“Of the more than 107,000 COVID-19 hospitalizations, fewer than 1,200 were in fully vaccinated patients (1.1%). That means that 98.9% of the hospitalizations occurred in unvaccinated persons. Vaccination is highly effective at preventing infection and if breakthrough infection does occur, vaccination uncouples infection from hospitalization and death.”
This is from an internal memo to employees of a hospital in which I work, July 2021. It’s available upon request with permission of the hospital system.
These undeniably impressive facts appear to make a clear-cut case for COVID vaccination – one that is apparently so clear it has been conferred into moral and existential imperative along with simultaneous disdain for the decision to (and increasingly, the people who) decline its benefits. The president and others are calling COVID vaccination patriotic duty and obligation to humanity, and on August 3 the president issued additional highly coercive mandates to federal employees and “anyone else who wants to do business with the government.”
I do not oppose vaccination. However, this rhetoric is dangerously overstated, and as such very highly disturbing. While encouragement for vaccination is reasonable for populations at risk, coercive mandates, especially for young persons at minimal risk for long-term disability from the disease are unfounded scientifically. The facts and concepts I shall succinctly present here should compel significant pause for all fair and clear-minded Americans concerned not just about government overreach, but the use of selective information to foster a narrative that is reasonable, but by no means certain. Coercion under these circumstances is improper.
The imposition of an unwanted medical treatment obviously contradicts the arguably sacrosanct notion of patient autonomy. Society ethically accepts breaches of autonomy – this most civilized and respectful of notions – only when “clearly” necessary. In the modern age, arguments for such necessity may be well scrutinized when relevant facts and justifications are honestly disclosed and discussed. Such is sadly not the current situation with COVID-19, but that disappointment is not the subject of this essay. Rather I wish to succinctly summarize why COVID-19 differs from other infectious diseases for which mandatory vaccination is well justified. In the process of doing so, an apt analogy with the military draft for a specific cohort of young healthy Americans is presented.
The imposition of mandatory vaccination and quarantine are well accepted for many infectious diseases, predicated upon the natures of those entities (for example childhood polio, smallpox, and measles). Coercive arguments are less sound for COVID-19, in particular for the special cohort of young, healthy, non-obese college students at near-zero risk of long-term disability or death from the disease.
Unlike COVID, meningococcal disease does primarily affect young healthy college students. Yet there are generally no mandates for this particular vaccine. Students are highly encouraged to receive the meningococcal vaccinations, but not subjected to social shaming or other coercion. A similar policy should be applied to COVID-19. However, vaccination for the latter has been all but mandated by coercive tactics imposed by school administrators and government officials and an absolute mandate has been threatened by at least some elected officials (e.g., New York City Mayor Bill DeBlasio). See The Problem with the Early Coronavirus Vaccine Mandates in National Review.
While chanting “herd immunity, herd immunity,” the key point lost upon mandate advocates is that this phenomenon does not protect a demographic that has (thus far) been shown to have essentially zero (statistical) risk of death from the disease. This is not a highly sophisticated or complex biological concept, which leads its undaunted vociferous promotion to be all the more disturbing.
In the case of COVID-19, our government has stated an agenda to reach herd immunity, but the only well-established rationale for this agenda is to protect the unvaccinated. Other claims are unsupported by other than rhetoric and conjecture. For example, the commonly held notion that more vaccinated individuals will lead to less clinically relevant wild-type mutation is, while plausible, not supported by actual data. Furthermore, although in theory reinfection with a more virulent strain could be bad for a vaccinated individual, this additional notional benefit of herd immunity also resides but within the realm of biological plausibility – i.e., again, significant data has yet to accumulate that such reinfection results in any increased morbidity and mortality for the vaccinated, re-infected individual.
Childhood vaccinations differ from COVID because young children (at extreme risk of death and disability from infection) cannot be fully vaccinated due to the immaturity of their immune systems. They consequently rely upon herd immunity of older children and adults to avoid the illnesses. If all children could be immediately vaccinated at birth and only those who refused vaccination would suffer, it could be proper to not compel childhood vaccination. The policy of mandatory vaccination for childhood diseases is at least scientifically-based, and can therefore at least be properly argued for, whether or not agreement is reached.
The case for COVID-19 related illness and morbidity is entirely different from that of childhood and most other dangerous infectious diseases. The risk of death or long-term disability from SARS-CoV2 (COVID) infection if young (<25), healthy, and non-obese appears to be essentially zero. Data by Richardson et al in 2021 on this risk supersedes a lesser quality research letter published in JAMA in 2020.
These are the papers:
Safiya Richardson et al. In-Hospital 30-Day Survival Among Young Adults With Coronavirus Disease 2019: A Cohort Study. Open Forum Infectious Diseases Received 11 November 2020; editorial decision 3 May 2021; accepted 5 May 2021.
* … College-Aged Patients (18–24 Years Old)
There were 119 patients in our study within this age group (median age, 22 years [IQR, 21–23]; 69% female). Median length of stay for these patients was 3 days (IQR, 1.9–4.9). Only 7 required invasive mechanical ventilation and, of those, 4 died. Two of the 7 who required invasive mechanical ventilation had no prior medical history except for obesity, whereas the remaining 5 patients all had comorbidities, including Down’s syndrome, congestive heart failure, end-stage kidney disease, and obstructive sleep apnea.
RESEARCH LETTER: Jonathan W. Cunningham, MD et al. Clinical Outcomes in Young US Adults Hospitalized With COVID-19. JAMA Internal Medicine. March 2021 Volume 181, Number 3; pp 379-381.
* Published Online: September 9, 2020. doi:10.1001/jamainternmed.2020.5313
On the other hand, there are some known short-term risks of COVID vaccination, and entirely unknown long-term risks from mRNA vaccination. In particular, the risks of introducing spike protein expression and/or deposition onto potentially every cell of the human body – with or without modulating presence of natural humoral (antibody-mediated) or cell-mediated (T-cells and such) immunity – is unknown.
When autonomous intelligent people decline something that seems to be “clearly in their best interest,” it would be respectful to understand their point of view. Such respect should lead to presentation of compelling data, rather than shaming, coercion, and mandates that are similar to a military draft. Rather than label, deride, and mock with contemptuous disdain, it is in a society’s interest to understand and convince its citizens, not compel them, in issues that are supposedly “only for their own good.” The fact of the matter is that there is definite risk, small as it may be, for myocarditis and thrombosis and an unknown long-term risk from mRNA COVID vaccination (this article cannot be considered authoritative, but its concerns are not unreasonable to consider), and that there are other definite risks from more traditional antigen vaccines. Respectful treatment of persons does not simply tell people to ignore these risks and “do what we (the government) say.”
Respectful treatment of persons requires adherence to the guiding principle of informed consent. Yet the following declaration, presented here is its entirety from the CDC website (accessed 7/18/2021 and again 8/3/2021) completely disregards that principle:
“CDC continues to recommend COVID-19 vaccination for everyone 12 years of age and older given the risk of COVID-19 illness and related, possibly severe complications, such as long-term health problems, hospitalization, and even death.”
This statement should be considered disturbing and disrespectful to readers not for its frightening rhetoric, but for its astounding lack of scientific substantiation. Its authors apparently wish their readers to simply trust them, without bothering to link to even a single supportive data set. In other related sections of the CDC website, there are links to information about myocarditis and reported adverse effects 6a, but again not a single citation to a published study, such as the ones I have included in this essay, that can help ordinary people and physicians decide upon relative risk vs benefit for themselves or their patients. Rhetoric presented in this manner should be considered arrogant and disrespectful. Readers are expected to implicitly trust this governmental “guidance” – without a single published citation – when for over a year (and even now) the declaring authoritative agency hasn’t been able to keep their advice straight on something as simple and benign as masking, and when initial declarations from its supporters told Americans to not even worry about the disease to begin with, and called efforts to halt travel from China “xenophobic.”
With that, I have no intention of being political here. I merely point out that the advice/prediction at the time, based on available data, was wrong.
Unreferenced scary dangerous statements made by government to its citizens without citation to even a single piece of data should be considered improper, to say the least. Young Americans being compelled against their will to receive a vaccine deserve to at least be pointed in the direction of a clue as to how many completely healthy, non-obese, non drug-abusing, under 25 year-olds have been shown to be at risk for all those stated CDC concerns, “including death.” Do they not? Do they not deserve that modicum of respect? Furthermore, for the CDC to blandly recommend vaccination equally regardless of antibody status (a marker of prior natural infection and protection against the disease (9)) strikes this physician as cavalier at best, and incomprehensible at worst. If there is actual data to support CDCs recommendations, why is none presented? Could the actual “data” ultimately be proven as reliable as the assurance of weapons of mass destruction in Iraq?
Given the near-zero risk of long-term disability or death from infection with SARS-CoV2 (the virus causing the COVID clinical syndrome), current data continues to suggest that the risk from COVID-19 vaccination in a young, healthy, under 25, non-obese person, and certainly one with circulating antibodies (2), approaches infinity (any risk divided by near-zero). This calculation may change upon new/ additional data, but so far this does not appear to be the case. See Lumley SF et al. Antibody Status and Incidence of SARS-CoV-2 Infection in Health Care Workers. N Engl J Med 2021; 384:533-540. Feb 11, 2021. DOI: 10.1056/NEJMoa2034545. This article was published online December 23, 2020, at NEJM.org.
Once again: The risk of death or long-term disability from COVID infection if young adult (<25), healthy, and non-obese remains essentially zero, and any long-term immunologic side effects from vaccination are unknown. The effects (and risks) of introducing spike protein expression or deposition onto potentially every cell of the human body is unknown. Further, while vaccinating people who have already been infected may be seen as a "booster shot," there is limited data as to whether prior infection is better or worse for the vaccinee in the long-term. These biologically plausible concerns are not trivial, yet they are simply understood: we do not and cannot know the long-term side effects for something in the short term. This is troublesome for a profession whose first and most sacrosanct principle is to “do no harm.”
Once again: There is definite risk, small as it may be, for heart inflammation (myocarditis) and blood clots (thrombosis), and unknown long-term risk from mRNA COVID vaccination. There are some other risks associated with the more traditionally prepared (not mRNA) vaccines, including several cases of devastating blood clotting in the brain (cerebral vein thrombosis).
Once again: The risk for long-term disability or death from COVID-19 infection in a young, healthy, under 25, non-obese person is very low, and for those with natural antibodies (from prior infection), this risk likely approaches zero. Hence the risk of vaccination in this particular cohort approaches infinity (any risk divided by near-zero serious morbidity). This calculus can obviously change, but only as more, reliable, and disclosed information arises.
While individual vaccination clearly benefits cohorts at risk from the native infection, young healthy non-obese people are not necessarily at risk and therefore unlikely to personally benefit from COVID vaccination. It may be good for them to get vaccinated, just as it may be good for them to start IRA accounts in their teens or to enlist in the military. But reasonable people may disagree with these life choices based upon their own values and actual known facts associated with the choices. The most important point policy makers considering abrogation of informed consent for involuntary vaccination must consider is this: that herd immunity confers definite benefit only to those who eschew vaccination. Thus the similarity to a military draft. Any compelled risk or injury sustained by young healthy persons at minimal risk (by analogy, draftees) specifically/primarily to create herd immunity (fight foreign wars) does not benefit those persons (soldiers) per se, only (if anyone) the herd back home.
Aside from my analogy to the military draft, the careful reader must admit that I do not provide opinion as to whether or not an autonomous respected citizen of the United States, or one of their children, should accept COVID-19 vaccination. I have received it, my wife has received it, my friends have received it, and I recommend it to almost all of my patients. But I do not coerce them, and here I offer for consideration merely a reasonable clarification of the current state of affairs that respects patient autonomy, arguably the most important medical ethics principle of the latter 20th century.
I favor duty to society. However, the superior moral argument for vaccination in young healthy adults remains one of autonomous personal risk assumption. If we are to compel anyone for the benefit of society, the superior moral argument would be to compel vaccination of high-risk patients, perhaps otherwise denying insurance claims for their COVID-19 related illnesses, rather than coercing young healthy persons in college or elsewhere, who are at essentially zero risk of death or long-term disability from native infection, to promote herd immunity for the benefit of vaccine refusers.
Dominick A. Rascona, MD, FCCP, is a Captain, Medical Corps, US Navy (ret.) and an MD in Pulmonary Medicine/ Critical Care (NBPAS/ABIM); Neurocritical Care (UCNS) in Norfolk, Virginia
Image: Pixabay / Pixabay License