The UK’s AstraZeneca vaccine decision strikes the right balance

Last week the Joint Committee on Vaccination and Immunisation (JCVI) recommended that people under the age of 30 be offered an alternative to the Oxford–AstraZeneca vaccine, in light of emerging evidence of dangerous blood clots in a tiny minority of those who have received that particular jab.

The announcement was made calmly – and greeted with little melodrama. On anything to do with vaccines, the UK system of regulation, communication and decision making appears to be well-functioning, and there appears to be little doubt that the Oxford–AstraZeneca decision is right and proportionate.

The decision in question is about a vaccine now or later, rather than not at all

When it comes to policies that affect the health of millions of people, the starting point is a crude kind of “act utilitarianism” familiar to anyone who has had to sit through a first-year ethics course. This demands that we choose whatever act will lead to the greatest overall wellbeing, which in this case means the prevention of death or serious disease. If a course of vaccines prevents 10,000 deaths from disease, but creates a risk of a thousand more from a side-effect, the crude act utilitarian would shrug and go ahead.

Yet such dry calculus is only a starting point. Students swiftly learn how blind adherence to such a course would recommend all sorts of actions regarded as deeply unethical: the classic counterexample to universal utilitarianism is of a doctor killing one patient to save five more, or police using torture to cut the incidence of crime. An individual’s rights have to be weighed in the balance, too, and particularly their right to retain some agency over decisions of life and death, and be fully informed of the risks that any one course may involve. Simple act utilitarianism also fails to capture the dynamic consequences of an action beyond its initial effect. In the hypothetical examples above, what such behaviour might do for trust in doctors or the police; in our current circumstances, what unthinking vaccine advocacy might do for long-term confidence in the programme.

If there were a straightforward formula for balancing a utilitarian calculus against alterative ethical considerations, the world could have been saved a few million pages of philosophy. It is a matter for case-by-case judgement. In this case, the regulator has struck the balance wisely. By identifying the age group for which there is a chance that the risk of blood clots outweighs the (equally tiny) risk of damage from Covid-19, it has a clear rationale for where the line should be drawn.

Note, too, that the decision is to give those in the sub-30 age range an option of a different jab if available, not a blanket ban on receiving the Oxford–AstraZeneca vaccine. When it comes to assessing tiny risks that largely affect an individual alone, that individual is where the decision should rest. It is fortunate that genuine alternatives exist, so that the decision in question is about a vaccine now or later, rather than not at all. The goal of national immunisation is barely affected.

The UK’s health establishment deserves credit for calm and clear communications

More surprising has been the UK public’s phlegmatic reaction, particularly in contrast to the vaccine hesitancy plaguing Europe with regard to AstraZeneca. A chunk of the credit for this must go to the calmer communication emanating from the UK’s health establishment. The graphics used by deputy Chief Medical Officer Jonathan Van Tam are a model of clarity^[1]; at a glance it is immediately apparent how the risk of blood clots stacks up against continued exposure to Covid-19. It also helps that the benefits of vaccination have been so apparent, so quickly in the UK – it is less than three months since the pandemic was killing well over a thousand people a day, a figure that is now well below a hundred. ^[2] In a normal vaccination drive, or any other attempt by the government to encourage behaviour with a tiny chance of improving life chances, there is a problem of the benefits not being sufficiently lurid and immediate to justify taking the trouble. Just a few weeks after such a deadly peak, that particular problem is absent.

The likelihood of dangerous new mutations, and consequent need for a constant programme of vaccination, makes all the more important such sensitive handling of issues like the emergence of blood clots. Public awareness of the value of vaccination may never be so high again. Reluctance might be fed from two sources; exaggeration of the risks of vaccination on the one hand, or insensitive denial of those risks on the other. Politicians, regulators and doctors have shown they knew how to strike the right balance in the fraught circumstances of early 2021. Hopefully, it is a skill they can hold onto for months and years to come.

1. Sparrow A, UK Covid: Van-Tam says AstraZeneca vaccine’s risk v benefit is finely balanced for younger people – as it happened, The Guardian, 7 April, (see 16:42), www.theguardian.com/politics/live/2021/apr/07/uk-covid-live-news-mhra-astrazeneca-vaccine-coronavirus-latest-updates
2. As the prime minister has emphasised, much of the reason for this fall in mortality lies with the strict lockdown observed since January; however, a particular fall in the more vaccinated elderly population does suggest a role for vaccination too.