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The Optimal Use of Suboptimal Vaccines

There's an interesting piece in the NYT warning against hasty FDA approval of a (potentially) suboptimal covid vaccine.  I'm especially interested in the third reason they offer:Third, the F.D.A. must consider the impact of an emergency authorization on existing vaccine studies. There are almost 40 continuing vaccine clinical trials, and several have been identified as promising. Those trials are blind, which means that the participants do not know whether they are getting the vaccine or a placebo. Would some participants drop out and opt for the newly authorized vaccine, undermining those studies? Would the trials be able to recruit additional participants who would risk getting a placebo once there was an authorized vaccine?It would seem pretty messed up if we had to deprive millions of people of a potentially life-saving vaccine (say, one that might cut covid fatalities by half) because that was the only way to ensure that we could find unvaccinated volunteers to test (potentially) better vaccines (to find one that would ultimately bring about the swiftest end to the pandemic).  Ideally, we should want most people to make use of the suboptimal vaccine in the meantime, whilst incentivizing/compensating research participants to forego the current vaccine and instead stick with their trials, to help society find an even better vaccine.If only our society had invented some means of exchange that could be used to provide the necessary incentive/compensation!  [More]

Against Prudish Research Ethics

We're all familiar with prudishness as it applies to sexual ethics: the prude thinks certain sex acts are immoral, even between happily consenting adults.  They also hold that sex work is inherently degrading, and that others should not be allowed to offer monetary compensation in exchange for one's sexual labour.  The prude is not willing to tolerate others engaging in consensual and mutually beneficial exchanges in this arena if they don't stem from what the prude regards as the "right" motivations and take place within "approved" institutional arrangements (e.g. marriage).  It's a deeply illiberal perspective that has thankfully fallen out of favour in recent decades.  We may, of course, have reasonable concerns about the exploitation of sex workers in practice.  But it's increasingly recognized that the best response to such practical concerns is to improve the options available to those in desperate circumstances, not to deprive them of (what they evidently regard as) their current best option.  So I think it's fair to say that liberals have won out over sexual prudes in our current cultural milieu.Sadly, the reverse appears true within the arena of research ethics.  Research prudes think that certain kinds of medical research (e.g. involving voluntary infection) are unethical, even when all involved are happily consenting adults.  They disapprove of offering monetary compensation to research participants, to make [More]

Innocuous vs Unjust Systemic Discrimination

It's now widely recognized that problematic discrimination need not involve malicious attitudes: certain political structures might systematically disregard the interests of ethnic minorities, for example, even if nobody involved was "racist" in the traditional sense of harbouring prejudicial attitudes.  Still, sometimes people -- even highly-respected philosophers! -- move from this to the opposite error of assuming that any disparity in group outcomes is in itself constitutive of unjust discrimination against the disadvantaged group.  I've found this especially common in debates about QALYs. (One may, of course, raise reasonable questions about how QALY values are determined in practice: perhaps they fail to accurately track the welfare facts in some cases, adjusting down for certain disabilities that are actually harmless. But my target here is the more sweeping complaint that any form of the metric will be "ageist" and "ableist" simply in virtue of its being systematically disadvantageous for the elderly and (detrimentally) disabled, relative to an alternative system that sought to indiscriminately save as many lives as possible.)Granted, if a vulnerable group is systematically disadvantaged in some context, that will often be a sign of unjust discrimination: we know it's not uncommon for minority interests to be systematically disregarded, after all, so that will often be a natural hypothesis for explaining disparate outcomes. (I think this is true of [More]

Three Neglected Advantages of Controlled Infection

I've increasingly come to think that my previous post on when SARS-CoV-2 Controlled Voluntary Infection is worthwhile was excessively pessimistic.  I previously noted the benefits of low viral load (variolation), timing the burden on the medical system, and enabling people to safely return to normal life.  Three additional factors to consider include:(1) Controlled infection enables pre-symptomatic treatment, which tends to be more effective (in some cases yielding "virtually total protection" against an illness whilst still developing protective antibodies and subsequent immunity to reinfection).(2) Reducing accidental spread.  Each person who undergoes CVI (followed by two weeks quarantine) is someone who won't unknowingly acquire an asymptomatic (or pre-symptomatic) infection and spread it to others without realizing.  This makes everyone else much safer.(3) With reduced spread comes reduced overshoot beyond herd immunity.It's completely insane that nobody seems to doing the necessary research to find out just how effective CVI could be, especially when some parts of the world are (either deliberately or de facto) pursuing a strategy of herd immunity via uncontrolled infectious spread, which we have every reason to expect to be vastly [More]

Op-ed on Pandemic Ethics

Co-authored with Peter Singer, 'Pandemic ethics: The case for experiments on human volunteers' was published online yesterday in the Washington Post!We begin:The pandemic has thrown previous moral assumptions into disarray. Most of us now accept restrictions on our freedom of movement and association that would have seemed unthinkable just a few months ago. Yet the research we are willing to do to combat the virus is still governed by assumptions developed in calmer times when less was at stake.Research ethics normally prohibits exposing human subjects to significant risk. The overriding aim is to prevent their exploitation by researchers whose interests may not coincide with those of the individual patient. But in a pandemic, the overriding aim must be to avoid a potentially catastrophic toll. We all face such heightened risk that restrictions on promising research (beyond the basic requirement of informed consent) could easily prove counterproductive in humanitarian terms.We discuss three kinds of "risky" research: (i) skipping lengthy animal trials for promising treatments, (ii) human challenge trials for vaccines (though what we say here could also extend to more speculative theories, e.g. using challenge trials to test the possibility of cross-immunity from cold coronaviruses), and (iii) variolation.  Regarding the latter, we argue:The seriousness of the coronavirus cuts both ways: more risk from the initial low-dose infection, but greater benefits if it does [More]

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