Second-order preferences and the ethics of nicotine vaccines

A couple of weeks ago, I taught a class in which I used a study about the new nicotine vaccine as an example, and posted the class outline (which I will shortly update with a few talking point notes for guiding the discussion, just in case anyone is interested in borrowing the curriculum).  This prompted a few questions about my general thoughts about the "vaccine", which I said I would answer.

Those scare quotes reflect that this is a sketchy use of the word:  The technology consists of introducing a substance into the body in order to stimulate the immune system to react to the target, which indeed describes the workings of a vaccine.  However, most definitions of the word include a "to prevent future disease" component, while this "vaccine" only prevents nicotine from affecting the brain in ways that clearly do not constitute disease.  The ability to experience the effects of nicotine is considered a disease only in the minds of a small tribe of aggressive political activists, and even they offer no definition of "disease" that supports such an interpretation.  (Please spare me "logic" like "smoking causes dozens of diseases, and therefore nicotine consumption is a disease"; by that twisted logic, the ability to derive benefit from driving a car or to enjoy sex constitutes a disease.)

Some definitions of "vaccine" specify that the stimulated immune response is to infectious agents.  Moreover, the immune reaction does not destroy the nicotine, as it would an infectious agent, but merely binds to it, making it too big to get into the brain.  Given these departures, it seems best to think of "vaccine" as a metaphor rather than a literal use of the word.  With that in mind, I will just go ahead and use it without quote marks.

(Keep in mind when reading this that nicotine can be delivered in ways that, unlike smoking, do not cause substantial risk of actual disease.  However, that only amplifies the points I am making; this analysis would still be valid even if all nicotine use created measurable risk of disease.)

So, it is improper to think of this vaccine as something that destroys a disease agent, but how should we think about its impact?  I think it is best characterized as a way of changing your preferences, something that is often desired.  Having a preference for having different preferences, while a bit awkward to write and read, is not unusual at all.  I definitely prefer drinking Coke to water, though if I could switch how much I enjoyed them, I most certainly would:  I would prefer a world in which I liked water as much as I currently like Coke and vice versa, and would pay thousands of dollars to cause that change.  The reasons for this should be fairly obvious, as they are for the preference pattern that most of us experience sometimes, "I really want to take a nap (or play a video game, or whatever) right now rather than working; I wish I could get inspired to work".  Put another way, I might prefer to not work at a particular moment, but I would prefer to prefer to work.

Such preferences about your more basic preference ordering are called "second order preferences".  My colleague at THRo, Catherine Nissen, and I have thought a lot about this concept in the context of smoking.  It seems pretty clear to us that it explains several phenomena (though as far as we can tell, we are the only ones arguing this viewpoint).  One example is the disparity between the common claim that almost all smokers want to quit and the fact that they have not acted on that preference.  It is because the claim about preferences naively misconstrues a second order preference for a basic first order preference. 

The research that produces those "almost everyone" statistics represents standard tobacco research sloppiness, asking questions like "do you want to quit smoking?"  Anyone who is any good at designing surveys, or who merely read this post, should see the flaw in that phrasing.  A question like "would you rather smoke later today or not?" is well defined and if most smokers answered "not", it would be legitimate to say "they want to quit".  But the actual vague questions will often get translated by respondents into something along the lines of "compared to continuing smoking, would you prefer a future that includes you not smoking and being happy to be in that state?"  That is a question about second order preferences, and is no more realistically interpreted as "they want to quit" than my above observation can be read as "I do not want to drink Coke".

So, circling back to the vaccine, if someone has a second order preference to be a non-smoker -- he would prefer to be someone who prefers to not smoke -- but he really prefers to smoke rather than abstain because he likes the effect of nicotine, then he might choose the vaccine to align his preferences (the first order, or basic preferences) with his second order preferences.  The vaccine takes away the effect of nicotine which, in this scenario, leaves him no reason to prefer to smoke. 

There are two important complications with this:

The first is that the vaccine merely lowers the welfare from being in one possible state, using nicotine, without raising the welfare enjoyed in the alternative.  Indeed, such lowering is typically the only available option for reordering our preferences.  After all, if we had a chance to raise our welfare when in a particular state, then we would just do it.  Setting a loud alarm clock across the room does not make us any happier to be awake on time -- it merely makes continuing to lie in bed so unpleasant that it is no longer our preferred option. 

Notice how I phrased my second order preference about drinking Coke: how much I liked the two beverages would be swapped, so drinking water would become as pleasurable as drinking Coke is now.  That would be a win-win.  If there was an option to make that change, I obviously would have already done it.  So, if I wanted to "self-command" (to use Schelling's term) myself to give up Coke in the real world, if somehow I thought that I would be much better off without it but were unable to resist, the best I could hope for would be to make it unappealing.  There is no obvious way to make plain water seem that yummy.

So, the vaccine takes away the pleasure (focus, stimulation, etc.) you get from nicotine when smoking, lowering the benefits to the those you get from nicotine when not smoking -- that is, down to zero.  One's preferences are reordered by taking away benefits from one of the options.  This does not seem like a great deal.  It might be desirable, however, if someones second order preference for wanting to prefer not smoking to smoking was sufficiently strong.  He could rationally choose to take the vaccine, so long as he knew what he was getting himself into.  But he should be clearly told "you know how you feel when you don't smoke?  Well, if you take the vaccine, that is going to be how you feel, whether you smoke or not.  So, you will not want to smoke, but you will not have the option of feeling like you currently do when you smoke."

So, as long as that is honestly communicated, the choice is an informed autonomous one and could be rational.  (And we can have faith that physicians and advocates will make this clear, right?  Of course they would never gloss over the bit where the vaccine will not make you any better off when you became abstinent than you are when you abstain without the vaccine.)  Fortunately, the vaccine's effects appear to mostly or entirely wear off, at least when used for a short period, so if someone tried it once and discovered it was a mistake, they could reverse the choice.

That brings us to the second issue:  Most of the discussion about the topic is not about the rational adult making an informed decision, but about involuntarily inflicting the vaccine on kids.  Those proposing it tend to gloss over that "involuntary" bit, and failure to even address this is a serious ethical problem in itself.  But, of course, unless we are talking about a current user who is wanting to quit, this is the only interpretation.  Either the kid is already choosing to not use nicotine, in which case he would see no reason to accept the side effects, or he is currently choosing to use nicotine, in which case he would prefer to avoid the vaccine.

Of course, we take actions that restrict kids' choices all the time.  But there is something rather different when the method involves altering their bodies to make it impossible to enjoy a particular choice (and that choice is not "inflict violence on others" or "commit suicide" or something of that nature).  If the effect were permanent, I think this would be an ethical no-brainer.  I suspect that a permanent effect is the goal of those pursuing research on this vaccine, and inflicting that on someone would clearly be unethical.  No, that is too mild -- it would be utterly appalling. 

Consider the other example (the only other one I can think of) in which adults permanently alter the body of a child to prevent the child from engaging in a behavior that entails some costs, and where they (the adults) do not approve of the kids enjoying the benefits:  the mutilation of girls' genitals practiced in some African communities, which you have no doubt read about.  Before anyone who cannot follow a logical argument flips out, I will point out that I am not claiming that either the damage done or the loss of benefits from the vaccine is as great as that from genital mutilation.  But the motivation and implications are otherwise similar:  enjoyment of sex/nicotine by youth is considered evil by those in power for some reason; the benefits of sex/nicotine result in temptation that can be removed by altering someone's body to diminish the benefits; yes, the behaviors that are thus prevented can increase risks of disease, but this does not appear to be the genuine motivation (e.g., because there are other ways to avoid disease that the proponents oppose).  I suspect that never in my life have I had a conversation with someone who thinks that genital mutilation is anything other than appalling, so why is there no hint of such ethical concern directed at the nicotine vaccine?

There is a real difference to the extent that the vaccine's effects will wear off completely once someone reaches the age that they can make rational choices about their own health.  But even then, this is pretty scary ethical ground.  Plus there is no solid evidence that years of vaccination can be completely reversed.

There is room to ethically defend the vaccine with an argument along the lines of the yet-to-be proven, "we have solid evidence that this will wear off in time for an adult to make her own choices" along with "teenagers using nicotine is so unacceptable because ... that we can justify altering their bodies to prevent it".  Or an argument could be made, "yes, we realize that this is basically like genital mutilation, but it differs in the following ways such that we think it is ok...."  I have seen no such justifications offered, presumably because (a) they would be utterly unconvincing and (not "or") (b) the vaccine proponents are so fanatical about their goals that they are unaware that there is any need to defend them.

Until the proponents of giving the vaccine to kids admit that they are treading on very dangerous ethical ground, and upon recognizing that present a compelling argument to defend their position, I believe we have to consider this, alongside genital mutilation, as an unethical infliction of physical damage and loss of liberty on innocents, motivated by goals that are based entirely on quasi-religious beliefs that are believed only by a minority that happen to hold power over some children.  The term "vaccine" is a bit strained, but the term "child abuse" seems to apply unambiguously.