognize that this phenomenal science that you and I both admire did not start with the pandemic and that the vaccines are standing on the shoulders of many years of development. So in a sense, we were prepared for the vaccine development. And I'm wondering what you think about our preparedness in other areas.From your perspective, as someone who has been through these discussions for many years, were we prepared? Could we have been better prepared?


Eric Meslin: So those are two again, two good questions. Where are we prepared? Could we have been better prepared? The answer to the latter question is always yes. It's sort of the the easy way out. You can always be more informed, better prepared. There's no perfect example, because every epidemic, every outbreak is different from another in certain respects. But were we truly prepared to address a global pandemic of this kind. At this point in history, a novel coronavirus. It's not the first-time coronaviruses have been around. There have been many epidemics that involve coronaviruses. This is not an unusual piece of biology, but I think our public health, our political structure and I say our I mean, much of the world's political structures were unevenly prepared to make difficult decisions. And this is the most, most awkward part of this. The science which we thought would be the hardest part of this turned out to be, forgive me, the easiest part, the proof is that we've got six, seven vaccines ready. What was the hard part? Making tough calls about signing contracts with companies. What where the tough calls? How do we make lists of who will get access to the first vaccines? Another tough call. What do we do when the science changes and we have different options? So while I think we were prepared at a kind of scientific level. I don't think we were adequately prepared to deal with the obvious ethical challenges of making decisions under conditions of incomplete or uncertain data. That is the lesson that we've been learning over and over and over again for decades. But we seem to still not learn how to do something with the lesson that we have learned. Should there be a permanent standing pandemic committee in Canada? Should there be a permanent emergency response system set up in Canada? There's lots of things that we can say now, but I worry very deep that we will get over this current surge. We will all hopefully be vaccinated. We will cross our fingers and hope that five or 10 years from now, when the next pandemic comes, we will have remembered, not just learned, but remembered the lessons of what happened this time around. And I'm not suspect, but I I'm not overly confident because history has shown us that we have a hard time remembering what we think we learned. 


Vardit Ravistky: What can we do in the next few years not to go back to the normal of, oh, we'll figure it out when it happens, but rather really lay the groundwork so that we can address ethical tensions and ethical dilemmas in an informed and nuanced and effective and fast way, if this ever happens again. 


Eric Meslin: This may sound a bit heretical and sort of biting the hand that feeds, but I'm becoming increasingly convinced that unless we in the bioethics community can do a better job of empowering others to speak about ethical issues and challenges, then we will quickly become relegated to the sort of the chair at that table, a singular chair at the multi chair table where people go around the table to say, tell us what the ethics are. And the one person puts their ethics hand up and says, this is what the issues are. I think what we need to do a better job of doing is to, as I say, empower others to identify, prepare for and and prepare to respond to this to these issues.Everyone can be a bioethicist when you think that these are issues that affect value choices and decisions. But I worry that as we become so specialized and specialized as a field that we will simply be one other data point, one other voice in a sea of of many voices. So I think we have to learn how to do a couple of things. One is to train and train and train the next generation to be able to translate our ethical commitments, values, concerns and issues into useful technologies of communication, useful policy strategies so that know it's almost like when when Harry Truman famously said, you can get an awful lot done if you don't care who takes the credit. It shouldn't be like bioethicists should claim that they solve the ethical dilemmas for for pandemic influenza or for COVID-19 or for Ebola, but that it took an entire community of thoughtful scholars and members of the public who have their own values to bring. So we need to be thinking of ways of democratizing the expertise we have and enabling and empowering a society to recognize these issues for what they are, not always tragic dilemmas. So I think we need to do some reflection as a field about how we can contribute to the policy conversation on topics like this, especially when they affect everybody, and in particular those who are most vulnerable more than others. So the pandemic is highlighting not just public health and population health issues, but all of the interconnectedness topics that we see that that affect the health and welfare of the planet. I would. I hope that we would take this seriously and that the bioethics of the future not only accommodates this as a new topic in the anthology of bioethics topics to study, but that it might force us to revisit some of those foundational questions that start in the field and recommit ourselves to what it means for a country or a world to care and worry about the health and well-being of the planet. 


Vardit Ravistky: So I wanted to share something with you and get your take on it. I was just invited to be expert witness as an ethicist, something that never happened to me before by a government that is being sued by one of its citizens regarding the public health measures that it implemented, that citizen claims that his individual rights, his liberty is being limited in an unethical and maybe even unconstitutional way. And the government is saying this is what we need to do to protect the well-being of the public, to promote the common good. Now, this is, of course, one of the key ethical tensions throughout a pandemic. We're all limited. We're all sacrificing in order to to protect others. But what are the boundaries? What are the limits? What is the scope of the sacrifice that we can be expected to make? You know, we all talked about solidarity and compassion. Sometimes there are people who do not want to express solidarity, but they are forced to do so. I'd love to hear your thoughts about how we emerge out of this, not just in terms of vaccines, but as a community after four years of being so limited and now maybe wanting to reclaim our liberties and freedoms. What do you think?


Eric Meslin: Again, just to be a little provocative, I've been thinking about this issue with respect to covid-19 on one aspect of it that is being discussed. It may not be front page above the fold, but it's it's being discussed and it is what to do if you are a country that has extra vaccine available, should you keep it in case you need it, should you donate it to another needy country? What should you do with it? Because in some ways, the concept of philanthropy in public policy is a version of what John Rawls, the philosopher, was referring to when he sort of talks about justice, as we can judge a judge, a country or a judge a society by how well it treats the least well off. And I think in some ways, the discussion about how as a country we decide to stand up for our own citizens and the citizens of the rest of the world says a lot about a country and says a lot about the people in the country. So with that little preamble, I've come to the conclusion that on this little topic of vaccine surplus, if we were to call it that, it is and I don't like this phrase,It is not unethical for a country to say we are going to look after all the people in our sovereign nation and our nation state first. They are. And I'm not using the word citizen. I'm saying the people in our country, people who are here, here legally, maybe even people who may not have legal status. But we are looking after the people within our borders first. So it is not inappropriate or unethical for a country to look after its own first long philosophic history about one's moral intuition is strongest to care for people you know well and care for deeply as opposed to those that you don't. I do care for my immediate family, my wife and daughters, more than I care for the person four blocks away from me. I don't think that makes me a bad person. That probably makes me human. But what happens after you have assured yourself and your country that everyone, and then the next words are really important, have had a chance to be vaccinated, have been vaccinated if they wish. Is it at that point that we say we've asked everybody, they've all put their hand up and signed up? Not everyone is vaccinated. We haven't achieved herd immunity. Now we're going to make the leftover available to other countries who are going to use it. That is a really tricky place for an elected government to go. I personally think that a government’s that is well-off, and Canada is one of them, does have a moral obligation, once it has satisfied its primary obligations, to do something with the extra. But I do think that countries right now are grappling with what it means to be a sovereign national state with people within its borders that the country's elected officials have promised to look after as part of their social contract with society, and that, as a member of the family of nations, has another separate but important obligation to contribute to the welfare of the planet. And I think that when this comes up in your particular expert witness scenario, or even just as we all think about this on our own, this example serves for me as a good case study for how to do that, that balancing, because it can't simply be a knee jerk reaction. We'll give away all the extra. Well, it's a very nice thing. Should we save for a rainy day? Should we keep forever or should we give away? These are profound questions that are more than just about allocation of a scarce resource. They are about one. It needs to be a country that looks after the people within its borders and looks on behalf of the world where it can help those who are in need.


Vardit Ravistky: Thank you, Eric. Great points. A lot to think about and digest. Thank you so much, Eric. It was lovely chatting with you.


Eric Meslin: My pleasure. Thanks a lot.