For epidemiologist Yves Coppieters, certain health measures taken by France to counter the coronavirus are moving away from concepts of ethics in public health.
The next day, the epidemiologist and professor of public health Yves Coppieters crackeda skeptical tweet with regard to French government announcements. According to him, some measures deviate from the concepts of public health ethics. The Echo therefore asked him 5 questions in order to clarify things.
Yves Coppieters, how do the measures taken by Macron differ from the concepts of ethics in public health?
Yves Coppieters: First of all, we have to consider the notion of rationale, that is, the purpose of the measure. The measures announced yesterday envisage the vaccination obligation for groups at risk, then, ultimately, more broadly. However, the goal has always been to relieve congestion in hospitals. Vaccine coverage is now very good for at-risk groups and the good vaccine dynamic in these groups continues, both in France and Belgium. So what is the aim of these new measures? We were not told that we wanted to achieve zero covid cases in society. Has the goal changed? Do we want to achieve zero covid cases or protect health care systems …
“Proportionality is the most important element, however. Do the benefits of these measures outweigh the damage they will cause to society?”
Proportionality is, however, the most important element. Do the benefits of these measures outweigh the damage they will cause to society? Today, since vaccination is starting to be optimal in the target groups, we do not know how to evaluate it. Proportionality can only be achieved if there is a real risk of a re-increase in hospitalizations and serious situations.
Then there is the notion of efficiency. The measure must thus make it possible to achieve objectives. Extending the health pass in daily life, is it effective in fighting the epidemic? I am not sure.
The necessity is another important concept in public health. We must always opt for the health strategy that will cause the least harm to the population. However, the French measures will, without doubt, increase divisions within society, by initiating liberticidal measures for part of the population.
Finally, we must also consider fair implementation. Are these measures beneficial in an equal way in all strata of society? Or will they increase inequalities? In fact, it is very often groups with common socio-cultural characteristics that oppose vaccination. We therefore lose equity in the population by marginalizing specific groups.
What are the concepts of ethics in public health based on?
YC: The concepts are based on medical ethics. These are the same concepts as those applied to the medical field when dealing with a patient: transparency, the validity of diagnosis and treatment, etc. These concepts are simply transposed to the whole community.
“The precautionary principles have, for example, justified taking radical decisions during the first wave, without worrying about ethics.”
However, these do not have the force of law. Biomedical laws, on the other hand, can protect a patient if, for example, the patient wants to complain about a medical error. We therefore have legislation, with bioethics laws, which protects patients.. However, there is no public health law in Belgium.
We are faced with an exceptional situation, a global pandemic which is now seeing variants emerge, should we not renounce ethics?
YC: The end justifies the means initially, that is to say in an acute health crisis. The precautionary principles have, for example, justified taking radical decisions during the first wave, without worrying about ethics. Now, a year and a half later, however, we understand the dynamics of the epidemic. Governments have also explained to the population that if we achieve good immunization coverage, we would tend towards a less restrictive society.
The Delta variant does not change the vaccine policy. This is not a novelty in the dynamics of the epidemic, there have been several variants before. This variant just takes on more importance because it is more contagious. However, it does not fundamentally change the way in which the epidemic is controlled, nor the clinical profile of those infected.. Reimposing very strong measures in terms of limitation is not proportional to the effort that the population has made in terms of vaccination. And that she continues to do more. Again, this is the famous problem of proportionality.
In your opinion, how should we therefore do to fight “ethically” against the coronavirus?
YC: We need strategies that protect the individual, but also the community. It is therefore not necessary forget about other preventive strategies. Contrary to what the French speech might suggest, vaccination is part of the solution to controlling the epidemic completely, but it is not the only one. It will always be necessary to return accessible testing, isolate positive people and do border control. You have to combine several strategies, because one will never be entirely effective. We must of course continue to promote vaccination. But we also know that free public health (in this case PCR tests) is a major factor in access and membership.
“Forcing people to be vaccinated, otherwise they will not be able to go to restaurants, will not travel, it is not ethical.”
Ethics is precisely using what we know is effective. However, we know that it is the combination of these strategies that will make it possible to control the epidemic and maintain a favorable situation. Forcing people to be vaccinated, otherwise they will no longer be able to go to restaurants, will no longer travel, this is not ethical. We know that this is not the only solution. We ignore the other strategies: in any case, we will always need testing, isolation, etc.
Wouldn’t 100% vaccination be enough?
YC: We will never reach 100% vaccination anyway.. Vaccine efficacy is not itself 100%. It is also estimated that around 10% of the population will not want or be able to be vaccinated. Some people are in fact subject to contraindications to vaccination for medical reasons. It would also take a global vaccination, so that it is really effective. Otherwise, we will always have a boomerang effect from abroad.
Ethics is therefore to say: the goal is to keep control of the epidemic and protect our populations. To succeed, in any case, it will always be necessary to have recourse to testing, to wearing a mask in crowds, etc. Unless we decide not to have any more interaction with the rest of the world. Which is not possible.