Vaccines: Making responsible decisions

“Arabian smallpox maliciously undermines man at the threshold of life and preys on the human species almost destroying it in its birth. This very sad thought is exacerbated by the repeated heavy losses of life caused by the disease and should persuade everyone to embrace with great enthusiasm and receive with equal gratitude the inoculation vaccine, a method that is as simple as it is effective in curbing the poisonous force of the disease.”

These words are from the Edict on Vaccination, June 20, 1820,[1] issued immediately after an epidemic of smallpox in the Papal States by the Secretary of State, Cardinal Ercole Consalvi, on behalf of Pope Pius VII. It provided, in case of epidemics, organizational measures of public health (quarantine, isolation) and the practice of vaccination (administration, records, certificates, supply), making it mandatory and free.

The British physician Edward Jenner (1749-1823) had confirmed, in 1798, the safety and efficacy of the procedure that used cowpox to treat the more serious smallpox. Those who came into contact with the bovine form of smallpox did not contract smallpox, obtaining what we now call immunization. It was thus possible to abandon the previous ancient use, from the Middle East, which for the same purpose, but with much greater risks, used material from infected humans. After about 20 years of practice, Jenner concluded that vaccination “produces a short benign disease without danger, does not cause the contagion of smallpox amongst  people living together and at the same time provides a defense against smallpox no less than inoculation with the products of true (human) smallpox.”[2]

The measure of Pius VII, however, was not very successful. Therefore, his successor, Leo XII, removed the obligation, “given the futility of insisting,” as noted by Fr. Enrico Baragli, when reviewing in this magazine the well-known film, Nell’anno del Signore (In the Year of the Lord) and pointing out various historical inaccuracies: the responsibility for this choice  to reject the vaccine was “neither that of popes nor of their governments, but was the result of popular prejudices, including those of doctors themselves, as well as of parish priests. The latter considered it ‘troublesome, difficult and odious to compile quarterly lists of births, and especially to expose the reasons for the failure to vaccinate, given the resentment that results.’”[3] Even in those times there was resistance and opposition to the use of vaccines.

The strategic role of vaccines in the current pandemic

Today, the situation has changed considerably. The causes that have determined the spread of the contagion and the propagation of Covid-19 in the globalized world are numerous, as are the consequences that must be re-examined if the human family is to recover from the damage that the crisis has partly caused, partly revealed.[4] Vaccines are not a panacea, but they play a crucial and urgent role in this process: they have undergone an enormous evolution in the last two centuries, proving highly effective for many diseases. It is estimated that about 25 million deaths have been prevented between 2010 and 2020, at a very low cost compared to other health strategies.[5] However, from a biotechnological, medical and social point of view they are not just simple tools due to how they are perceived and culturally represented.

Their story is marked not only by success, but also by failure , which have contributed to a recent resurgence of what is called “vaccine hesitation.”[6] This is a well-known phenomenon, spanning a spectrum from mild hesitancy to outright refusal (anti-vaxers). Didier Fassin, a world-renowned physician and anthropologist, has been interested in public health and social justice. He recollects how the field of medicine is fertile ground for the development of “conspiracy” theories, since vaccination is a practice based on a well accredited scientific truth today, and on a high ethical principle, such as that required of those who take care of sick and fragile people. To think that science could be used for occult and malicious purposes and that medicine operates in contrast with its fundamental axiom: primum non nocere (first, do no harm) therefore strikes at the heart of truth and moral principles.

Like the plague in the 14th century, cholera in the 19th century, and HIV/AIDS since the 1980s, Covid-19 has caused an epidemic of conspiracy theories. Its sinister shadow even reaches vaccines. While one must rule out intentional planning of such goals, one must nevertheless acknowledge that accidental side-effects have fueled suspicion of and opposition to vaccines. The spread of hepatitis C, linked to improper use of syringes during the anti-trypanosomiasis (sleeping sickness) vaccination campaign in Cameroon, is one example.[7] The conversation on vaccines must therefore take into account these multiple dimensions if it is to lead to actions based on responsible choices.

Remote and recent interventions of the Holy See

A statement repeated several times by Pope Francis invites us to take into account different implications of the issue. Following the line set out by many of his predecessors – Pius VII, Leo XII, Gregory XVI, Pius IX – he affirms that vaccinating against Covid-19 is an “ethical option” and warns against “suicidal denialism.”[8]

 An ethical action is the result not only of correct information, but also of a critical examination of suspicions and fears. For this to happen, it is necessary to distance oneself from emotional reactions: to recognize them, understand them and examine where they lead, so as not to follow them if they are misleading or “disordered,” to use the language of discernment. They must therefore be responsibly assessed, in the context of the good of other people.

The pope pointed out clearly that vaccination involves aspects that concern others: “You are gambling with your health, with your life, but you are also gambling with the lives of others.” Moreover, if one takes a broader view, the common good and justice are also in question: “If there is the possibility of curing a disease with a drug, it should be available to everyone, otherwise it creates injustice”[9]; “pharmaceutical marginality” must be avoided.[10] “Social and economic differences on the global level risk dictating the order of distribution of anti-Covid vaccines, with the poor always at the end of the line and the right to universal health care affirmed in principle, but stripped of real effect.”[11] In order to clarify this complex matter and to give answers to those who ask questions about the safety, effects and lawfulness of vaccines, the Holy See has recently published two Notes that address the various aspects.

Vaccines and abortion

The first, Note on the Morality of the Use of Certain Anti-Covid-19 Vaccines, comes from the Congregation for the Doctrine of the Faith (CDF) and examines a very specific problem, but one that has been discussed for some time, especially within the ecclesial community: the use of vaccines produced using cell lines extracted from the tissues of voluntarily aborted fetuses.[12] This problem has also been raised by some vaccines administered to children: first of all, the rubella vaccine, but also those against hepatitis A and rabies. In particular, there is concern about a cell line (HEK293) obtained in 1973 from the kidney tissue procured as the result of an abortion that occurred in Holland.

Neither the identity of the parents nor the precise reasons for the termination of the pregnancy are known, although they appear to have no connection with the objective of preparing cell lines for laboratories.[13] Some Covid vaccines use such biological material in one or more phases of their preparation. Those already approved in the U.S. and Europe, manufactured by Pfizer-BioNTech and Moderna with messenger RNA technology, do not use such cell lines for production, but only for some verification tests.[14]

The CDF Note reiterates what has already been stated in a previous Instruction, where it was first specified that you cannot justify voluntary abortion, even for public health reasons: both the extraction of cell lines to prepare vaccines and their distribution and marketing are, in principle, morally illicit. The Instruction noted, however, that “within this general picture there exist differing degrees of responsibility. Grave reasons may be morally proportionate to justify the use of such ‘biological material.’”[15]

With reference to the current situation, the CDF explains the reasons and conditions under which “it is morally acceptable to use Covid-19 vaccines that have employed cell lines from aborted fetuses in their research and production process” (Note, No. 2). The argument used to support this position is that it differentiates between ways of cooperating with a morally illicit action performed by others. The principle is of great interest because it is a conceptual tool that the tradition of moral theology has developed to address the complexity of human decision-making, which never occurs in an abstract space, but is always intertwined with the actions of other subjects and in composite circumstances.[16]

In our case, consideration must be given to the fact that cooperation with cell lines from the 1973 abortion is material, passive and remote (see Note 1, No. 3). These are terms that designate well-defined conditions. First, cooperation is material when one does not share the intention of the person who performed the principal action, in this case, the presumably deliberate killing of an innocent person. Secondly, it is passive. In fact, you do not actively participate in the conduct of the act, which is also impossible, since the event happened in the distant past, and – an important aspect to remember, because sometimes it is misunderstood – it does not require the procuring of other abortions: for the preparation of vaccines, cells already available in laboratories from the 1970s and 1980s are used. Third, therefore, the action that is performed is remote, that is, it is distant in time and peripheral to the core of meaning of the behavior to which it refers. These criteria can help to locate and differentiate the responsibilities of other subjects involved in the process required by the research and preparation of vaccines.

Personal responsibility

As we can see, our moral evaluation of voluntary abortion remains negative and it is necessary to avoid any perception of complicity with it (thus avoiding causing scandal), when one engages in the search for ways of production that employ other biological material. But, in the absence of alternatives and because of the gravity of the situation, the use of these vaccines is considered legitimate. And in the current circumstances, it can certainly happen that there is no real possibility of choosing an alternative vaccine, both because of the scarcity of available doses and because of the constraints imposed by health systems.

In fact, we must remember that the lengthy time required for vaccinations entails an increase in the probability that more contagious variants will develop, which are more lethal and/or more resistant to the available vaccines. The more time we give the virus to replicate, the greater the likelihood of mutation. It is true that Sars.Cov.2 is more stable than other viruses (such as influenza), at least from the point of view of antigens: being equipped with a good molecular “proofreading” device, copying errors are reduced. The variants known so far – such as the British, Brazilian and South African – seem sensitive to current vaccines. However, we cannot exclude the possibility of resistant forms taking hold.

Therefore, as the U.S. bishops also point out, in the same way that the use of the rubella vaccine is acceptable, so too, “because of the lack of alternatives and the serious risk to public health, it would be permissible to accept the AstraZeneca vaccine.”[17] And the Latin American bishops reiterate: “Vaccination cannot be considered to be in cooperation with evil (for example, abortion), but a direct act of care for life.”[18] So let us see how the importance of circumstances is brought to bear in evaluating the good to be done. Also because what is at stake is not only personal health, but also the health of others and the common good.

Therefore, there is a very real responsibility for everyone to get vaccinated: what is at stake is the protection not only of one’s own health, but also of public health. In fact, vaccination, on the one hand, reduces the exposure of people who, for medical reasons, cannot receive it (for example, immuno-compromised people) and who will be protected by the vaccination coverage of others (and by the achievement of herd immunity); on the other hand, it limits the number of sick people and hospitalizations, reducing the overload in health systems, which are already struggling to provide the necessary care to patients with other diseases. We have seen how in various countries treatment has had to be rationed due to lack of resources. The refusal of the vaccine, therefore, means risking the fundamental safety of others, both personally and socially.[19]

The first steps of the vaccine pathway: research and testing

The second Note, Vaccine for All. 20 Points for a More Just and Healthy World[20], this time from the Vatican Covid-19 Commission and the Pontifical Academy for Life, focuses on aspects that concern the broader context of public health, also on a global level. The text analyzes the entire life cycle of the vaccine and, in addition to the issues already mentioned regarding production and administration, examines the ethical implications of each step. The principles it refers to are those of the Church’s social doctrine (starting with human dignity, justice, solidarity and subsidiarity), and the values shared with emergency medicine practitioners.[21]

The very short time taken to develop several vaccines is an exceptional achievement, fruit of the worldwide commitment of researchers and both public and private institutions, the availability of advanced knowledge in the field of infectious diseases and oncology, the economic effort and the simplification of administrative procedures, with the elimination of bureaucratic inefficiencies. It has also been possible to carry out research and development in parallel phases that normally occur in sequence, without departing from scientific requirements.

Given the rapidity of these steps, some question the efficacy and, above all, the safety of the new vaccines. But the fact that the regulatory authorities who routinely approve the use of drugs have been authorizing these products, guarantees the use of the standards that are applied to every new drug prior to its approval.

There is no doubt that the situation in which we find ourselves sees vital issues at stake. In addition, the political and public pressure to speed up procedures is very high. But there has been no shortage of examples of how the balance between risks and benefits has been carefully assessed: for example, the examination of some data that did not seem convincing has led to the suspension of some trials and new controls. It will be important to integrate the data not yet collected, monitoring the long-term effects of vaccines, as is usually done in the surveillance phase following the diffusion of a drug. Certainly, given the global dimensions of the pandemic, coordination and mutual recognition between the national authorities approving the product in order to share results and eliminate delays, could be of great help (see Note 2, No. 10).

Economic dimension and commercial exploitation

Regarding the economics of vaccines, we have witnessed a substantial mobilization of resources, with extensive funding available both through the investment of public resources (either research grants or prior purchase of doses) and through donations from private entities, distributing the risk of research among different bodies.

Note 2 supports the commitment to make the vaccine a “public good,” as stated by several politicians and scientists.[22] This implies that the vaccine is not subject to free competition, but that the price is agreed and fixed with criteria that allow a distribution based on actual needs, according to criteria of equity and universality. Since the vaccine is not “an existing natural resource (such as air or oceans), nor a discovery (such as the genome or other biological structures), but an invention produced by human ingenuity, it is possible to subject it to economic consideration, which allows the recovery of the research costs and risks companies have taken on. Nonetheless, given its function, it is appropriate to consider the vaccine as a good to which everyone should have access, without discrimination” (Note 2, No. 7).

To ensure universal access and equitable distribution, it has also been proposed to remove patents, although this measure could reduce the speed of research and the number of companies involved. However, it is possible to imagine forms of limitation and the granting of regulated licenses at the international level, also introducing financial instruments for the recovery of resources invested (for example, vaccine bonds). The Covax global program, whose partners include the World Health Organization (WHO), has the objective of allowing all countries to access a vaccine, avoiding the dominance of the richest ones. The priority should be “to vaccinate some people in all countries rather than all people in some countries.”[23] This objective requires international agreements between different parties and transparent and collaborative procedures, avoiding antagonism and competition that lead to “vaccine nationalism.”[24]

As has been seen with the Pfizer-BioNtech vaccine, the goal is difficult to achieve, given the scope of interests involved and the multiplicity and size of the actors involved. We have noted how arduous it is to proceed with collaboration and subsidiarity in the vaccine production phase (see Note 2, No. 9). It too requires a stronger understanding and synergy between states, pharmaceutical companies and other organizations, so that the vaccine can also be produced in the territories where it is to be distributed. This would make it possible to increase the availability of doses – and therefore the speed of administration – as well as making the most of local resources. However, there is considerable resistance to this, perhaps linked to patent management.

Access and administration

Characteristics of each vaccine will impact access as storage conditions (e.g. temperature control) are harder to attain in less well-equipped countries. Again, only a willingness to collaborate will effectively overcome barriers. Paths that contribute to the more stable construction of an international solidarity that overcomes the inequalities and limitations in health protection that many countries still suffer from need also to be established. 

As for the order of administration, there is widespread agreement (at least in theory) on the priority to be given to professional groups that perform tasks of prime concern. Frontline health workers receive priority, as do other categories of people more exposed to transmission of infection with public services of greater importance (such as schools and police). The most vulnerable, among whom there is a higher rate of mortality and sickness, are also given priority (such as the elderly and those with particular illnesses). However, these criteria do not allow for a response to all situations that arise. Gray areas remain where more analytical population stratification will be necessary (see Note 2, No. 11).

Note 2 does not mention the possible compulsory aspect of vaccination. In this regard, we are in agreement with the document of the Italian National Committee for Bioethics, which supports in principle the voluntary approach to vaccination.[25] It is in fact desirable that health treatments are administered according to the free choice of the subject and not by imposition, which is one of the factors that increases vaccination hesitation. However, it is ethically and legally legitimate to make vaccination compulsory for particular occupational groups more exposed to infection or transmission of the virus, or on the basis of maintaining a safe workplace. The same would apply if adherence were not achieved in such a way as to obtain a sufficient reduction in the circulation of the virus and the indirect protection of groups that cannot vaccinate themselves, or that would not allow the resumption of the work and social activities on which a balanced human coexistence is based.   

For effective communication

From the above, the importance of communication is clear. It must be complete, transparent, understandable and up-to-date. Here again, the task is demanding, both for the type of data that science provides (always revisable and subject to a thorough validation process), and for the fact that communication cannot be reduced to information. Regarding vaccines, there is a distorted perception of risk compared to the objective assessment of the danger, given the clearly favorable and well-documented benefits and risks. Certainly the fact that the people to be treated are healthy can affect matters, but this reason is not sufficient to explain the phenomenon of resistance, since interventions in which this relationship is much less favorable are much more socially accepted.

These notions were already clear to Cardinal Consalvi, as we have seen, but today are emphasized by other factors. On the one hand, greater importance is given to the patient in his or her relationship with the doctor, which is certainly legitimate but not always easy to calibrate. On the other hand, there is a generalized crisis of trust in human relationships, both personally and in structured and institutional forms. Pope Francis puts it very simply: “I do not know why someone says: ‘no, the vaccine is dangerous.’ If the doctors present it to you as something that can go well, that has no special dangers, why not take it?”[26] A simple argument, but full of wisdom. In fact, researchers note that the perception of risk is a predominantly unconscious cognitive process, affected not only by the probability of damage that you can suffer by exposing yourself to a danger, but also, and above all, by an emotional component, consisting of a set of feelings, such as fear, resentment and anger. While the probability of damage in the face of danger can be calculated objectively – and this is the task of experts, as the pope says – the emotional component depends on a multiplicity of variables.[27]

Therefore, it is not enough to field logical arguments and scientific data on a biomedical and statistical level: it is necessary to involve the emotional and relational levels, in which behaviors are rooted. Moreover, a widespread climate of mutual trust is of great importance, which is the result of serious and honest attitudes in the habitual fabric of social coexistence. There is even a specific area of health communications that examines these multiple elements in their various dimensions.[28]

From competition to collaboration

Note 2 concludes with some recommendations for specifications that can mobilize both civil and ecclesial institutions and networks to contribute correct information, responsible behavior and equitable and universal access to the vaccine. It recalls the importance of the decisions that are taken at this juncture: although they concern immediate goals and cures, they may have important effects for a more just society, one that proceeds in a more inclusive and integrated manner. This is recalled in the encyclical, Fratelli Tutti, and also in the introductory paragraph to Note 2: “If responses are limited solely to the organizational and operational level, without the re-examination of the causes of the current difficulties that can dispose us toward a real conversion, we will never have those societal and world-wide transformations that we so urgently need.”[29]

DOI: La Civiltà Cattolica, En. Ed. Vol. 5, no. 3 art. 11, 1020: 10.32009/22072446.0321.11

[1].    E. Consalvi, “Editto sulla vaccinazione”, June 20, 1820, in Efemeridi letterarie di Roma 8 (1822) 102 (see www.brunacci.it/1822—l–editto-del-consalvi-sulla-vaccinazione-obbligatoria.html).

[2].    Quoted in G. Icardi – S. Schenone, “Aspetti della comunicazione nella storia delle vaccinazioni”, in D. Fiacchini et al. (eds), Comunicare i vaccini per la salute pubblica, Milan, Edra, 2018, 11.

[3].    E. Baragli, “Nell’anno del Signore”, in Civ. Catt. 1970 I 271.

[4].    See, for example, E. Morin, Cambiamo strada. Le 15 lezioni del coronavirus, Milan, Cortina, 2020; C. Giaccardi – M. Magatti, Nella fine è l’inizio. In che mondo vivremo, Bologna, il Mulino, 2020; G. Giraud, “Starting anew after the Covid-19 emergency,” in Civ. Catt. English Edition, in laciviltacattolica.com/starting-anew-after-the-covid-19-emergency/

[5].    Cf. R. Rappuoli – A. Santoni – A. Mantovani, “Vaccines: An achievement of civilization, a human right, our health insurance for the future”, in Journal of Experimental Medicine, vol. 216/1, 2019, 7, in https://doi.org/10.1084/jem.20182160

[6].    Cf. G. Icardi – S. Schenone, “Aspetti della comunicazione nella storia delle vaccinazioni”, op. cit.; European Center for Disease Prevention and Control, Catalogue of interventions addressing vaccine hesitancy (www.ecdc.europa.eu/catalogue), April 25, 2017; H. Y. Lawrence, Vaccine Rhetorics, Columbus, The Ohio State University Press, 2020.

[7].    Cf. M. W. Sonderup et al., “Hepatitis C in sub-Saharan Africa: the current status and recommendations for achieving elimination by 2030”, in The Lancet 2 (2017) 910-919.

[8] .   Francis, Intervista al Tg5, January 11, 2020, see www.ansa.it/sito/notizie/cronaca/2021/01/09/il-papa-vaccino-contro-il-covid

[9] .   Id., Speech to the Members of the “Banco Farmaceutico” Foundation, September 19, 2020, in www.vatican.va

[10].   Ibid.

[11].   Id., Message for the 55th Day of Social Communications, January 23, 2021.

[12].   Cf. Congregation for the Doctrine of the Faith, Note on the Morality of the Use of Certain Anti-Covid-19 Vaccines, December 21, 2020. That text cites two earlier Notes published by the Pontifical Academy for Life in 2005 and 2017.

[13].   Cf. J. Suaudeau, Vaccines against SARS-Cov-2, 17 and 19, in www.fiamc.org/bioethics/vaccins-against-sars-cov-2

[14].   See D. Prentice, “Update: Covid-19 Vaccine Candidates and Abortion-Derived Cell Lines” (https://lozierinstitute.org/update-covid-19-vaccine-candidates-and-abortion-derived-cell-lines), January 4, 2021; United States Conference of Catholic Bishops – Committee on Doctrine and Committee on Pro-Life Activities, Moral Considerations Regarding the New Covid-19 Vaccines, December 11, 2020, 4f. Vaccines using these cells for preparation include one from Oxford University and AstraZeneca, as well as Sputnik 5, under development in Russia (produced by the Gamaleja National Center for Epidemiology and Microbiology). The vaccine of Janssen and Johnson & Johnson (which, however, is at a less advanced stage) uses a cell line (PER.C6) from retinal cells of a 1985 abortion.

[15].   Congregation for the Doctrine of the Faith, Dignitas personae. On some questions of bioethics, June 20, 2008, No. 35.

[16].   Cf. K. Demmer, Interpretare e agire. Fondamenti della morale cristiana, Milan, Paulines, 1989, 188-193.

[17].   United States Conference of Catholic Bishops – Committee on Doctrine and Committee on Pro-Life Activities, Moral Considerations Regarding the New Covid-19 Vaccines, op. cit., 6.

[18].   Celam, Vacunas con fetos abortados, October 21, 2020 (https://prensacelam.org/2020/10/21/opinion-vacunas-con-fetos-abortados). Cf. Bishops’ Conference of England and Wales – Department of Social Justice, Covid-19 and Vaccination, December 3, 2020 (www.cbcew.org.uk/home/our-work/health-social-care/coronavirus-guidelines/update-on-covid-19-and-vaccination).

[19].   Cf. R. Pegoraro, “Vacciniamoci per salvarci insieme,” in Avvenire, January 14, 2021, 15.

[20].   Cf. Vatican Commission Covid-19 – Pontifical Academy for Life, Vaccine for All. 20 Points for a More Just and Healthy World, December 29, 2020 (www.press.vatican.va/bollettino/pubblico/2020/12/29); henceforth Note 2.

[21].   See Nuffield Council for Bioethics, Fair and equitable access to COVID-19 treatments and vaccines, London, May 29, 2020, 3: equal respect for people, based on recognition of dignity and human rights; reduction of suffering; and fairness, which includes non-discrimination and balanced distribution of burdens and benefits.

[22].   See U. Von der Leyen, Statement, at http://ec.europa.eu/commission/presscorner/detail/ov/SPEECH_20_2258/; R. Speranza, “Covid-19 vaccine must be a global public good, a right for all”, May 19, 2020, at www.salute.gov.it/portale/nuovocoronavirus/dettaglioNotizieNuovoCoronavirus.jsp?lingua=italiano&menu=notizie&p=dalministero&id=4783/; National Committee for Bioethics, Vaccines and Covid-19: Ethical Issues for Research, Cost, and Distribution, November 27, 2020; M. Yunus – C. Donaldson – J.-L. Perron, “COVID-19 Vaccines. A Global Common Good”, in The Lancet (www.thelancet.com/healthy-longevity), October 2020.

[23].   Note 2, No. 12. See T. Ghebreyesus, Address to the press conference on Covid-19, August 18, 2020.

[24].   Note 2, No. 8. See T. Ghebreyesus, Address to the press conference on Covid-19, September 4, 2020; Council of Europe – Committee on Bioethics, Covid-19 and vaccines: Ensuring equitable access to vaccination during the current and future epidemics, January 22, 2021; Accademia Nazionale dei Lincei, Accesso equo ai vaccini, June 1, 2020, 2; R. Lafont Rapnouil, “La guerre du vaccin aura-t-elle lieu?”, in
https://esprit.presse.fr/actualites/manuel-lafont-rapnouil/la-guerre-du-vaccin-aurat-elle-lieu-43076

[25].   See Comitato Nazionale per la Bioetica, I vaccini e Covid-19: aspetti etici per la ricerca, il costo e la distribuzione, op. cit., 10f.

[26].   Francis, Intervista al Tg5, op. cit.

[27].   Cf. D. Fiacchini – N. Damiani – V. Di Buono, “Percezione del rischio nella pratica vaccinale”, in D. Fiacchini et al. (eds), Communicating Vaccines for Public Health, op. cit., 21f; R. Brotherton, Menti sospettose. Perché siamo tutti complottisti, Turin, Bollati Boringhieri, 2017.

[28].   Cf. D. Fiacchini et al, Comunicare i vaccini per la salute pubblica, op. cit., 32-36.

[29].   Note 2, Introduction; cf. Francis, Fratelli tutti, No. 7