# Vaccine refusal in cancer patients at the French hospital: a normative re-analysis through a 'neopotterian theory of global bioethics'

Henri-Corto Stoeklé, Sakina Sekkate, Jaafar Bennouna, Philippe Beuzeboc, Christian Hervé

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Henri-Corto Stoeklé, Sakina Sekkate, Jaafar Bennouna, Philippe Beuzeboc, Christian Hervé. Vaccine refusal in cancer patients at the French hospital: a normative re-analysis through a 'neopotterian theory of global bioethics'. Monash Bioethics Review, 2025, 10.1007/s40592-025-00263-0. hal-05237192

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# Vaccine refusal in cancer patients at the French hospital: a normative re-analysis through a 'neopotterian theory of global bioethics'

Henri-Corto Stoeklé¹,² · Sakina Sekkate¹ · Jaafar Bennouna¹ · Philippe Beuzeboc¹ · Christian Hervé¹,³

Accepted: 27 July 2025
© The Author(s) 2025

## Abstract

Two normative studies in empirical bioethics on the bio-ethical issues associated with the refusal of cancer patients to be vaccinated against COVID-19 or flu at the hospital, in France, applying a 'neopotterian theory of global bioethics', have been published, respectively in 2022 and 2023. Since then, substancial progress in this theory have also been published, in 2024. The publication formalizes why and, above all, how global bioethics should integrate 'moral pluralism'. Based on these advances, we performed a normative re-analysis of the secondary information extracted from the two empirical bioethics' publications. At the end of the day, the solutions are now more explicitly discerned, which are different forms of indirect obligation for vaccination — to be understood as a more or less strong incentive to vaccinate rather than a legally formalized obligation. These solutions could have an appreciable relevance in mainland France, less in French overseas territories, even in other countries.

**Keywords** Vaccine refusal · Cancer patient · Empirical bioethics · Global bioethics · Moral pluralism · French hospital

## Abbreviations

COVID-19 Coronavirus disease 2019
MTM Multidisciplinary team meetings

<footnote>Extended author information available on the last page of the article</footnote>
# 1 Introduction

Empirical bioethics is a disciplinary subdomain concerned with the bio-ethical issues identified from data and/or information relating to the field (Ives and Dunn 2017). In August 2022, the results of a first longitudinal normative study in empirical bioethics aiming to identify and resolve the major bio-ethical issues associated with the refusal of cancer patients to be vaccinated against COVID-19 at the hospital, in France, was published in *BMC Medical Ethics* (Stoeklé et al. 2022). This prospective single-center cohort study was performed between April and November 2021. It focused on adult patients managed at the day hospital for solid tumors who had refused vaccination and the oncologists responsible for their management. In February 2023, the *European Journal of Cancer* published the results of a second, cross-sectional study aiming to identify and resolve the major bio-ethical issues associated with the refusal of vaccination against COVID-19 and flu (Stoeklé, Sekkate, Stoeklé et al. 2023a, b). This study was performed by almost the same investigators, one year after the first study, in November 2022, but focusing on the entire population of adult patients with solid tumors.

Both studies combined different methodological approaches, first and foremost the ‘normative approach’ (Kon 2009). This approach requires the application of an ‘ethical theory’, in other words, the use of a coherent set of ethical duties and/or purposes, to resolve the bio-ethical issues empirically identified — defined as tensions between health and/or life sciences practices and moral values and/or standards. In the framework of the two studies mentioned above, the ethical theory applied was a ‘neopotterian theory of global bioethics’. Indeed, it is explicitly derived from that of the American biochemist and bioethicist Van Rensselaer Potter first developed in the 1970s. However, as highlighted by a latest publication in July 2024 in the *Journal of Translational Medicine* (Stoeklé et al. 2024), substancial progress has been made in this neopotterian theory since the publication of these first two studies. Based on these advances, we performed a normative re-analysis of the secondary information extracted from these empirical bioethics’ publications —all starting from the same scientific evidence that these vaccinations are truly beneficial in terms of survival, particularly for cancer patients, as shown by various colleagues (Kamboj et al. 2024; Verdier et al. 2023; Desai et al. 2021; Shigayeva et al. 2015).

# 2 Method

This new work took place in a French hospital, from September to October 2024. The investigators were bioethicists and oncologists from the establishment in question, all with direct experience of the subject considered. There was no sampling, in the strict sense of the term, as we performed a normative re-analysis of secondary information extracted from a sample of scientific publications identified at the start of the study. No primary data were collected, and no secondary raw data were processed. We performed an analysis of the content and themes of the two publications before performing a normative analysis of secondary information — reinforced by triangulation of the investigators. This new work differs from the two previous ones, firstly
in its retrospective rather than prospective approach; secondly, and above all, in the
application of a more mature ethical theory.

Indeed, this neopotterian theory of global bioethics is now more formally based
on two postulates. The first postulate is that ‘survival’ and ‘happiness’ are the two
bio-ethical purposes common to all humanity. The second is that these purposes are
conditioned by ‘bio-ethical criteria’ that vary between ‘cultural areas’ due to the
corresponding ‘moral frameworks’. The advances made lie in a preliminary crite-
riology characterized on the basis of identified ‘moral frameworks’ (Stoeklé et al.
2024), together with the distinction between ‘macro-bio-ethical’ (e.g. country, etc.)
and ‘micro-bio-ethical’ issues and/or solutions (e.g. hospital, etc.). Therefore, the
suitability of the solutions depends on the zone and/or scale considered, together
with the context, and may be assessed in terms of social and/or political acceptance,
whether individual and/or collective, explicit or implicit, real or potential, evaluable
in a quantitative and/or qualitative manner, based on appropriate indicators.

## 3 Results

The analysis of the content and themes is graphically summarized in Table 1. The normative analysis is graphically summarized in Table 2. At the end of the day, vaccination policy becomes, more explicitly, a macro-bio-ethical issue, and, above all, macro-bio-ethical and micro-bio-ethical solutions are now, more explicitly, discerned (Table 2).

## 4 Discussion

The bio-ethical criteria should be very similar between the studies considered, which
were performed in the same cultural area and geographic zone: the Western world
and France, perhaps mainland France more specifically (Table 1, a and b). Indeed, in
mainland France, but not necessarily in French overseas territories, we could deduce
from these theoretical advances that the predominant moral frameworks, at the level
of society, but not necessarily at the level of individual, are the ‘Lay framework’ and
the ‘Catholic framework’, and infer that ‘equality’ is an essential bio-ethical criterion
(Stoeklé et al. 2024) But, this equality is mostly expressed as ‘equal freedom’ in the
Lay framework, and ‘equal dignity’ in the Catholic framework. More precisely, we
find respect for equality of freedom of choice on the one hand, and respect for the
equal dignity of all humans on the other hand. Therefore, there could be, at least, two
main bio-ethical criteria: equal freedom and equal dignity.

The longitudinal and cross-sectional studies provided convergent macro-bio-eth-
ical solutions (Table 1, a and b) (Stoeklé et al. 2022; Stoeklé, Sekkate, Stoeklé et al.
2023a, b). However, the modalities diverged. In the longitudinal study (Table 1, a)
(Stoeklé et al. 2022), the ‘sanitary pass’ or ‘vaccination pass’ embodied a specific
articulation of the explained bio-ethical criteria, and justified by the particular context
of a major pandemic. Here, such an ‘indirect obligation’ (N.B. to be understood as a
more or less strong incentive to vaccinate rather than a legally formalized obligation,
<table><caption>**Table 1** Graphical synthesis of the results of the content and themes analyses</caption><thead><tr><th>Studies</th><th>Publications</th><th>Contents</th><th>Features</th><th>Figures</th><th>Themes</th></tr><tr><th></th><th>References</th><th>Problems</th><th></th><th></th><th>Overview</th></tr></thead><tbody><tr><td>a.</td><td>Stoeklé HC, Sekkate S, Angellier E, Kennel T, Bennaziane A, Mabro M, et al. From a voluntary vaccination policy to mandatory vaccination against COVID-19 in cancer patients: an empirical and interdisciplinary study in bioethics. BMC Medical Ethics. 2022;23(1):88</td><td>Identification and resolution of the bio-ethical issues associated with the refusal of anti-COVID-19 vaccination in a population of cancer patients</td><td>Longitudinal<br>Single-center<br>Vaccination<br>Cancer patients<br>Oncologists<br>Data</td><td>April–November 2021<br>Day hospital<br>COVID-19<br>n=29<br>n=5<br>Questionnaires, interviews</td><td>Refusal=April<br>Refusal=October<br>5.6% = 29/522<br>1.9% = 10/522</td></tr><tr><td>b.</td><td>Stoeklé HC, Sekkate S, Vallée A, Beuzeboc P, Hervé C. Refusal of vaccination against influenza and COVID-19 in patients with solid cancers: from bio-ethical issues to solutions. European Journal of Cancer. 2023;183:139–41</td><td>Identification and resolution of the bio-ethical issues associated with the refusal of vaccination against COVID-19 and flu in a population of cancer patients</td><td>Cross-sectional<br>Single-center<br>Vaccination<br>Cancer patients<br>Data</td><td>November 2022<br>Day hospital<br>COVID-19, flu<br>n=168<br>Questionnaire</td><td>Coverage=COVID-19<br>Coverage=flu<br>90.36% = complete<br>22.62% = annual</td></tr></tbody></table>

Graphical synthesis of the results of the content and themes analyses of (a) Stoeklé et al. 2022 (N.B. '522' corresponds to the total number of cancer patients managed at the day hospital), and (b) Stoeklé, Sekkate, Stoeklé et al. 2023a, b (N.B. 'complete' indicates that the vaccination schedule for COVID-19 was completed, in terms of the number of doses received; 'annual' indicates annual vaccination against flu over x years) — referred to as the 'longitudinal study' and the 'cross-sectional study' in the text. The references are given in Vancouver format
i.e. a ‘direct obligation’; it should be noted that healthcare workers were constrained
by a direct obligation to be vaccinated against COVID-19 during the pandemic, or
risk suspension by their employer.), for the general population, to be vaccinated,
made it possible to avoid discriminating against a particular population, such as can-
cer population, with each individual considered of equal dignity. It also respected
equality between individuals in freedom of choice, but with this freedom moderated
by an exceptional need to put the collective needs first. The acceptance of the health
or vaccination pass, even if collective, was implicit but real (i.e., while criticizing the
pass, or the vaccine, the vast majority of people got vaccinated to get it), as could
be seen from the quantitative increase in vaccination coverage at this time (Fischer,
Peretti-Watel, and Ward 2025, Oliu-Barton et al. 2022). This acceptance could origi-
nate from this articulation, and highlight the relevance of the solution, at least in
mainland France.

In the cross-sectional study (Table 1, b) (Stoeklé et al. 2023), a vaccination pass could be less well accepted, as less justified by a context in which the risk of serious forms of the disease and, thus, of hospital saturation, had greatly decreased in the general population. Nonetheless, in the cancer population, the risk of serious forms remained markedly higher. The macro-bio-ethical solution retained an indirect but more implicit obligation to be vaccinated, with vaccination directly accessible at the end of routine consultations at the day hospital. The articulation of the bio-ethical criteria remained the same. There would still be no discrimination against a particular population because vaccination would become an integral part of the typi- cal treatment trajectory of cancer patients. And respect for the equal dignity of each individual would be therefore maintained, as would be respect for equal freedom of choice as each individual patient remains free to refuse vaccination. This respect should favor greater acceptance of the solution. Nevertheless, the suitability of the solution would be more appreciable if it were actually implemented. Thus, its accep- tance could be evaluable through vaccination coverage as an appropriate quantitative indicator (Table 1, b).

The longitudinal and cross-sectional studies provide two different micro-bio-eth-
ical solutions, at the scale of healthcare establishments (Table 1, a and b) (Stoeklé
et al. 2022; Stoeklé, Sekkate, Stoeklé et al. 2023a, b). For the longitudinal study
(Table 1, a) (Stoeklé et al. 2022), the first solution is indicated in the particular con-
text of a pandemic justifying the use of a health or vaccination pass, without actually
preventing a very small minority of cancer patients from refusing vaccination. In
the face of such cases, the object of the ‘emergency multidisciplinary team meetings
(MTM)’ would be the exceptional inclusion of bioethicists in the medical decision-
making process of the care teams. Finally, the equal freedom and dignity of all indi-
viduals would be respective, the objective of this emergency MTM being to agree
on a strategy for managing these refractory cancer patients without insisting on their
vaccination (N.B. as a reminder, these patients, who consequently did not have a
pass, were, normally, no longer authorized to enter the healthcare establishment at
which they were treated for their cancer, during the COVID-19 pandemic). The col-
lective acceptance of this solution, which was both explicit and real, evaluated quali-
tatively on the basis of feedback from healthcare workers, but in a non-pandemic
<table><caption>**Table 2** Graphical synthesis of the results of the normative re-analysis</caption><thead><tr><th>Studies</th><th>Macro-bio-ethical issue</th><th>Macro-bio-ethical solutions</th><th>Solution</th><th>Solution</th><th>Micro-bio-ethical solutions</th></tr></thead><tbody><tr><td>a.</td><td></td><td></td><td>Indirect obligation for vaccination = health or vaccination pass</td><td>Scale</td><td>Emergency multidisciplinary team meeting(MTM)</td></tr><tr><td></td><td></td><td></td><td>Country = France</td><td>Zone</td><td>Institutions = healthcare establishments</td></tr><tr><td></td><td></td><td></td><td>Mainland France</td><td>Context</td><td>Mainland France</td></tr><tr><td></td><td></td><td></td><td>Pandemic</td><td>Population</td><td>(non-) Pandemic</td></tr><tr><td></td><td></td><td></td><td>General</td><td>Criteria</td><td>Cancer patients</td></tr><tr><td></td><td></td><td></td><td>Equal freedom and dignity</td><td>Acceptance</td><td>Equal freedom and dignity</td></tr><tr><td></td><td></td><td></td><td>Collective, implicit, real</td><td>Indicator</td><td>Collective, explicit, real</td></tr><tr><td></td><td></td><td></td><td>Quantitative = vaccination coverage</td><td></td><td>Qualitative = feedback from care staff</td></tr><tr><td>b.</td><td></td><td></td><td>Indirect obligation for vaccination = care pathway (consultation)</td><td>Solution</td><td>Supportive care, telemedicine</td></tr><tr><td></td><td></td><td></td><td>Country = France</td><td>Scale</td><td>Institutions = healthcare establishments</td></tr><tr><td></td><td></td><td></td><td>Mainland France</td><td>Zone</td><td>Mainland France</td></tr><tr><td></td><td></td><td></td><td>Non-pandemic</td><td>Context</td><td>Non-pandemic</td></tr><tr><td></td><td></td><td></td><td>Cancer patients</td><td>Population</td><td>Cancer patients</td></tr><tr><td></td><td></td><td></td><td>Equal freedom and dignity</td><td>Criteria</td><td>Equal freedom and dignity</td></tr><tr><td></td><td></td><td></td><td>Collective, implicit, potential</td><td>Acceptance</td><td>Collective, implicit, potential</td></tr><tr><td></td><td></td><td></td><td>Quantitative = vaccination coverage</td><td>Indicator</td><td>Quantitative = vaccination coverage</td></tr><tr><td></td><td></td><td></td><td>Scale</td><td>Scale</td><td>Institutions = healthcare establishments</td></tr><tr><td></td><td></td><td></td><td>Zone</td><td>Zone</td><td>Mainland France</td></tr><tr><td></td><td></td><td></td><td>Context</td><td>Context</td><td>Non-pandemic</td></tr><tr><td></td><td></td><td></td><td>Population</td><td>Population</td><td>Cancer patients</td></tr><tr><td></td><td></td><td></td><td>Criteria</td><td>Criteria</td><td>Equal freedom and dignity</td></tr><tr><td></td><td></td><td></td><td>Acceptance</td><td>Acceptance</td><td>Collective, implicit, potential</td></tr><tr><td></td><td></td><td></td><td>Indicator</td><td>Indicator</td><td>Quantitative = vaccination coverage</td></tr></tbody></table>

Graphical synthesis of the results of the normative re-analysis of the secondary information extracted from (a) Stoeklé et al. 2022; and (b) Stoeklé, Sekkate, Stoeklé et al. 2023a, b – referred to as the ‘longitudinal study’ and the ‘cross-sectional study’, respectively, in the text

<figure><img src="image_2.png" /></figure>
context (Stoeklé, Billard, Stoeklé et al. 2023a, b), suggests that this solution could be relatively pertinent.

For the cross-sectional study (Table 1, b) (Stoeklé et al. 2023), it remains the possibility that the healthcare workers would not always have the time and/or means to convince cancer patient refusing vaccination, even when it could be possible to be vaccinated directly at the end of the consultation. Therefore, it was envisaged including this educational work in these new structures dedicated to supportive care. Telemedicine tools could also be useful to strengthen interactions between healthcare workers and cancer patients, notably to fight anti-vaccination activism (Huret et al. 2022). The equal freedom would be respected, the cancer patients remaining free to maintain their refusal to be vaccinated. The equal dignity would also be respected, because this refusal would not result in any discrimination in care practices. A greater acceptance of this solution could be, again, favored. But the suitability of the solution would still be more appreciable if it were implemented in practice, and then its acceptance evaluable through vaccination coverage (Table 1, b).

## 5 Conclusion

Finally, some might still think that it would be morally justified to legally require vaccination only among patients at high risk of severe forms of COVID-19 and/or influenza, such as cancer patients, even during a pandemic. Perhaps they are morally right, in theory. In practice, we believe that such a solution would not be socially, or even politically, acceptable, due to ignorance of a fundamental bio-ethical criterion: equal dignity. And this is possibly why such a policy has not been implemented in France. Others might still think that there can be no freedom if there is constraint. Remember that in the West, and France is no exception, the first corollary of freedom is probably responsibility, and one of corollaries of responsibility may be knowledge. In short, can I truly be a free moral agent, and therefore responsible, if I do not act with full knowledge of the facts, and/or if I act in ignorance of the consequences of my actions? In this case, we believe that is the role of states and/or institutions to compensate for this lack of knowledge, but always in a way that is politically and socially acceptable, in a given space and/or time — without ever lapsing into radical moral relativism (Stoeklé et al. 2024).

## 6 Limitations

The fact remains that the macro-bio-ethical and micro-bio-ethical solutions proposed for the macro-bio-ethical issue identified could have an appreciable relevance in mainland France, less in French overseas territories — the sanitary or vaccination pass in particular, as we saw during the COVID-19 pandemic. The colonial history of France may explain the existence in these territories of non-western moral frameworks, and/or ad hoc moral frameworks emanating from a unique relationship with the political power exerted by the former colonizer. As a result, other criteria probably apply in these particular zones. Furthermore, these criteria may have a cer-
tain relevance in mainland France, at the level of healthcare establishments. Cancer patients originating from French overseas territories may live in mainland France, or sometimes be simply treated there. Approaches of this type would also be appropriate for patients from other cultural areas present in France, and for other types of vaccination, notably vaccination against human papillomaviruses.

**Acknowledgements** We thank Foch Hospital and our colleagues for support. We thank the reviewer for her/his comments, which have enabled us to improve this manuscript.

**Author contributions** HCS and CH contributed to the conception of the paper, the drafting of sections and discussions about how the different sections should be refined and integrated. PB, SS and JB made substantial contributions to conception and design. All the authors have seen and approved the final manuscript.

**Data availability** No datasets were generated or analysed during the current study.

## Declarations

**Competing interests** The authors declare no competing interests.

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Authors and Affiliations

Henri-Corto Stoeklé<fnref n="1" />,<fnref n="2" /> · Sakina Sekkate<fnref n="1" /> · Jaafar Bennouna<fnref n="1" /> ·
Philippe Beuzeboc<fnref n="1" /> · Christian Hervé<fnref n="1" />,<fnref n="3" />

<figure><img src="image_3.png" /></figure>

Christian Hervé
christian.herve@parisdescartes.fr

Henri-Corto Stoeklé
h.stoekle@hopital-foch.com

Sakina Sekkate
s.sekkate@hopital-foch.com

Jaafar Bennouna
j.bennouna@hopital-foch.com

Philippe Beuzeboc
beuzeboc.philippe@gmail.com

<footnote n="1">1 Hôpital Foch, Suresnes, France</footnote>

<footnote n="2">² Versailles Saint-Quentin-en-Yvelines University, Versailles, France</footnote>

<footnote n="3">³ Université Paris Cité, Paris, France</footnote>