European health agencies this week faced, with millions of lives in the balance, a staggeringly high-stakes incarnation of what ethicists call the trolley problem.
Imagine standing at a railway switch. If you do nothing, a trolley barreling down the track will hit three people in its path. If you pull the lever, the trolley will divert to an alternate track with one person. Which option is morally preferable: deliberately killing one person or passively allowing three to die?
In Europe’s version, German regulators identified seven cases of a rare cerebral blood clot, three of them fatal, out of 1.6 million who had received the AstraZeneca vaccine. Regulators had no proof they were linked, only a statistical anomaly. Still, continuing vaccinations might make them responsible for putting a handful of people in harm’s way — like pulling the lever on the trolley tracks.
Instead, the German authorities withdrew approval for the vaccine starting Monday. Neighboring countries followed, waiting for the European Union drug regulator to deem the vaccine safe, which it did on Thursday.
a third viral wave claiming thousands of lives per day in Europe, even a brief pause seemed all but certain to imperil many more lives than the unproven, very rare side effect.
Still, medical ethics can be tricky. Experts tend to view Europe’s decision as either an understandable, if risky, cost-benefit calculation or, as the Oxford University ethicist Jeff McMahan put it, “a disastrous mistake.”
Dr. McMahan, who studies life-or-death dilemmas, said that the extra Covid deaths likely to occur would “be by omission, or by not doing anything, rather than by causing. But you have to ask, does that make any difference in this context?”
But Ruth Faden, a Johns Hopkins University bioethicist and vaccine policy expert, called the pause “an extremely tough call.”
“If the only thing that mattered was deploying the vaccine in such a way as to reduce severe disease and death as quickly as possible, then you just go ahead,” Dr. Faden said. But it isn’t. While countries that continued vaccinations “probably made the right call,” she said, Germany and others faced real considerations around public trust and ethical duty.
principle calls for pausing any policy that might bring unforeseen harms in order to study those harms before proceeding. Imposing blind risk, however small, on unknowing citizens would be wrong.
But Dr. Persad said that he had “never really been able to make sense of how you would apply that principle in a pandemic.”
For one, even if vaccinations did carry some risk or uncertainty, the risk and uncertainty introduced by withholding them, therefore allowing cases to spread, was surely higher. It was not as if infections paused for bureaucratic process.
For another, vaccinations are voluntary.
“This is not a case where you’re imposing risk on unconsenting people,” Dr. Persad said, and therefore violating the precautionary principle. “You’re allowing people to consensually protect themselves from a big risk by taking a very small one.”