Pandemics Flashcards
Re-discuss the concept of autonomy and liberal democracies
‘FREEDOM’ (AUTONOMY) IS CENTRAL TO LIBERAL DEMOCRACIES
- “That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.”
- On Liberty (1859) by JS Mill
- However, what constitutes harm such that intervention is appropriate:
- Is mere risk of harm sufficient?
- What degree of harm is required?
- Can mere speech harm?
- In ordinary times, the harm principle is an important factor in defining our freedom, primarily by restricting the scope of law and government; but what of extraordinary times?
- For example, in time of war (notionally, a collective existential threat) we might draft (compel) individuals into the armed services.
- Are there other reasons, such as entering a ‘state of emergency’, that justify making such exceptions?
Describe issues of autonmy and privacy as it relates to infectious disease
- Those with infectious diseases represent a (potential) harm to others.
- Whilst one might expect (employers to facilitate) an infectious colleague to take precautions—perhaps WFH, take a sick day, or wear a mask—one cannot be blamed for infecting others, at least for easily transmitted and commonly circulating diseases.
- Indeed, there are very few cases where the state has acted to constrain an individual’s liberty for this reason alone.
- Doing so temporarily may be justified (quarantine) and longer-term restrictions are deeply problematic (Typhoid Mary).
- The need to monitor diseases that pose a risk to public health some infectious diseases are legally notifiable.
- However, notifying authorities of a case is not necessarily the same as providing the authorities with the identity of the patient.
- Ordinarily, public health authorities track overall infection rates.
- Whether as a matter of their disease or, perhaps, their behavior, it is only when an individual poses a risk of infection to the public will they be monitored.
Describe the principles of vaccination and broadly outline Australia’s vaccine program
- Obviously, some notifiable diseases are also conditions that we are able to vaccinate against.
- Not only do vaccines protect individuals from specific diseases they are a vital part of ensuring modern public health, being vaccinated also protects others.
- That this is the case might change our view on the responsibility individuals have vis-à-vis posing a risk of infection to others.
- Most vaccines are delivered at various points in childhood per Australia’s National Immunization Program Schedule:
- This ranges from birth (Hep. B), 2, 4, 6 & 12 months (diphtheria, tetanus, pertussis, MMR, Hep. A.) Recently, HPV has been introduced in teenage years. Some variation for Aboriginal children esp. TB. and additional Pneumococcal shots.
- Some vaccines are delivered in adulthood, generally to specific sections of the population (healthcare workers, older people, those at ‘high-risk’).
Describe differences in vaccination of children vs adults
As previously noted:
- Patients can refuse treatment and, barring a lack of capacity, they can do so for any reason or none.
- Parents generally make medical decisions for their children; this has limits (best interests)
Should parents be able to refuse vaccinations on behalf of their child?
- Being vaccinated is generally in the child’s best interests, but given a high level of vaccination, the risk of infection is minimal (free-rider).
- Is direct intervention warranted? Perhaps not, but many states intervene indirectly e.g. not allowing un-, improperly or incompletely vaccinated children to attend school, whilst also placing a duty on parents to ensure their child is appropriately educated.
Can adults refuse vaccinations?
- Well, yes, but none are (yet*) mandated.
- Some healthcare professionals are strongly encouraged to get the (relatively ineffectual) flu vaccine.
Discuss the phenomenon of vaccine hesitancy
VACCINE HESITANCY
Despite vaccines being highly efficacious and incredibly safe, the phenomena of vaccine refusal or vaccine hesitancy has continued to grow (since Wakefield).
- Just prior to the pandemic, there was an outbreak of measles in NZ & the Pacific Islands. A fairly successful programme of vaccination was undertaken.
- However, given the pandemic seems to have increased hesitancy and distrust, such outbreaks may well reoccur.
- The mishandling of the AZ vaccine recommendations by the ATAGI (relative risk) arguably contributed to uncertainty and skepticism in Australia.
In a sense, the efficacy of certain childhood vaccinations has resulted in vaccination in general becoming a victim of its own success. It is, therefore, worth countering common assumptions,
- A vaccine may or may not produce sterilizing immunity, meaning the immune system eliminates the virus before the infected become infectious.
- Vaccination cannot prevent infection per se. This occurs when bodies encounter viruses, something that a vaccine cannot prevent.* Vaccines merely increase the rapidity and strength of our immune response.
Nevertheless, vaccination decreases the infection risk an individual represents and will, therefore, slow the overall rate of transmission.
Did we get it right?
Despite early evidence of significant resistance to C19 vaccination in the Australian population (and a late start to the roll out) rapid and widespread uptake meant we quickly became a highly vaccinated nation (+95%). However, take up of booster shots has been lower… any guesses for 3rd and 4th shots?
The underlying question here is what constitutes getting a vaccination program right during a pandemic? This is not distinct from:
- The effects of the virus, specifically death rates. It may also include who it is that is dying; Covid-19 does not kill young children (a flu pandemic will).
- The consequences of the kinds of measures being taken, such as lockdown, that vaccination will alleviate.
- The efficacy of the vaccination with regard to lowering infection rates and decreasing the severity of the illness caused by the virus.
- Public opinion and the populations response to the possibility of a mandate.
Ironically, widespread support for vaccination makes mandates* more possible, but also less necessary (and vice versa).
This is a political decision; it cannot be determined by ‘the science,’ ‘the ethics,’ or both combined.
What constitutes a (government) mandate?
When people raise mandates they suppose a government edit that requires citizens to get vaccinated. But what does this mean? The use of force? Prison or fines for those that refuse?
Various other proposals that would have in some sense required individuals to get vaccinated have been discussed, primarily in theory. This includes vaccine passports (to go out in public, to attend large events) and premiums on health insurance. Others have proposed incentives (entry in a lottery, additional paid sick days for those vaccinated). Are these mandates? Are they coercive?
In March 2020 Morrison promised vaccination would not be mandatory. Was he right to make this commitment at this time?
In 2021 some ‘essential workers’ (spanning Aged Care Workers and those working for electricity companies) were required to be vaccinated if they were to continue in their jobs. Does this contradict Morrison’s promise?
Shortly thereafter it was established that employers could legally require their employees to be vaccinated. Is it right that they can do so? Does this contradict Morrison’s promise?
What would contradict Morrison’s promise?
Describe other responses to notifiable disease (other than notifying, and vaccinating)
- Border Screening for SARS (travel questions; state of health; temp.)
- Legally mandated self-monitoring & reporting (yellow fever).
- What should Australia do about a measles outbreak in New Zealand? Close borders, require advance testing?
- Entry vs immigration.
Statutory rules must balance coercive and compulsory measures with individual liberties; they must be proportional. In the case of quarantine, they must be strictly necessary, according to the Siracusa Principles,
Quarantine does not necessarily mean being imprisoned: it can mean being required to stay at home if you have certain diseases. Most comply simply because when you’re sick, you do not want to go out. But if advice is ignored, it may be possible to escalate.
sDescribe the Siracusa principles
Limitations on rights (quarantine) must be ‘strictly necessary’:
- Respond to a pressing public or social need (health)
- Proportionately pursue a legit. aim (prevent spread of infect. dis.)
- Be the least restrictive means required for achieving the purpose
- All restrictive actions must be scientifically well-supported
- All information must be made available to the public
- All actions must be explained to those whose rights are restricted & to the public
- All actions must be subject to regular review and reconsideration.
- Basic needs such as food, water, medicine & preventive care should be provided.
- Communication with loved ones / caretakers will be permitted.
- Constraints on freedom will be applied equally.
- Patients will be compensated fairly for losses, including salary.
These are internationally agreed upon principles, but rarely prosecuted
Describe cases in which being diagnosed with a notifiable disease puts legal obligations on the patient
In some cases, the knowledge that you are infectious may place certain legal duties upon you.
For example, the NSW Public Health Act (2010) used to enjoin HIV+ individuals to disclose their status prior to sexual intercourse, although taking appropriate precautions provided a defense.
Now it simply enjoins all those with any listed notifiable disease to take appropriate precautions against infecting others (penalty: 6 months).
In the case of HIV, this can mean using condoms or maintaining a sufficiently low viral load via PreP.
During the pandemic knowledge that you were infected meant you were required to stay home, should we be doing the same for influenzas?
How might we enforce both regard and disregard for such requirements; law or culture? How do we protect those paid by the hour?
also COVID
Describe the biosecurity act
For the purposes of biosecurity, the state can exert greater control over individuals (including citizens) as and when they cross into Australia.
The Act provides officials with particular powers when it comes to listed diseases (COVID-19 added on 21/1/20). People can be held, tested, and, ultimately, kept or ordered into quarantine.
Sec. 60: Biosecurity Officers can issue control orders in relation to individuals who must comply with an isolation measure or a traveler movement measure for the first 72 hours. They do not have to comply with other orders (e.g. testing), but refusals to do so may result in isolation/movement orders while the view of the Chief Biosecurity Officer can be sought. Individuals must comply with orders made by CBOs!
Technically, individuals cannot be compelled to accept treatment (including vaccination). However, visas can be refused.
The act also allows declaration of Human Biosecurity Emergency (COVID declared on 18/3/20), 3-month sunset clause, but infinitely extendable.
Describe changes to the power of the state during pandemics
Ordinarily, powers to limit citizens’ liberties are highly constrained. However, in certain circumstances, governments can legally declare a state of emergency, thereby facilitating actions that would not normally be permitted.
- Typhoid Mary
- Historically, terrible consequences have resulted from the use of such powers. Thus, The Reichstag Fire Decree paved the way for the Third Reich. And Bush’s response to 9/11 led to torture of prisoners in Guantanamo Bay. (Also Julius Caesar and Emperor Palpatine).
During the pandemic, a declaration was made under the Biosecurity Act. Each state also made declarations under their own legislation. Doing so enabled lockdowns and various other responses to the pandemic.
“Accordingly, while COVID-19 has caused extraordinary economic and social upheaval, it has also been a significant constitutional event. Authorities have been empowered to impose restrictions on individual freedoms and movement that suspend constitutional norms, using directions that circumvent normal parliamentary scrutiny.”
The question we now face is whether or not we used these powers correctly during the pandemic.
What are some future directions for pandemic response?
There is probably no one right way to respond to the COVID 19 pandemic, and future pandemics may be very different. Even if hindsight suggests we should have done certain things differently, that does not mean it will be the right response to any future pandemic.
Independent and Government reports are starting to emerge (CSIRO, Ramsey Foundation’s Fault Lines), points being made include:
- Better targeting of financial support. (esp. sick leave, casual workers)
- Over-reliance on lockdown & border closure (state & national?).
- Schools should have stayed open (after the initial period)
- Transparent decision-making
- Build-in feedback processes (better use of data)
Bigger picture: ACDC, or investment on quarantine facilities?
