Manual of Catholic Medical Ethics – Chapter IV

on-line edition as of 2023 edited by Willem J. cardinal Eijk, MD PhD STL, Lambert J.M. Hendriks, PhD STD and prof FransJ. van Ittersum, MD PhD MSc

Ⓒ Katholieke Stichting Medische Ethiek 2014 - 2023

IV.1.5 Preventive Medicine Ethical analysis

Some members of Orthodox Protestant denominations oppose the prevention of disease by vaccination for religious reasons [14Nederlandse Patiëntenvereniging. Vaccinatie in de reformatorische gezindte Informatie voor de jeugdgezondheidszorg. Nijmegen 2013.] [15Nederlandse Patiëntenvereniging. Vaccinatie: voorzienigheid, vertrouwen en verantwoordelijkheid. Nijmegen 2013.]. They base this rejection on Jesus’ words in Matthew 9.12: “It is not the healthy who need a doctor, but the sick” (cf. Luke 5.31; Mark 2.17). This would imply that one should use medical treatment only when suffering from a current condition, but should not do so when healthy, only for the purpose of preventing an illness. However, Jesus only says that the sick need a doctor, to make it clear why he goes among sinners (the ‘sick’), but does not speak at all about the prevention of illness in this context. By disease here is meant spiritual illness, sin [16W.J.A. Pijnacker Hordijk. Vaccineren – levensgevaarlijk of levensreddend? . Stichting Promise; 2019, 2019]. Furthermore, some Orthodox Protestants base their rejection of disease prevention on the definition of Divine Providence according to question 27 of Sunday 10 of the Heidelberg Catechism: “The omnipotent and omnipresent power of God, by which He maintains heaven and earth, together with all creatures, even as with His hand yet, and so governs, that foliage and grass, rain and drought, fruitful and unfruitful years, food and drink, health and infirmity, riches and poverty, and all things, do not come to us by chance, but from His Fatherly hand. ” This definition implies, among other things, that health and sickness come to us not by chance but by God’s hand. For this reason, man should not prevent an impairment of his health by non-ordinary means, such as vaccination, because that would imply opposition to God’s judgement. However, once affected by a disease, one should be allowed to make use of medical treatment on the basis of the text from Matthew 9:12 quoted above. At most, one may use ordinary means to prevent disease, such as sanitary measures. This position came under severe criticism when epidemics of poliomyelitis broke out in some Dutch villages in 1971 and 1978. The latter epidemic affected 110 people, all Orthodox Protestant, who had not been vaccinated: one of them died, while only a few suffered long-term or lifelong paralyses [17J. Douma and W.H. Velema. Polio. Afwachten of afweren? , Amsterdam: Ton Bolland; 1979.] (the orthodox Protestants referred to do not share the aforementioned rejection of preventive medicine, by the way).

In addition, there is group of people who reject vaccination not for religious reasons, but because they dislike artificial intervention in man’s nature, such as people who place great value on homeopathy. They reject vaccines because, as artificially manufactured substances, they are not peculiar to the human body or at least contain substances that do not occur naturally in the human body. The fact that vaccines are administered when a person is generally still healthy reinforces their resistance to vaccination. Similar views can be found among adherents of the anthroposophical view of man, who want to leave it to man’s nature to protect himself from disease. The view that the fight against disease should be left entirely to nature itself does not do justice to medicine, which uses what is available in nature to develop and prepare medicines and perform surgical procedures by means of rational knowledge (obtained, incidentally, by using man’s natural intellectual faculties).

The Roman Catholic Church and the vast majority of Protestants give a different interpretation of God’s Providence. God created man in his image and likeness. As a result, man has the ability to think and the ability to act freely within a certain space. This means that man has a degree of providence, a reflection of God’s Providence. It is therefore inherent in God’s Providence that man has a providence – albeit limited. This providence creates obligations. Man cannot only prevent diseases, but must do so to the best of his ability. Having oneself vaccinated or one’s children vaccinated is therefore a morally good act. Side effects can be accepted on the basis of the principle of the double-effect act, because the intended effect (immunisation) is not achieved through the collateral effect and there is a proportionally serious reason to accept these side effects (see Principles of Medical Ethics, Chapter I.2.2.1 and Chapter VI.3.2.) In the 2020-2021 COVID pandemic, the trade-off of the proportionality of the two effects of vaccination fell in favour of vaccination: the intended benefit (immunisation of the population) far outweighed the rare occurrence of side effects.

Also, the human person is essentially a social being. From this flows the principle of sociality and solidarity (Chapter I.2.2.5). The limited degree of providence we have implies that we bear responsibility not only for our own health but also for that of fellow human beings. When we vaccinate ourselves and parents vaccinate their children, we contribute to making infectious diseases less easily spread. Our own vaccination and the vaccination of children can prevent others who are not vaccinated, children under the vaccination age or people who do not get vaccinated for reasons of principle from contracting infectious diseases. This is a contribution to the common good.

For these reasons, vaccination is not only a moral good for the individual, but also for the common good.

Besides the fact that the use of preventive medicine is permissible and often a duty, there are some ethical aspects that deserve further attention. Vaccination – however limited – involves violating the integrity of the body, usually through penetration of the skin for the injection of the vaccine itself and then the subcutaneous or intramuscular injection of the foreign body material for the sake of preventing disease. As stated in the introduction to this section, there is no difference between treatment or prevention of disease in terms of moral assessment. To preventive medicine, therefore, as noted earlier, the totality principle or therapeutic principle also applies (Chapter I.2.2.3). This principle implies that interventions in the human body aimed at preserving the life or health of the human person as a whole can be justified, provided its functional integrity remains intact. As vaccination at most affects anatomical integrity to a negligible extent and can prevent the threat to life or health from the possible future contracting of a disease, vaccination can therefore be legitimised on the basis of the therapeutic principle.

Other difficulties lie in the questions of whether vaccines are safe, whether this safety has been established according to current scientific methods and whether vaccines have been produced in morally responsible ways. In particular, given the aforementioned discussion about the possible relationship between MMR vaccination and the occurrence of non-specific colitis and autism, there is an obvious requirement that scientists must act honestly and objectively, without conflicts of interest. While side effects occur, the risks are certainly proportionate to the good effect they work. One of the bigger problems in discussions about vaccination Western European media in 2018-2019 concerned the fact that opposition to vaccination was very often not based on scientific data. As indicated above, serious side effects, such as paralysis, autism or increased risk of cancer, are invoked as a motive to refrain from vaccination, but these side effects are usually not or hardly reported and documented or conclusively established. They have unfortunately become a major factor in discussions about vaccinations as ‘fake news’ and incorrect or unsubtle messages are repeated over and over again on social media. It is difficult to resist this massive disinformation. The major media attention generated by the medical profession and politicians to increase vaccination coverage focuses mainly on refuting this disinformation.

When preparing vaccines containing attenuated or inactivated microorganisms, the bacteria and viruses that are the basis for vaccines must be grown on a nutrient medium. Viruses require live cells for this purpose. These are often cell lines, cells that were once, often years ago, obtained from a human or animal and then grown on in the laboratory. So new human or animal donors are not needed all the time to have these cells available. The source of the cells is different for different vaccines. For the vaccines against mumps and measles, the cells used are derived from a chicken embryo, vaccines against influenza and yellow fever are produced on incubated chicken eggs, the vaccine against human papillomavirus (HPV, the causative agent of cervical cancer) on cells from Trichoplusia ni, a species of moth. There are four cell lines derived from human, aborted foetuses: the Medical Research Council cell strain 5 (MRC-5), derived from connective tissue cells from lung tissue of a 14-week-old foetus aborted in 1966, the WI-38 cell line, also derived from connective tissue cells from lung tissue, this time from a 3-month-old male foetus aborted in 1960, the HEK293 cell line, derived from kidney tissue of a foetus aborted in 1973 in the Netherlands and the PER. C6 cell line developed around 1996 from HER199 cell line derived from retinal cells of a human embryo. These first two cell lines were or are used for the production of vaccines against adenoviruses (no longer in production), rubella (rubella), chickenpox and shingles (herpes zoster), ebola, polio, and rabies (rabies); the second two for production or post-production control of vaccines against SARS-CoV-2 virus (“Coronavirus”). [18Charlotte Lozier Institute. Update: COVID-19 Vaccine Candidates and Abortion-Derived Cell Lines. Arlington: Charlotte Lozier Institute,; 2020, 29 september 2020] In the Netherlands, the polio vaccine is not produced on a human-derived cell line, but on a cell line derived from African grivet monkeys. CureVac’s mRNA vaccine against SARS-CoV-2, whose development was discontinued in early October 2021, used HeLa cells (cervical cancer cells obtained without the knowledge of Henrietta Lacks, who died of her disease in 1951) for control testing.

During the COVID-19 pandemic in 2020, it became clear that, in addition to the classical vaccines described above (inactivated, attenuated or fragmented viruses, cultured specifically for this purpose), other types of vaccine development techniques had been prepared and are being used in the development of a vaccine against the SARS-CoV-2 virus. These are vaccines based on either laboratory-prepared surface molecules of a virus, messenger RNA (mRNA) or a vector (DNA). The mRNA and vector vaccines encode for viral surface molecules that can cause the human body to produce these molecules. [19G.A. Poland, I.G. Ovsyannikova, S.N. Crooke and R.B. Kennedy. SARS-CoV-2 Vaccine Development: Current Status. Mayo Clin Proc. 2020/10/06 ed 2020, 95, 2172-2188 doi:10.1016/j.mayocp.2020.07.021] [20G.A. Poland, I.G. Ovsyannikova and R.B. Kennedy. SARS-CoV-2 immunity: review and applications to phase 3 vaccine candidates. Lancet. 2020/10/17 ed 2020, 396, 1595-1606 doi:10.1016/S0140-6736(20)32137-1.] [21World Health organization. DRAFT landscape of COVID-19 candidate vaccines – 12 November 2020. 2020, 12.] The European Union took options on about eight vaccines in 2020-2021. Development of the Curevac vaccine was discontinued in October 2021. The Valneva vaccine, the assessment of which started in December 2021, like the Chinese Sinovac vaccine (which is not available in Europe), resembles a classical vaccine: they contain inactivated virus grown on Vero cells (cells obtained from the kidneys of grivet monkeys). Sanofi and Novavax’s vaccines contain a molecule found on the surface of the SARS-CoV-2 virus and produced in a Baculovirus system, a production system that uses viruses found in insects. It is expected to produce an immune system response similar to that of conventional vaccines. The four other vaccines use the newer technique in which the vaccine contains mRNA or a DNA vector. The vector is an attenuated adenovirus derived from monkeys that helps to get the DNA encoding a surface protein of the virus into the cell. For these four vaccines, either HEK293 or PER.C6 cells are used in control (mRNA vaccines) or production (DNA vector vaccines). [22Charlotte Lozier Institute. Update: COVID-19 Vaccine Candidates and Abortion-Derived Cell Lines. Arlington: Charlotte Lozier Institute,; 2020, 29 september 2020]

In some documents of the Roman Magisterium [23Pontificia Academia Pro Vita. Moral Reflections on Vaccines Prepared from Cells Derived from Aborted Human Fetuses. Rome 2005.] [24Congregatio de Propaganda Fide. Dignitas Personae, Instructie betreffende bepaalde bio-ethische kwesties. Kerkelijke Documentatie 2009.] [25Pauselijke Raad voor de pastoraal van de gezondheid. Nieuw handvest van de werkers in de gezondheidszorg. Vaticaanstad 2017, nr. 119.] rejects the use of cells from aborted foetuses. At the same time, the Congregation for the Doctrine of the Faith points out in its aforementioned instruction that there are different degrees of responsibility regarding cooperation in obtaining cell lines in a morally impermissible manner: the person who performed the abortion in the previous century and harvested the foetal tissue was directly involved in the abortion, while the person who now uses the vaccine grown on perfused cells from over 25-50 years ago no longer has any direct involvement with this abortion. There is, therefore, an indirect and distant form of cooperation in the abortion in this case. Moreover, if the user of the vaccine does not consent to abortion provocatus, it is a material form of cooperation in the abortion that took place in the distant past (cf. Chapter I. Serious reasons may justify the use of such vaccines. This is particularly the case in situations where there is a serious disease and no other vaccine or treatment is available for it. However, at least the people working with these types of vaccines, but possibly others as well, have a duty to protest to the extent possible against the unauthorised way in which the cell lines were obtained and to encourage the search for other production options. Regarding the SARS-CoV-2 vaccines, the Congregation for the Doctrine of the Faith reiterated this position (grave situation, removed, no direct involvement in the abortion at the time, duty to press for other production methods). [26Congregatio de Propaganda Fide. Note on the morality of using some anti-Covid-19 vaccines. Rome 2020] Obviously, prudence here requires a different action from doctors or nurses, than from parents who have their child vaccinated.

The use of DNA, RNA and vector vaccines involves administering DNA or RNA that is incorporated directly or with the help of the vector into certain cells in the body with the aim that these cells, e.g. antigen-presenting cells, start producing viral surface molecules against which the immune system can then start a defence response. Intentionally making the body produce these molecules in this way does not encounter a moral dilemma. It is a safe way of exploiting natural properties of the immune system. With the vaccine, it leads the human cell to produce one or a few viral surface molecules; with a viral infection, the cell starts making many full copies of virus. The administered mRNA enters only the cytoplasm (cell body), and not the cell nucleus, of certain body cells and leads there to production of surface molecules (peptides or proteins) that will be presented by the cell on its surface. When DNA vaccines or vector vaccines are used, DNA does travel to the cell nucleus in certain body cells. Even then, the situation resembles an ordinary virus infection. The vectors used so far are derived from monkey viruses and cannot replicate themselves in humans. So on theoretical grounds, there is no risk that these vectors could have harmful effects in humans.

According to some, introducing mRNA or DNA into the body would be a form of genetic engineering. This is incorrect: the mRNA most likely does not alter the human’s own DNA. The vaccine DNA could, however, change human DNA in some cells, but it is important to understand this well. Viruses themselves can also change human DNA during infection. Some changes are even still inherited in the DNA. However, this is different from what is meant by genetic engineering. In the latter case, the act aims to change the DNA and then also with the aim of editing better properties of the organism. In the case of vaccination, it is about curing a disease and the change in DNA is not intended at all. This makes it not comparable to genetic engineering.