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The ethics of a COVID-19 vaccine: An in-depth interview with Dr. Steve Doran

This story was updated on Dec. 16, 2020.

As cases of COVID-19 and its death toll continue to mount in Omaha, in Nebraska and across the nation, pandemic-weary people want to know: When will it be over?

In the United States alone, over 16.8 million people have been infected with the COVID-19 virus since the first case was confirmed in January, and deaths due to the infection now exceed 304,000. Nebraska has reported more than 151,000 cases and more than 1,450 deaths.

A multi-pronged strategy has been undertaken to fight against the pandemic: testing, social distancing, hand hygiene, the wearing of masks, pharmaceutical therapeutics and vaccines.

Hopes for a speedy end to the pandemic hinge on a safe and effective vaccine. On Dec. 11, the U.S. Food and Drug Administration granted its first emergency use authorization (EUA) for a vaccine developed by Pfizer and BioNTech. EUAs for vaccines developed by other pharmaceutical companies are expected to follow in the coming weeks.

Some of these vaccines have been developed using cell lines that were first established using tissue from aborted fetuses, raising ethical concerns for Catholics. This and other ethical issues surrounding vaccines tend to be complex and not easily reduced to sound bites. To fully grasp and resolve them, expertise is needed.

Since it began, Dr. Steve Doran has served as a consultant to the Archdiocese of Omaha on issues related to the pandemic. He currently works as a neurosurgeon at MD West One (formerly Midwest Neurosurgery & Spine) in Omaha, a position he has held since 1996.

Having a strong interest in bioethics, he has also earned a certification in bioethics from the National Catholic Bioethics Center in Philadelphia and a master’s degree in theology with an emphasis in bioethics from Holy Apostles College and Seminary in Connecticut.

Doran and his wife, Sharon, are members of St. Margaret Mary Parish in Omaha. He is also in diaconate formation for the archdiocese.

Doran submitted answers to the following questions to help readers of the Catholic Voice understand the scientific and moral principles involved in the development and use of COVID-19 vaccines.

Q: Your training and practice in medicine is in neurosurgery. You also have a post-graduate certification in biomedical ethics. How did you become interested in biomedical ethics?

As a neurosurgeon, I treat patients with a variety of problems of the nervous system, including life-threatening conditions such as traumatic brain injury, cerebral hemorrhages and malignant tumors. At the end of life, patients and families are often confronted with decisions regarding discontinuation of care, assisted nutrition and hydration, “Do Not Resuscitate” orders, etc.

To best help patients, I need an understanding of the ethical issues associated with these decisions. In addition, upon entering formation for the permanent diaconate, I was encouraged to pursue post-graduate work in bioethics so that I might be a resource for both clergy and laity throughout the Archdiocese of Omaha. To that end, I have certification in bioethics from the National Catholic Bioethics Center and a Master of Arts in Theology with an emphasis in Bioethics from Holy Apostles College and Seminary.

Q: You currently provide consultation to the archdiocese regarding the coronavirus pandemic. On what sorts of issues have you provided expertise?

As the chief medical officer of Midwest Surgical Hospital, I am a member of the coalition of chief medical officers of the Omaha metropolitan area. This group created policies on many COVID-related issues, including allocation of scarce resources, triage protocols and restrictions on elective surgeries. I was tasked with writing the “Crisis Standards of Care” document, which was adopted by the State of Nebraska.

I was appointed chief medical officer for the Nebraska isolation and quarantine centers, working with the Department of Health and Human Services, the Nebraska Army National Guard and the University of Nebraska Medical Center’s Global Center for Health Security. These facilities were located on the campuses of the University of Nebraska Omaha, University of Nebraska Lincoln, University of Nebraska Kearney and Wayne State, providing housing for people exposed to COVID or COVID-positive patients who did not have the ability to effectively separate themselves from other people. This experience enabled me to provide consultation to the St. John Paul II Newman Center with the development of COVID-related policies. On a fairly regular basis, I am asked to give recommendations on specific COVID exposures that have occurred throughout the archdiocese.

Q: What are the key ethical issues related to the pandemic in which you have taken an interest?

The allocation of scarce resources was the first key ethical issue that was of interest to me, which led me to author the “Nebraska Crisis Standards of Care.” In the early stages of the pandemic, it was uncertain if Nebraska hospitals had enough ICU beds and ventilators, raising the difficult question, “If there are not enough ventilators, who gets one?” The “Crisis Standards of Care” document addressed this question, using illness severity scores to help predict who would most likely survive. Hospitals were encouraged to create committees to help guide these decisions. Fortunately, this worst-case scenario has yet to occur.

The key ethical issues now are related to vaccine development and distribution.

Q: How do vaccines work and how are they produced?

Vaccines have been a part of our lives for decades. In 1796, Edward Jenner invented a method to protect against smallpox by taking material from a blister of someone infected with cowpox and inoculating it into another person’s skin. As scientific knowledge progressed, large scale production of vaccines became possible in the early 20th century.

The list of recommended vaccines continues to grow: diphtheria, tetanus, pertussis, measles, mumps, rubella, polio, Haemophilus influenzae type b (Hib), hepatitis B, varicella (chicken pox), hepatitis A, rotavirus, meningococcus, pneumococcal and influenza. Vaccines are directed against bacteria and viruses and often require multiple doses to be effective. Because the viruses causing influenza A and B are constantly changing, an annual vaccine is necessary to protect against the flu. On average, the flu vaccine is about 40% effective in preventing illness.

Vaccines contain the same germs that cause disease. (For example, measles vaccine contains measles virus, and Hib vaccine contains Hib bacteria.) However, the germ in the vaccine has been either killed or weakened to the point it will not make you sick. Some vaccines contain only a part of the disease germ. A vaccine stimulates your immune system to produce antibodies, exactly like it would if you were exposed to the disease. After getting vaccinated, you develop immunity to that disease, without having to get the disease first.

To create a vaccine against a virus, a small amount of the weakened or dead virus is placed in a cell, such as cells from chicken embryos or cell lines that reproduce repeatedly. The cell produces multiple copies of the virus, which are then extracted and used for the vaccine.

Q. Which COVID-19 vaccines have been approved for distribution in the United States?

As of Dec. 14, the vaccine produced by Pfizer and BioNTech has received Emergency Use Authorization (EUA) by the federal Food and Drug Administration (FDA). It is anticipated that the vaccine produced by Moderna will also receive similar authorization in the very near future. The vaccine produced by AstraZeneca and Oxford has not yet been approved for distribution in the U.S., but many expect it to be released soon for distribution in the United Kingdom.

Q. How do the vaccines produced by Pfizer and Moderna work?

Both Pfizer and Moderna are “mRNA” vaccines, which is a new technology. COVID-19 mRNA vaccines give instructions for our cells to make a harmless piece of what is called the “spike protein.” The spike protein is found on the surface of the virus that causes COVID-19. Next, the cell displays the protein piece on its surface. Our immune systems recognize that the protein doesn’t belong there and begin building an immune response and making antibodies, like what happens in natural infection against COVID-19. There are currently no licensed mRNA vaccines in the United States. However, researchers have been studying and working with them for decades.

Q. Are these vaccines effective?

Both the Moderna and Pfizer vaccines are greater than 90% effective in preventing symptomatic COVID illness. It is unknown how effective they are in preventing asymptomatic transmission. Both Pfizer and Moderna vaccines require two doses spaced a few weeks apart.

Q. Are these vaccines safe?

Neither vaccine has caused serious side effects in clinical trial volunteers. Recipients have experienced mild symptoms after being injected, including headaches, mild fevers, fatigue and aches, which is an indication of the immune system responding appropriately to the vaccine.

Q. What does it mean for these vaccines to receive Emergency Use Authorization?

Emergency Use Authorization (EUA) means that the FDA has closely examined the results of the clinical trials and has determined that the known and potential benefits outweigh the known and potential risks of the vaccines. An EUA is a mechanism to facilitate the availability and use of medical countermeasures, including vaccines, during public health emergencies, such as the current COVID-19 pandemic. The FDA expects vaccine manufacturers to continue their clinical trials to obtain additional safety and effectiveness information and pursue licensure.

Q. How will these vaccines be distributed?

The Centers for Disease Control and Prevention (CDC) has provided guidelines on prioritization for vaccine reception, although each state ultimately makes its own plan. The initial round of vaccines (Phase 1A) will be given to health care providers and residents of long-term care facilities. In Nebraska, the next group (Phase 1B) to receive vaccines will be critical workers: first responders and those in the education sector, food/agriculture, utilities and transportation. The next group (Phase 1C) will be those greater than 65 years, vulnerable populations (disabled, homeless, etc.), and those in congregate settings (incarcerated, colleges/universities, etc.). The final round (Phase 2) will be for the general population.

Federal officials have estimated there could be enough vaccines to inoculate about 30 million people in the U.S. in January and then about 50 million in February, with more in the months following. Hopefully by the spring of 2021, anyone who wants to receive the vaccine should be able to do so.

Q. What are the ethical concerns surrounding these vaccines?

The good news is that cell lines derived from aborted fetuses are not used for the production of the Pfizer and Moderna vaccines. This is in contrast to some of the other vaccines in development, including the one produced by AstraZeneca and Oxford, which uses fetal cell lines for development and production.

However, it appears that both the Moderna and Pfizer vaccines did use the HEK293 cell line for confirmatory testing. The HEK293 cell line was first created in the 1970s from kidney cells taken from an aborted fetus.

Because COVID-19 is a grave threat to a person’s health, the U.S. Conference of Catholic Bishops (USCCB) (https://www.usccb.org/moral-considerations-covid-vaccines) and the National Catholic Bioethics Center (https://www.ncbcenter.org/ncbc-resources-for-covid19) have determined that a Catholic in good conscience can receive the vaccines from Pfizer and Moderna.

The confirmatory testing using HEK293 cells represents remote material cooperation with evil (see below for further discussion on cooperation with evil), which can be tolerated for grave reasons. A Catholic can receive this vaccine in good conscience as explained in the magisterial document “Dignitas Personae”: “Danger to the health of children could permit parents to use a vaccine which was developed using cell lines of illicit origin, while keeping in mind that everyone has the duty to make known their disagreement and to ask that their healthcare system make other types of vaccines available.”

Because the vaccine developed by Oxford and AstraZeneca uses fetal cell lines for production, it is more morally compromised and should be avoided if alternatives are available. However, according to the USCCB, “It may turn out, however, that one does not really have a choice of vaccine, at least, not without a lengthy delay in immunization that may have serious consequences for one’s health and the health of others. In such a case … it would be permissible to accept the AstraZeneca vaccine.”

Q: Tell us more about the morality of producing and receiving a vaccine created using cells from aborted fetuses.

In 2008, the Congregation for the Doctrine of the Faith issued “Dignitas Personae,” which addressed a number of bioethical concerns, including the use of cell lines obtained from aborted fetuses. “Dignitas Personae” stresses that a scientist of good conscience cannot use biological materials of illicit origin, such as embryonic stem cells or cells obtained from aborted fetuses: “There is a duty to refuse such ‘biological material’ even when there is no close connection between the researcher and the actions of those who performed the artificial fertilization (used to create embryonic stem cells) or the abortion” (no. 35). A scientist who uses cells of immoral origin is an example of a type of cooperation with evil that is impermissible (see below for more on cooperation with evil).

For grave reasons, it can be morally permissible to receive a vaccine that was developed using cells from aborted fetuses or other morally illicit origins. For example, the current rubella vaccine was developed many years ago using cells taken from an aborted child infected with rubella. Rubella poses a serious threat to the pregnant mother and the unborn child.

Q: What is meant by the term ‘cooperation with evil’?

We live in a fallen world, and as such, it is impossible to live our lives without interacting with evil. At times, a person may cooperate with another person or organization that is doing an evil act. To cooperate is to provide free and knowing assistance to the one doing the evil act. Depending on the circumstances, the cooperator may also be held morally responsible for the evil act.

Cooperation may be either formal or material. Formal cooperation occurs when the cooperator not only acts in such a way to help an evil-doer achieve his goal, but also joins with the evil-doer’s bad willing. With formal cooperation, the cooperator intends or wills the evil act along with the person performing the act. To will what is evil is to have an evil will, and this is wrong. Formal cooperation with evil is immoral.

With material cooperation, the cooperator does not share the intention of the evil act but participates in some way. Formal cooperation is always clearly wrong, and as such, is often easier to identify and morally assess than material cooperation. Therefore, most dilemmas in regard to cooperation relate to questions of material cooperation.

Material cooperation is further divided into immediate and mediate. Immediate material cooperation with evil occurs when the cooperator contributes to the essential circumstances of the immoral act; this type of cooperation is immoral. Mediate material cooperation with evil occurs when the cooperator contributes to the nonessential circumstances of the immoral act; this type of cooperation may or may not be immoral depending on the circumstances. Mediate cooperation is also further divided into proximate and remote. Another issue to consider is proportionality: as the evil worsens, a proportionally greater good is needed to justify cooperation.

Q: What is an essential circumstance as opposed to a nonessential circumstance? Can you give us an example or two?

Imagine the following scenario: Dr. Smith performs direct sterilizations at County Hospital. Dr. Smith’s actions are immoral. Nurse Jones works in the operating room handing instruments to the surgeon. Nurse Jones personally thinks that sterilizations are immoral, but her job requires her to assist with these surgeries. Since Nurse Jones does not agree with or intend the act of sterilization, her actions are an example of material cooperation with evil. However, because Dr. Smith cannot perform the sterilizations without the help of Nurse Jones, Nurse Jones’ actions are directly ordered to an essential circumstance of the immoral act of sterilization. Therefore, Nurse Jones’ actions are an example of immediate material cooperation with evil and are not moral.

Now consider another example: Nurse Johnson works in the recovery room of County Hospital and cares for patients just after surgery, regardless of the type of procedure performed. Nurse Johnson also believes sterilization is wrong but her actions are not directly ordered towards the essential circumstances of the sterilization. She is not present in the operating room, and while care in the recovery room is important, it is not an essential part of the procedure itself. This would be an example of mediate material cooperation with evil. While Nurse Johnson has some degree of moral culpability, it is less than Nurse Jones. There may be a grave reason for Nurse Johnson to justify cooperating with the sterilization as a recovery room nurse: perhaps Nurse Johnson is a single mother with no other means of supporting her family and this job was the only job she could find after a lengthy search.

Q: Why is contributing to the essential circumstances of an evil act always immoral? What about situations involving duress?

Sometimes cooperation is so closely related to the evil action that it cannot be separated from the evil action itself. Some even argue that immediate material cooperation with evil is equivalent to formal cooperation with evil. However, some circumstances may reduce or eliminate entirely the moral responsibility of the cooperator. Freedom is an important determinant of moral responsibility. Someone with less freedom has less moral responsibility than someone with more freedom. A person under duress has limited freedom and even though he contributes to the essential circumstances of an evil act, his actions may not necessarily be immoral. Consider the following: The teller of a bank is being robbed at gunpoint. She is told to hand over the cash, or she’ll be shot and killed. Handing over the cash is essential to the commission of the robbery. But is it not morally permissible, given the circumstances?

Q: How does the terminology of cooperation with evil apply to a vaccine derived from aborted fetal tissue?

As can be seen, the terminology of cooperation with evil is complicated and may be difficult to apply to a given situation. If we look at the specific example of a vaccine produced using cells from aborted fetuses, even if the scientist making the vaccine is against abortion, the use of those cells would represent proximate mediate material cooperation with abortion, even if the cell lines were first created many years ago.

On the other hand, the person receiving the vaccine would not have any cooperation with the abortion itself, but it could be argued that by receiving the vaccine, that person may be supporting the company that produced the vaccine, which would represent an example of remote mediate material cooperation with evil.

Q: Why is it important that this kind of cooperation also be remote and not proximate?

The further someone is removed from the evil act, the less moral responsibility. The scientist who uses the cells from aborted fetuses has a choice of cell lines to use and by choosing cells from aborted fetuses, is much more closely associated with the act of abortion. The person who receives the vaccine has no say-so in how the vaccine is produced and has much less moral responsibility.

Q: Can I be forced to receive the COVID-19 vaccine?

Whether COVID-19 vaccination will be mandated has yet to be determined and may depend upon the state where you live, your occupation or other factors. Looking at other vaccines might provide some insight. For example, most states or local public-school districts require children to be vaccinated against many childhood illnesses. Likewise, most colleges require students to receive the meningococcal vaccine, especially if they reside in dormitories. On the other hand, while influenza vaccination is voluntary for the general public, hospitals usually require employees involved with direct patient care to receive an annual influenza vaccine.

However, according to the National Conference of State Legislatures, as of June 2020, 45 of 50 states allowed a religious exemption from school vaccinations, and 15 allowed a broader philosophical or “conscience” exemption. Assuming these laws do not change following the (recent) election, it is likely that even if the COVID-19 vaccination is mandated, the current exemptions should apply. In addition, allergies or other medical conditions may prevent someone from receiving the COVID-19 vaccine.

Q: If more than one COVID-19 vaccine is released, will I be able to choose one that does not use fetal cells?

Maybe. Much will depend on how and when the vaccine or vaccines are distributed. In order to quickly vaccinate the most people, it is likely that more than one vaccine will be distributed. It remains to be seen whether distribution is based on location, and in which case, you may not have access to a vaccine that is available in another location. There is not an obligation to travel long distances to receive a vaccine that does not use immoral cell lines. This would be overly burdensome. However, if all things are equal (efficacy, side effects, etc.), and there is the opportunity to choose between vaccines, a person should choose the vaccine developed using cell lines from morally acceptable sources.