The matter in question regards the lawfulness of production, distribution and use of certain vaccines whose production is connected with acts of procured abortion. It concerns vaccines containing live viruses which have been prepared from human cell lines of foetal origin, using tissues from aborted human foetuses as a source of such cells. The best known, and perhaps the most important due to its vast distribution and its use on an almost universal level, is the vaccine against Rubella (German measles).     Rubella and its vaccine   Rubella (German measles)1 is a viral illness caused by a Togavirus of the genus Rubivirus and is characterized by a maculopapular rash. It consists of an infection which is common in infancy and has no clinical manifestations in one case out of two, is self-limiting and usually benign. Nonetheless, the German measles virus is one of the most pathological infective agents for the embryo and foetus. When a woman catches the infection during pregnancy, especially during the first trimester, the risk of foetal infection is very high (approximately 95%). The virus replicates itself in the placenta and infects the foetus, causing the constellation of abnormalities denoted by the name of Congenital Rubella Syndrome. For example, the severe epidemic of German measles which affected a huge part of the United States in 1964 thus caused 20,000 cases of congenital rubella2, resulting in 11,250 abortions (spontaneous or surgical), 2,100 neonatal deaths, 11,600 cases of deafness, 3,580 cases of blindness, 1,800 cases of mental retardation. It was this epidemic that pushed for the development and introduction on the market of an effective vaccine against rubella, thus permitting an effective prophylaxis against this infection. The severity of congenital rubella and the handicaps which it causes justify systematic vaccination against such a sickness. It is very difficult, perhaps even impossible, to avoid the infection of a pregnant woman, even if the rubella infection of a person in contact with this woman is diagnosed from the first day of the eruption of the rash. Therefore, one tries to prevent transmission by suppressing the reservoir of infection among children who have not been vaccinated, by means of early immunization of all children (universal vaccination). Universal vaccination has resulted in a considerable fall in the incidence of congenital rubella, with a general incidence reduced to less than 5 cases per 100,000 livebirths. Nevertheless, this progress remains fragile. In the United States, for example, after an overwhelming reduction in the number of cases of congenital rubella to only a few cases annually, i.e. less than 0.1 per 100,000 live births, a new epidemic wave came on in 1991, with an incidence that rose to 0.8/100,000. Such waves of resurgence of German measles were also seen in 1997 and in the year 2000. These periodic episodes of resurgence make it evident that there is a persistent circulation of the virus among young adults, which is the consequence of insufficient vaccination coverage. The latter situation allows a significant proportion of vulnerable subjects to persist, who are a source of periodic epidemics which put women in the fertile age group who have not been immunized at risk. Therefore, the reduction to the point of eliminating congenital rubella is considered a priority in public health care.     Vaccines currently produced using human cell lines that come from aborted foetuses   To date, there are two human diploid cell lines which were originally prepared from tissues of aborted foetuses ( in 1964 and 1970) and are used for the preparation of vaccines based on live attenuated virus: the first one is the WI-38 line (Winstar Institute 38), with human diploid lung fibroblasts, coming from a female foetus that was aborted because the family felt they had too many children (G. Sven et al., 1969). It was prepared and developed by Leonard Hayflick in 1964 (L. Hayflick, 1965; G. Sven et al., 1969)3 and bears the ATCC number CCL-75. WI-38 has been used for the preparation of the historical vaccine RA 27/3 against rubella (S.A. Plotkin et al, 1965)4. The second human cell line is MRC-5 (Medical Research Council 5) (human, lung, embryonic) (ATCC number CCL-171), with human lung fibroblasts coming from a 14 week male foetus aborted for “psychiatric reasons” from a 27 year old woman in the UK. MRC-5 was prepared and developed by J.P. Jacobs in 1966 (J.P. Jacobs et al, 1970)5. Other human cell lines have been developed for pharmaceutical needs, but are not involved in the vaccines actually available6.   The vaccines that are incriminated today as using human cell lines from aborted foetuses, WI-38 and MRC-5, are the following: 7  

A)Live vaccines against rubella8: –the monovalent vaccines against rubella Meruvax®II (Merck) (U.S.), Rudivax® (Sanofi Pasteur, Fr.), and Ervevax® (RA 27/3) (GlaxoSmithKline, Belgium); -the combined vaccine MR against rubella and measles, commercialized with the name of M-R-VAX® (Merck, US) and Rudi-Rouvax® (AVP, France); -the combined vaccine against rubella and mumps marketed under the name of Biavax®II (Merck, U.S.), -the combined vaccine MMR (measles, mumps, rubella) against rubella, mumps and measles, marketed under the name of M-M-R® II (Merck, US), R.O.R.®, Trimovax® (Sanofi Pasteur, Fr.), and Priorix® (GlaxoSmithKline UK).

 

B) Other vaccines, also prepared using human cell lines from aborted foetuses: – two vaccines against hepatitis A, one produced by Merck (VAQTA), the other one produced by GlaxoSmithKline (HAVRIX), both of them being prepared using MRC-5; – one vaccine against chicken pox, Varivax®, produced by Merck using WI-38 and MRC-5; – one vaccine against poliomyelitis, the inactivated polio virus vaccine Poliovax® (Aventis-Pasteur, Fr.) using MRC-5; – one vaccine against rabies, Imovax®, produced by Aventis Pasteur, harvested from infected human diploid cells, MRC-5 strain; – one vaccine against smallpox, ACAM 1000, prepared by Acambis using MRC-5, still on trial.

    The position of the ethical problem related to these vaccines   From the point of view of prevention of viral diseases such as German measles, mumps, measles, chicken pox and hepatitis A, it is clear that the making of effective vaccines against diseases such as these, as well as their use in the fight against these infections, up to the point of eradication, by means of an obligatory vaccination of all the population at risk, undoubtedly represents a “milestone” in the secular fight of man against infective and contagious diseases. However, as the same vaccines are prepared from viruses taken from the tissues of foetuses that had been infected and voluntarily aborted, and the viruses were subsequently attenuated and cultivated from human cell lines which come likewise from procured abortions, they do not cease to pose ethical problems. The need to articulate a moral reflection on the matter in question arises mainly from the connection which exists between the vaccines mentioned above and the procured abortions from which biological material necessary for their preparation was obtained. If someone rejects every form of voluntary abortion of human foetuses, would such a person not contradict himself/herself by allowing the use of these vaccines of live attenuated viruses on their children? Would it not be a matter of true (and illicit) cooperation in evil, even though this evil was carried out forty years ago? Before proceeding to consider this specific case, we need to recall briefly the principles assumed in classical moral doctrine with regard to the problem of cooperation in evil9, a problem which arises every time that a moral agent perceives the existence of a link between his own acts and a morally evil action carried out by others.     The principle of licit cooperation in evil   The first fundamental distinction to be made is that between formal and material cooperation. Formal cooperation is carried out when the moral agent cooperates with the immoral action of another person, sharing in the latter’s evil intention. On the other hand, when a moral agent cooperates with the immoral action of another person, without sharing his/her evil intention, it is a case of material cooperation. Material cooperation can be further divided into categories of immediate (direct) and mediate (indirect), depending on whether the cooperation is in the execution of the sinful action per se, or whether the agent acts by fulfilling the conditions – either by providing instruments or products – which make it possible to commit the immoral act. Furthermore, forms of proximate cooperation and remote cooperation can be distinguished, in relation to the “distance” (be it in terms of temporal space or material connection) between the act of cooperation and the sinful act committed by someone else. Immediate material cooperation is always proximate, while mediate material cooperation can be either proximate or remote. Formal cooperation is always morally illicit because it represents a form of direct and intentional participation in the sinful action of another person.10 Material cooperation can sometimes be illicit (depending on the conditions of the “double effect” or “indirect voluntary” action), but when immediate material cooperation concerns grave attacks on human life, it is always to be considered illicit, given the precious nature of the value in question11. A further distinction made in classical morality is that between active (or positive) cooperation in evil and passive (or negative) cooperation in evil, the former referring to the performance of an act of cooperation in a sinful action that is carried out by another person, while the latter refers to the omission of an act of denunciation or impediment of a sinful action carried out by another person, insomuch as there was a moral duty to do that which was omitted12. Passive cooperation can also be formal or material, immediate or mediate, proximate or remote. Obviously, every type of formal passive cooperation is to be considered illicit, but even passive material cooperation should generally be avoided, although it is admitted (by many authors) that there is not a rigorous obligation to avoid it in a case in which it would be greatly difficult to do so.     Application to the use of vaccines prepared from cells coming from embryos or foetuses aborted voluntarily   In the specific case under examination, there are three categories of people who are involved in the cooperation in evil, evil which is obviously represented by the action of a voluntary abortion performed by others: a) those who prepare the vaccines using human cell lines coming from voluntary abortions; b) those who participate in the mass marketing of such vaccines; c) those who need to use them for health reasons. Firstly, one must consider morally illicit every form of formal cooperation (sharing the evil intention) in the action of those who have performed a voluntary abortion, which in turn has allowed the retrieval of foetal tissues, required for the preparation of vaccines. Therefore, whoever – regardless of the category to which he belongs – cooperates in some way, sharing its intention, to the performance of a voluntary abortion with the aim of producing the above-mentioned vaccines, participates, in actuality, in the same moral evil as the person who has performed that abortion. Such participation would also take place in the case where someone, sharing the intention of the abortion, refrains from denouncing or criticizing this illicit action, although having the moral duty to do so (passive formal cooperation). In a case where there is no such formal sharing of the immoral intention of the person who has performed the abortion, any form of cooperation would be material, with the following specifications. As regards the preparation, distribution and marketing of vaccines produced as a result of the use of biological material whose origin is connected with cells coming from foetuses voluntarily aborted, such a process is stated, as a matter of principle, morally illicit, because it could contribute in encouraging the performance of other voluntary abortions, with the purpose of the production of such vaccines. Nevertheless, it should be recognized that, within the chain of production-distribution-marketing, the various cooperating agents can have different moral responsibilities. However, there is another aspect to be considered, and that is the form of passive material cooperation which would be carried out by the producers of these vaccines, if they do not denounce and reject publicly the original immoral act (the voluntary abortion), and if they do not dedicate themselves together to research and promote alternative ways, exempt from moral evil, for the production of vaccines for the same infections. Such passive material cooperation, if it should occur, is equally illicit. As regards those who need to use such vaccines for reasons of health, it must be emphasized that, apart from every form of formal cooperation, in general, doctors or parents who resort to the use of these vaccines for their children, in spite of knowing their origin (voluntary abortion), carry out a form of very remote mediate material cooperation, and thus very mild, in the performance of the original act of abortion, and a mediate material cooperation, with regard to the marketing of cells coming from abortions, and immediate, with regard to the marketing of vaccines produced with such cells. The cooperation is therefore more intense on the part of the authorities and national health systems that accept the use of the vaccines. However, in this situation, the aspect of passive cooperation is that which stands out most. It is up to the faithful and citizens of upright conscience (fathers of families, doctors, etc.) to oppose, even by making an objection of conscience, the ever more widespread attacks against life and the “culture of death” which underlies them. From this point of view, the use of vaccines whose production is connected with procured abortion constitutes at least a mediate remote passive material cooperation to the abortion, and an immediate passive material cooperation with regard to their marketing. Furthermore, on a cultural level, the use of such vaccines contributes in the creation of a generalized social consensus to the operation of the pharmaceutical industries which produce them in an immoral way. Therefore, doctors and fathers of families have a duty to take recourse to alternative vaccines13 (if they exist), putting pressure on the political authorities and health systems so that other vaccines without moral problems become available. They should take recourse, if necessary, to the use of conscientious objection14 with regard to the use of vaccines produced by means of cell lines of aborted human foetal origin. Equally, they should oppose by all means (in writing, through the various associations, mass media, etc.) the vaccines which do not yet have morally acceptable alternatives, creating pressure so that alternative vaccines are prepared, which are not connected with the abortion of a human foetus, and requesting rigorous legal control of the pharmaceutical industry producers. As regards the diseases against which there are no alternative vaccines which are available and ethically acceptable, it is right to abstain from using these vaccines if it can be done without causing children, and indirectly the population as a whole, to undergo significant risks to their health. However, if the latter are exposed to considerable dangers to their health, vaccines with moral problems pertaining to them may also be used on a temporary basis. The moral reason is that the duty to avoid passive material cooperation is not obligatory if there is grave inconvenience. Moreover, we find, in such a case, a proportional reason, in order to accept the use of these vaccines in the presence of the danger of favouring the spread of the pathological agent, due to the lack of vaccination of children. This is particularly true in the case of vaccination against German measles15. In any case, there remains a moral duty to continue to fight and to employ every lawful means in order to make life difficult for the pharmaceutical industries which act unscrupulously and unethically. However, the burden of this important battle cannot and must not fall on innocent children and on the health situation of the population – especially with regard to pregnant women.   To summarize, it must be confirmed that:   -there is a grave responsibility to use alternative vaccines and to make a conscientious objection with regard to those which have moral problems; – as regards the vaccines without an alternative, the need to contest so that others may be prepared must be reaffirmed, as should be the lawfulness of using the former in the meantime insomuch as is necessary in order to avoid a serious risk not only for one’s own children but also, and perhaps more specifically, for the health conditions of the population as a whole – especially for pregnant women; – the lawfulness of the use of these vaccines should not be misinterpreted as a declaration of the lawfulness of their production, marketing and use, but is to be understood as being a passive material cooperation and, in its mildest and remotest sense, also active, morally justified as an extrema ratio due to the necessity to provide for the good of one’s children and of the people who come in contact with the children (pregnant women); – such cooperation occurs in a context of moral coercion of the conscience of parents, who are forced to choose to act against their conscience or otherwise, to put the health of their children and of the population as a whole at risk. This is an unjust alternative choice, which must be eliminated as soon as possible.   1J. E. Banatvala, D.W.G. Brown, Rubella, The Lancet, 3rd April 2004, vol. 363, No. 9415, pp.1127-1137