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Ethics in an emergency must balance the obligation to find a solution for a problem quickly and the elimination of obstacles with the inherent danger of the dam bursting and consequent the flood of ethical problems in these solutions.
I have presented arguments as to how one must behave ethically both in terms of administering an experimental drug and volunteering to take part in a clinical trial.
According to Jewish ethics, it is permitted to agree participate in experimental vaccine and that healthy people are allowed to volunteer their children as well as themselves for clinical trials even though it might endanger their lives as long as there is a good chance that the drug being tested will prove to be safe and efficacious.
Introduction: Judaism’s approach to children’s vaccination
I read with great interest the article of Atuire et al.1 The article presented the ethical challenges of conducting a paediatric vaccine trial against COVID-19. Following their remarks, I would like to clarify and emphasise several points from the Jewish ethics perspective.
There is a difference between the point that was discussed in the article and the viewpoint of Jewish ethics: children are considered to be vulnerable, but they are not of legal age to give informed consent for participation in clinical trials, and Atuire et al cite the relevant ethical principles that should guide their participation, but Jewish ethics takes a different approach.
According to Jewish ethics, we must think of the role of parents/guardians who volunteer their children as participants in clinical vaccination trials. This is an outcome of the understanding that it is being done for the good of their children and for all the children who will benefit from the trials. Responsibility for the health of their children is high among parental and religious duties, and this sometimes requires taking a series of risks regarding their medical care. These issues have resonated in Jewish ethics since the smallpox vaccine was first discovered all those many years ago.
Edward Jenner’s development of the first vaccine in 1796, which was for smallpox, was welcomed in the Jewish world. Rabbis of the time rushed to support vaccination, notwithstanding the risk involved in this innovative, experimental treatment.2
After the discovery of the vaccine, in the face of the question whether children should be vaccinated or would it endanger them needlessly, some of the Jewish legal adjudicators wrote that the parental obligation was not to take their children out of the town, but to have them vaccinated.
In 1785, somewhat more than a decade before Jenner developed safe vaccination, a rabbi in London, Rabbi Abraham Hamburg, published out a book entitled Aleh Terufah (Leaf of Medication). He wrote that even if one in a thousand children die from the vaccination, nevertheless one should not refrain from having them vaccinated.3
At the end of the 18th century, Rabbi Ishmael Hacohen of Modena, one of the important contemporary rabbis in Italy, wrote that children should be treated against smallpox even if ‘we fear that one in a thousand of them will die’.4 In those days, the procedure, which was called variolation or inoculation, was carried out by cutting into the child’s arm and inserting exudate taken from a person infected with the lethal disease into the cut. It might have been thought that in the face of an action that could infect and kill a child, rabbis would have instructed their communities not to vaccinate and hope for the best. However, Rabbi Hacohen wrote that he relies on the testimony of the doctors specialising in the field that among thousands of recipients not even one person would die. The vaccination against smallpox, which was supported by rabbis from both the East and West, led to the eradication of the disease, even among religious communities. Hundreds of years ago, rabbis were contemplating the efficacy of inoculation even though some children were dying from the procedure.
Several years after Rabbi Hacohen’s book was published, Dr Edward Jenner announced a modification of his vaccination protocol, which involved using a pathogen that caused cowpox, which, in effect, launched the age of safe vaccination.
The approach to experimental vaccines in Jewish ethics
The danger in connection with an experimental vaccine should be considered in the contexts of the risk of death in extreme cases and/or the risk to a patient’s good health and physical activity when one is in a less serious condition.
Rabbi Shlomo Zalman Auerbach (1910–1995) was a renowned Orthodox rabbi and one of the most important 20th-century halakhic arbiters. In his book Minchat Shlomo,5 he noted that it is permitted to volunteer to take part in research to develop an experimental drug because the fight against a disease is the same as war; just as war obliges an individual to endanger himself and risk his life, it is logical that the same applies to a war against disease. However, his argument was not entirely valid: if the fight against a disease has the same rules as a war, everyone is apparently obliged to fight, and it is not dependent on an individual’s generosity and is it conceivable that everyone would be called on to take part in a clinical trial. Rabbi Auerbach also dealt with the question of adults volunteering to participate in a medical experiment and compared it to volunteering for war. However, this cannot be compared with parents volunteering minors to take part in medical experiments. Thus, the comparison to war is not really apt, as war is only against an enemy’s armies, whereas dealing with disease requires addressing ethical and medical issues in the light of the applicable laws.
Jewish ethics with regard to the efforts to develop a vaccine against SARS-CoV-2
In a letter to his disciple, Rabbi Yehuda Leib Wiener, the rabbi of Cedars-Sinai Medical Center in Los Angeles, Rabbi Asher Weiss (Israel, 1953–), of the Sanz Hasidic sect and the chaplain of Shaare Zedek Hospital in Jerusalem and one of the most important contemporary rabbis in the city, addressed the issues involved in the development of experimental vaccines. He noted that the essential approach has to be that it is not a matter of someone who endangers himself to save another, but rather of someone who endangers himself to save himself together with others. So, when children—with the consent of their parents—participate in a medical experiment designed to save millions of other children in the world, they endanger themselves to save themselves and many others; that is, if this vaccine does indeed prove to work, they are also helping to heal themselves. However, he wrote, it is clear that it is forbidden to administer an experimental drug unless the intended recipient is informed of the risk involved and agrees to go ahead. Furthermore, a person is permitted to endanger himself to a limited degree to earn his living or for other quality of life issues and not necessarily to save others from death. So, too, it appears that it is permitted for someone to risk an experimental drug on the chance that he/she will be healed from corona even though such a drug might further damage his/her health.
In answer to the question as to whether one may volunteer for a clinical test of an experimental vaccine, Rabbi Weiss wrote that if one is talking about a young, healthy person for whom in the natural course of things there is no danger to life, although he/she would be endangering his/her health, such volunteering should be permitted. When there is an urgent need to improve public health, an individual may volunteer out of the goodness of his/her heart and to serve even when there is extra risk. For example, one may choose to become a policeman, or a firefighter or a member of a rescue unit, etc, where he/she takes on greater risk than what is expected or required from others. In every civilised society, it is right and proper that there be those ready and available to act for the benefit of the community.
Rabbi Weiss also says that for any act that will improve society, it is right and proper for some people to volunteer for certain dangerous jobs. Therefore, it is permitted for a young, healthy person to volunteer and expose him/herself to the COVID-19 virus in a controlled way since the risk to young people without underlying conditions is more remote. Apart from that consideration, the benefit of this research is enormous and can save thousands, so it is permitted to engage in clinical trials and to allow healthy people to volunteer.6
Ethics in an emergency has to balance the obligation to find a solution for a problem quickly and the elimination of obstacles with the inherent danger of the dam bursting and the consequent flood of ethical problems in these solutions. However, as Aturie et al1 noted, attention is not being directed toward these areas, and the protections against the dangers in some clinical trials for the treatment of COVID-19 collapse. I have presented arguments as to how one must behave ethically both in terms of administering an experimental drug and volunteering to take part in a clinical trial.
From everything discussed, it appears that according to Jewish ethics, it is permitted to agree participate in experimental vaccine and that healthy people are allowed to volunteer their children as well as themselves for clinical trials even though it might endanger their lives as long as there is a good chance that the drug being tested will prove to be safe and efficacious.
I hope and trust that awareness of this kind of religious backing will encourage participation in the critical COVID-19 medical research now in progress. Future studies should deal with other questions that were asked by Aturie et al.1 These studies may contribute to the conduct of ethically and medically worthy research on humans for the sake of humans.
Data availability statement
There are no data in this work.
Patient consent for publication
Handling editor Seye Abimbola
Contributors TR is the sole author of this commentary.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.