The Future of the Center for Biomedical Ethics and Law (CBEL)
Report. Some reflections upon retirement.

CBEL Report Volume 5, Issue 2

Editorial

The Birth of Epidemiological Public Health Ethics
Akira Akabayashi *be vaccinated against influenza than those who inter-Introduction
Before stepping down as Professor at the University

acted less.

of Tokyo, I would like to introduce a new research area

This paper has been nominated for a 2023 Interna-that I have developed an interest in through my activities

tional Research Awards on Pediatrics, Perinatology andat the CBEL and BICRO.

Child Health.

In collaboration with Drs. Komada, Lee andWatanabe at Tokyo University of Health Sciences, weDiscussion

published an article on December 13, 2022 in ahigh

What can we infer from the fact that contact with aranking, peer-reviewed journal Vaccine: X(Publiclarge number of people is associated with higher volun-Health, Environmental and Occupational Health: Q1,tary vaccination rates? After considering conventional

Elsevier) [1].

interpretations of the data, I felt something was missing

This study was based on a secondary analysis of datain terms of the analysis.

from an original health questionnaire survey of 5,002

I stepped outside conventional epidemiological rea-participants randomly selected from approximately

soning to account for the results. The study showed that

100,000 local residents aged 20–79 years living in thethose who had more contact with others on a daily basis

Tohoku region. The original study was conducted inwere significantly more likely to receive the influenza

2011 after the H1N1 influenza pandemic in 2010 andvaccine than those who had less contact. The standard

before the COVID-19 pandemic in 2019. The resultsinterpretation might be as follows: people decided to be

showed that among those aged 20–64 (about 3,000 peo-vaccinated 1) for their own self-protection, and 2) thatple), those who interacted with five or more people inpeople who have considerable contact with others havetheir neighborhood were about 1.4 times more likely toa lot of information to exchange. However, we further

be vaccinated against influenza than those who inter-

considered the possibility that, 3) people act to avoid

acted with four or fewer people (relevant confounding

spreading the infection to others; that is, a motivation

factors were adjusted, such as gender andbased upon altruism.

education).

We found that the issue of interaction was independently

The statistical analysis showed that there were many

significant, regardless of other factors. Those who inter-other significant factors. However, our interpretation ofacted more with others were significantly more likely to3) strongly resonated with the reviewers and editors of*

Department of Biomedical Ethics, Faculty of Medicine, University of Tokyo
Division of Medical Ethics, School of Medicine, New York University13CBEL Report Volume 5, Issue 2

Akira Akabayashi

Vaccine X, and it seems that this paper was accepted pre-[2]. However, vaccination coverage against the Omi-

cisely because of this innovative thinking. In this way,cron strain is still only at 36% (as of January 7, 2023)

the possibility of the existence of Japanese altruistic be-[3]. It is well known that healthy people and children are

havior was demonstrated for the first time from an un-often mildly ill or asymptomatic when infected with thebiased secondary data analysis.

Omicron strain of COVID-19, and the public knows this.

The social situation when this paper was accepted for

Nonetheless some healthy people and children are notpublication was such that although the pandemic had

willing to be vaccinated fearing adverse side-effects.

subsided, on January 6, 2023 the number of deaths

However, there is a risk that such people may becomereached a record high of 498, and the number of seri-vectors of infections and transmit them to the elderly orously affected also increased to 659 [2]. The number ofpatients with weakened immunity.

deaths alone had soared to 228 (12/9/2022), 259(12/16/2022), 315 (12/23/2022), and 326 (12/30/2022)

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The Future of the Center for Biomedical Ethics and Law (CBEL)
Report. Some reflections upon retirement.

So, I summaries the paper [1] as follows:

CBEL Report Volume 5, Issue 2“harm to others” principle, and “the public good.” However, the concept of the public good is very vague. Dur-Even after eliminating various factors, the pres-ing the COVID-19 pandemic, this core concept of pub-ence or absence of opportunities to come into con-lic health ethics was not well known in Japan.

tact with many people is related to vaccination

I would like to reiterate that as a breakthrough in ac-rates. We have found the possibility that the Japa-

ademic methodology that quantitative results from un-nese may act altruistically (for the sake of others)

biased data supports the possibility that altruism moti-

for the first time, based on the unbiased analysis ofvates decision making in Japanese people.

data.

One of the strengths of CBEL and BICRO is that we
can ask other fields’ experts about the validity of the in-What makes our work groundbreaking is that, until

terpretation of these results. I asked a well-known epi-now, core concepts in the humanities and social sciences

demiologist. He said: "We epidemiologists can't write

were primarily philosophically based, and that there

this much, but if it is a "possibility," as Dr. Akabayashi

were few scientific methods to support their existence.

says, it is well understood. Also, the bias is certainly re-For example, how can we investigate whether concepts

ducing."such as "kindness" or "good will" really exist in a mate-

New academic endeavors may seem to go out on a

rial way? For example, suppose we asked the question,limb. However, change cannot come without risk. This

"Are you kind?" respondents may then misrepresent

study is not a hypothesis-proving study, but rather anthemselves and give the answer that society expects. It

exploratory one. However, for an exploratory study, I

does not prove that the concept of kindness really exists

think the results are of interest.

or that kind acts are performed, or indeed, what the motivation for them is.

There are many discussions about the characteristicsof Japanese altruism, which are related to the concepts

We have found that, at least in the context of vaccina-of gift exchange and volunteerism. It is said that Japa-tion, people who frequently come into contact with oth-nese altruism is "altruism that seeks reward," which isers may be doing so for self-protection, but they may

different from altruism that offers something for free.

also be doing so for the sake of others’ wellbeing andAlso, Japanese altruism may include the family-oriented

this may be reflected in their behavior. The results wereattitudes, through which all that is good for the family

the first to be analyzed in a manner that does not rely onunit is in itself good, and that vaccination is acceptedsubjective self-assessment, but rather through the use of

because people do not want their family members to be

rigorous statistical analyses.

infected. This issue of family is also discussed in the ar-In the field of public health, ethics has been actively

ticle concerning the low number of brain-dead donors instudied for more than 20 years. Public health ethics has

Japan [4]. My colleagues and I are now conducting fur-often been viewed as a conflict between "individual lib-ther enquiry into philosophical and public health ethics

erty" – which is only limited by John Stuart Mill’s

considerations regarding the Japanese concept of15

CBEL Report Volume 5, Issue 2

altruism.

Akira Akabayashi

co-payment for vaccination? For those without money

I hope that this emerging methodology, "Epidemio-(often the elderly and sick, or people with other vulner-

logical Public Health Ethics,” which integrates epide-abilities) the co-payment of vaccines would affect their

miological statistical methods with public health ethicalstandard of living. Consequently, social disparities

analysis, will lead to the development of a new, power-would widen.

ful research methodology that integrates the humanities and sciences.

In conclusion, I believe that the Japanese people areat heart altruistic, and that if sufficient explanations aregiven, the number of people being vaccinated will in-Directions for the Futurecrease.

Finally, I would like to address some specific suggestions for vaccine policy in practice.
I believe that this paper has significant implications

References[1] Komada T, Lee JS, Watanabe E., Nakazawa E,

for the future of infectious diseases in Japan and for pub-Mori K, Akabayashi A. Factors of Influenza Vac-lic health ethics regarding vaccination. I believe thatcine inoculation and Non- Factors of Influenza

healthy people and children are now strongly encouraged to be vaccinated with Omicron strain-compatible
vaccines as well as to mask wearing. To this end, it

Vaccine inoculation and Non- inoculation Behavior of Community-Dwelling Residents in Japan:
Suggestions for Vaccine Policy and Public Healthwould be effective for public health promotion to inEthics after COVID-19, 2023, Vaccine: X, include a personal message, such as "It protects you andprevents the spread of infection to others," when callingfor vaccination, rather than merely expressing abstractpress) https://doi.org/10.1016/j.jvacx.2022.10024[2] Ministry of Health, Labour and Welfare. 2023.

concepts such as the public good and self-protection [5].

data shows -Information on new coronavirus in-This will be same in mask wearing discussion [6]fection-. Available at: https://covid19.mhlw.go.jp/Finally, questions arise regarding the economic effect[3] Japan Broadcasting Corporation. 2023. Vaccina-of vaccination. If there was a vaccine shortage, theretion Status in Japan. Available at:would be an issue of who should be vaccinated. How-https://www3.nhk.or.jp/news/special/corona-ever, currently there is no such shortage. There remains

virus/vaccine/progress/#mokuji1

the issue of pressure on medical costs — comparing
the cost of 500 deaths and 650 seriously injured people
every day (entailing ICU maintenance, lack of medical
personnel and the enormous medical costs of not know-[4] Akabayashi Ar., Nakazawa E., Ozeki R., Tomiyama K., Mori K., Demme R., Akabayashi Ak.
Twenty years after enactment of the Organ Transplant Law in Japan: Why are there still so few de-ing how long this situation will continue), to vaccinating
at least the remaining 60% of the population. Would thehealth care cost crisis really be reduced by requiring a16

ceased donors? Transplantation Proceedings
50:1209-1219, 2018.

The Future of the Center for Biomedical Ethics and Law (CBEL)
Report. Some reflections upon retirement.

CBEL Report Volume 5, Issue 2[5] Takahashi S, Nakazawa E, Akabayashi A. In
Whose Best Interest? Parental Hesitancy toward
the COVID‐19 Vaccine for Children in Japan: A
Literature Survey Study. COVID 2022;2: 827–836. https://doi.org/10.3390/covid2070060(Chapter will appear in a book titled “ResearchDevelopments in Medicine and Medical Science” 2023 (London: BP International, in press)[6] Akabayashi Ak, Akabayashi Ar, Nakazawa E.

Mask-wearing during the COVID-19 pandemic: A theoretical analysis from the perspective of public health ethics. BioMed 2022 Nov3; 2(4):386-390. doi: 10.3390/biomed2040030.

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