**4. Applying the Ethico-Epistemic Framework to Public Health and COVID-19 Vaccine Policy**

To attain an exceptional level of certainty in many practical areas of life, including public health, is rare. Certainty is relatively attainable with regard to the sorts of simple claims mentioned earlier in this paper (e.g., Sacramento's status as California's current capital), but such certainty quickly deteriorates in a world of greater complexity, continuous discovery, reformulated theories, and considerations of moral, political, cultural and psychological realities and differences. Many things once thought of as fact, even in science, are now known to be false or inscrutable. Deliberately bleeding patients to stimulate recovery from disease was once commonplace but has been abandoned because other medical practices proved superior after experimentation. On this model, and with a firm commitment to the epistemic assumptions that we have discussed, medical and public health errors and inferior methods can be overcome and continuously improved upon.

A great challenge to current public health policy development, messaging, and instantiation of recommendations in social practices is accounting for this nearly continuous process of aiming for aptness but dealing with imperfect and incomplete knowledge, while simultaneously honing the skills elaborated by Sosa. To err, and err publicly, opens one's reputation to public scrutiny, and makes one vulnerable to the assaults of those who are often least adroit at scrutinizing the reasons and justifications for those errors or oversights. Whether such scrutiny stems from simple antagonism, a lack of information, a polluted public arena and media environment populated by self-styled political and social influencers, or results from honest disagreements on how facts are read and moral values are instantiated, the loss of public trust and social stability undermines public well-being. As with most imperfect ventures, the most successful long-term antidote appears to be systemic efforts to learn the truth and compellingly communicate justifiable true beliefs using historically sincere and accurate messengers who are seen as credible because of their typical accuracy, adroitness and general aptness. Experience counts. There is, unfortunately, no easy means for overcoming reputational damage from errors, other than to continue to ground one's empirical claims more firmly in a rigorous scientific method and to analyze and adjust one's recommendations consistent with new knowledge and our evolving sense of our obligations to our community. Error, and the responsible manner of dealing with error when it inevitably comes to pass, in this respect, is not tantamount to the "anything

goes" policy of a post-truth society. Rather, such a process is the alternative to a policy of rampant and vulgar subjectivism.

In light of the foregoing discussion, how might we assess the claims made by various groups and individuals for a COVID-19 vaccine exemption? Anticipation of an efficacious vaccine was present in most of 2020, as various companies designed, put through trials, and rolled out vaccines to great fanfare in December 2021 with full deployment in early 2022. But the speed of their development, the use of new mRNA technologies, concerns about drug trials, and accompanying public health, political, and cultural turmoil complicated the process. In much of the world, the most pressing issue was how to obtain clinically tested vaccines for ravaged populations, and issues related to the logistics and financing of vaccine rollout and determination of vaccine priority were decisive considerations. In the United States those concerns occupied the public health infrastructures of all fifty states as well. However, in this context one of the most important issues that needed to be addressed was whether and on what basis to permit COVID-19 vaccine exemptions, given the assumed need for widespread vaccination to reduce the spread of the disease and unrelenting pressure on the public health system and economy.

A first case in which our epistemic and normative tools can be used in action is the situation in which the presence of specific allergies are advanced as medical justifications for a public health exemption from the COVID-19 vaccine. The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) suspected rare allergies to at least two compounds in the four major COVID-19 vaccines. It appeared that polyethylene glycol (PEG) in the Pfizer and Moderna vaccines might provoke severe allergic reactions in a small portion of the population. A similar suspicion applied to polysorbate present in the Novavax and J&J vaccines (De Vrieze 2020). Individuals who had real or suspected adverse anaphylactic reactions to either of those compounds in actual vaccines or in other common products such as shampoo and toothpaste seemed *prima facie* to be likely candidates for a justified medical exemption. Still, a lack of certainty about the causal relationship between those compounds and anaphylaxis also prompted the CDC to recommend that those who had experienced a severe reaction to any vaccine or injectable medication consider avoiding the COVID-19 vaccines.

With respect to standards of evidence, an assertion of a JTB requires that these compounds have been shown to likely cause a severe allergic reaction in some potential vaccine recipients. There is evidence these two compounds are known to be allergic irritants to some people, and though few recipients have severe reactions, the reactions occur at a consistent frequency across the monitored US population. The US Department of Health and Human Services (HHS) database tracking adverse reactions (HHS 2022) was designed systemically to display how frequently these reactions occurred with a best hypothesis as to the cause. Although this was an imperfect diagnostic tool, it conformed to a systemic means of identification and determination of symptoms accompanied by a reasonable hypothesis as to the cause of allergic reactions.

The cited evidence offers a reasonably strong justification to allow medical exemptions based on CDC guidelines. It uses scientific objectivity insofar as data is available, and it is consistent with the application of Sosa's three-pronged approach: It is accurate insofar as the allergies are systemic. It is adroit with respect to using skill (data) to avoid harming. And it is apt to the degree that it prevents unnecessary harm. At the same time, the CDC has been criticized for poor and infrequent communication regarding a number of factors, including confusing messaging about quarantine and return-to-work guidelines (Simmons-Duffin 2022). With the reputation of the CDC's data-gathering function undermined by flawed messaging and poor communication, a waning credibility of its testimony, and in some high-profile instances unfortunate presentation of data, the successful fulfillment of its role and task eroded. Though the CDC employs some of the foremost global experts in immunology, sincerity—as judged by the public—is a matter of perception, and the perception of the CDC was quickly compromised because the public was not sufficiently familiar with any prior good reputation associated with the agency, something exacerbated by the rapid onset of the COVID-19 pandemic. Given these factors in their totality, it is a reasonable conclusion that at the height of the pandemic the CDC offered the public at best a weak justification for believing its sincerity, if not its accuracy, when it came to recommendations for any action, including medical vaccine exemptions specifically. As mentioned by Coady (1992), much of what makes a person or organization appear sincere is a consistent, truthful message, but with very little prior experience with the CDC among most of the public, there was little to no history from which to develop trust-based judgments. Only time and improved messaging can repair this harm. All of this creates significant failure with respect to the justificatory value of testimony.

#### **5. Epistemology and Religious Exemptions**

If challenges surface with respect to justifying vaccine exemptions for health reasons, they are even more complicated for public health professionals and others when they are based on religious claims. One definition of religion derives from Latin and describes the act of venerating God or the gods (Smith 2009; Noss and Grangaard 2017). A more culturally inflected and expansive definition of religion comes from Grabenstein: "religions are fundamentally sets of beliefs about God or spirituality held by groups of people. Like all groups, religious groups develop their own systems of culture . . . [however] behaviors of like-minded individuals are not necessarily related to the theological basis of their religions. 'Religious' differs from 'theological,' in part, as social differs from scholarly" (Grabenstein 2013, p. 2012). These definitions of religion give rise to divergent justifications that individuals and groups put forward for their religious beliefs, the truth claims they assert, and the self-understandings and identities as religious adherents that they embrace.

Following scholars working in the field of the comparative study of religion, we can distinguish two common categories with respect to believers' justifications for their belief. First, justification for belief can be seen in individuals and religious groups that affirm an axiomatic belief in God; the authority of specific religious scriptures, dogma, official teachings and interpretations of authoritative texts; and theological doctrines and the pronouncements of religious leaders as either absolutely true or inspired in some way based on faith. Second, a recognized social construct that generates reasons for religious belief and justifications for related choices is what Neil Van Leeuwen argues is an *identity-constituting role* (Van Leeuwen 2014, 2018). In this expression of religious belief, the believer's position among a like-minded community committed to specific values, roles, world-construal, and normative ways of being in the world is the basis for religious truth claims. Adherence to and recourse to religious doctrines as the basis for truth claims and motivation for normative choices are of secondary importance. Here, I examine these two modes of religious reasoning in greater detail.
