**1. Introduction**

This essay asks whether, in the context of making public health policy, claims for, and the granting of, religious exemptions for COVID-19 vaccinations meet *prima facie* ethical and epistemological standards for such requests insofar as such exemptions are recognized as "reasonable," that is, justifiable, legitimate, compelling, and authoritative. To explore this issue, I employ two distinct though synergistic philosophical fields, namely (1) epistemology (the study of knowledge) and its grounding in an empiricist scientific methodology; and (2) normative ethics and its instantiation in virtue theory. I use this approach to analyze various claims for medical and religious exemptions to COVID-19 vaccines, particularly because medical and scientific reasoning, as well as analytic philosophical reasoning, are both committed to the scientific method of inquiry.

Many scholars exploring cultural or spiritual rationales for impactful and policyforming beliefs advance or examine various versions of reason-giving and moral justification provided by various religious traditions. While members of a given religious community might be moved by the arguments advanced by their own tradition on the issues under consideration, there is no guarantee that they will find compelling the descriptive or normative claims of those in other—including various secular—traditions. I seek to provide a non-religiously grounded entry into this debate, and one that commends to religious and non-religious thinkers, alike, a set of presuppositions and starting points for critical reflection and policy development around the myriad of issues related to COVID-19 and public health. While secular and employing the analytic tools of philosophy, the empirical method I favor, which legitimates modern science and advances a theory of morality that links judgements of specific acts and practices to the consistent character of the individuals who advance such normative claims, should be seen itself as one voice in

**Citation:** Quinn, Aaron. 2023. The Arbitrariness of Faith-Based Medical Exemptions. *Religions* 14: 934. https://doi.org/10.3390/rel14070934

Academic Editors: Andrew Flescher and Joel Zimbelman

Received: 30 January 2023 Revised: 31 March 2023 Accepted: 6 April 2023 Published: 19 July 2023

**Copyright:** © 2023 by the author. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

the conversation among diverse traditions. Unlike the parochial and partial perspectives of various religious voices, however, it has more to commend it, strategically and practically speaking. I hope to show how Western analytic epistemology and one version of a normative secular virtue ethic inform beliefs and justifications that can be morally compelling for secular thinkers, even for individuals from various global religious and cultural traditions. The ethico-epistemic methodology I embrace suggests that in order to make good moral decisions one needs to be properly informed regarding the facts tantamount to moral decision-making, particularly in complex cases in which moral intuitions are unable to provide adequate guidance in making such decisions. Additionally, it asserts that specific ways of reasoning from such facts, and what those facts imply about the sorts of humans we are, must be accounted for in our moral judgments, decisions, and even in the shaping of our public health policies.

This paper will evaluate and assess three sorts of claims for and against vaccine exemptions: (1) those advanced by people with medical claims to exemptions; (2) those advanced by people with religious claims to exemptions; and (3) claims advanced by a broader population of agents whose well-being might be compromised by the spread of COVID-19 through those who are granted vaccine exemptions for whatever reason. These foci serve as the basis for formulating and exploring three questions:


In what follows, I acknowledge that there are diverse forms of religious reasoning and that those who are religious, or who at least tend to find reasoning which proceeds from religious premises to be the most persuasive, might naturally object to what they see as a favoritism displayed on my part towards a non-sectarian methodology. While fully respecting the *de facto* nature of different means of arriving at "truth" in the process of policy-making, I nevertheless argue that a secular approach, while not totally free from making errors, represents our best chance of approximating accuracy, accommodating inevitably divergent perspectives in pluralistic, non-homogeneous settings like the ones reflected in our society, and, as such, is the one which is most commensurate with pursuing the ideal of objectivity.

#### **2. Epistemology and the Basis for Believing**

Epistemology—or the study of knowledge—is a branch of Western philosophy that, among other things, focuses on whether or how we can come to know facts about the world as a way to attain, in the words of Steup and Ram, "cognitive success" (Steup and Ram 2020). The term derives from the Greek word *episteme*, meaning "knowledge," or "understanding." One of the most common definitions of knowledge is a "justified, true belief," (hereafter JTB) that is grounded in a tripartite analysis of knowledge (Gettier 1963; Ichikawa and Steup 2017), structured as follows:

*S* knows that *p* if and only if:


Here is an example of how such justified belief arises. I can claim with high confidence that the statement "Sacramento is the current capital of California" is a justified true belief (JTB) of mine, because it is true; I believe it; and I am justified in believing it. I can argue the claim is true because of a decision made by state leaders long ago. I believe it is true because of my experience of what it means for a city to be a capital. Additionally, I have only encountered assertions that Sacramento is the current capital of California and I have never encountered an assertion that claims a different current capital of California. All of these experiences provide me with an empirical basis for the establishment of my belief. No existing text or person has ever contradicted this experience. Finally, and because of the truth claim, the nature of the evidence, and the way I have come to believe that truth, I am justified in believing the status of Sacramento as California's capital.

While this logic seems basic enough, it is crucially relevant to any analysis of what circumstances there are, if any, which warrant exempting oneself from the law of the land when that law is meant to safeguard the well-being and health of a population. Can private beliefs which do not accommodate universalization ever be authoritatively cited as a means of legitimately not adhering to laws intended to apply to everyone for the sake of the good of everyone? I argue that the final conclusion of the tripartite—justified belief—can be a useful tool for validating many of our assertions in various practical contexts, including the key example from public health of vaccine exemption this essay considers. At the same time, the tripartite analysis of knowledge as the means of arriving at JTBs is not without challenges, problems, and limitations. To demonstrate challenges with the JTB tripartite theory let me raise two additional issues.

First, if I have established that an assertion is true and that I believe it, why should there be a need for a justification beyond that it's true? In other words, when it comes to what I will refer to as *simple claims of knowledge*, the fact that a statement is true itself should be enough justification for one's belief, because steps two and three of the tripartite are redundant. Thus, one could argue that simply establishing "true belief" is sufficient to justifying that belief, again, when this involves simple claims such as the one asserting Sacramento as California's capital. What happens, however, when the claims being advanced are what might be called "complex claims to knowledge"? A 1963 paper by Edmund Gettier titled "Is Justified True Belief Knowledge" offered cases in which justified true belief was derived from a false, but apparently justified, belief (Gettier 1963). Dreyfus (1997, p. 292) offered one such case when he described someone searching for water on a hot day. The water-seeker suddenly sees what she believes is water in the distance. In fact, what she observes is a mirage. However, when she follows the mirage, there just happens to be water there. For Gettier and Dreyfus, both, the case in question reveals that the JTB may establish the set of necessary though not sufficient conditions for knowledge. It is likely a necessary set of conditions, but what more is necessary still seems unsettled in the literature (Dreyfus 1997).

Let me offer another example of such a challenge from the early days of the COVID-19 pandemic in 2020. At that time, many independent physicians and public health officials proposed that shoppers wash or sterilize food, the bags in which the food was transported, and the surfaces that they might have touched before sanitization. What these officials generally knew was that many or most viruses are killed on contact with certain sterilizing agents. What they did not know was whether (armed with little evidence to support their assertions and policy recommendations) those sterilizing agents could be applied effectively to COVID-19 in the way they suggested. As more and better empirical evidence became available, such recommendations were eventually found to be excessively cautious or unproductively ineffective, not efficacious for slowing the spread of the virus. Were these individuals wrong in initially asserting their recommendations and policies regarding such precautions? Given the range of unknowns concerning the natural history of COVID-19, the virus's initial risk to some individuals and groups, and the lack of society's preparation in addressing the emerging pandemic, it seemed clear to many that the beliefs, concerns, costbenefit analysis, and precautions that undergirded these early and provisional public health practices were initially justified. Similarly, recommendations for broad public masking, social distancing, isolating, and quarantining were also proposed in several contexts in response to the best construal of the data and out of a similar abundance of caution. In hindsight these appear to have been part of an overall life-saving strategy, even if not yet fully justified at the time they were implemented. Both recommendations were made

without complete empirical data or scientific certainty, and not all of them turned out to be fully accurate. Taken together, however, they were arguably justified in the context of an early-stage pandemic and in a manner consistent with the fundamental methodological principles of public health based on empirical evidence. Still, there was a public trust cost with regard to treating these health measures as beyond questioning (Frieden 2022).

A second limitation with claims of the necessity and sufficiency of JTB's tripartite structure and components surfaces when we note that most of our concerns in applied or practical epistemology and ethics are not simple, definitional truth claims like "Sacramento is the capital of California". The city's status was simply asserted and legally decreed once a set of procedural and material criteria were met and agreed to. As a result, it serves as a facile example to test the adequacy of the theory of JTB. Employing such an example to establish an epistemic theory fails to appreciate the complexity of how we come to justify more complex truth claims.

In contrast, a more interesting epistemic challenge arises from an assertion such as the statement: "Sacramento is the *right* city to be the capital of California." This formulation raises a range of practical questions that puts significant pressure on the sufficiency of the tripartite structure of arriving at JTB. In this formulation, there is room for debate, empirical error, divergent judgements, various readings of the facts, and even a recognition that miscalculations of several aspects of what hierarchy of needs might be best for a capital city are likely. One could assume an evolving debate about whether a particular placement of the capital is justified, with that decision ultimately based on how well informed decisionmakers were in the past, and what anticipated or unanticipated new information might surface over time. What should a capital city be like? What aspects of those criteria are held by Sacramento and other competing cities? How might the construal of facts (and the way we apprehend such facts) inform our belief about the truth claims made on behalf of the city, and what would it mean to justify such a claim in ways that meet our provisional definition of JTB? Finally, how might cultural, political, and ethical considerations shape our evolving sense of what the "right" choice might be?

It appears as if the establishment of any JTB will have to factor in many, potentially opposing, value-laden moral considerations in some way. Even the basic example above raises a host of concerns about employing exclusively the tripartite establishment of JTP as the basis for all of our claims to legitimate judgement and action. Indeed, a straightforward example like this, complicated only a bit beyond its "facile" formulation, serves to exemplify how tricky it might be ever to arrive at "true, justified belief", and thus calls into question the prospect of agreeing upon rules to live by "universally". More will have to be established if we are to place special faith in regulatory health guidelines intended for a *population* of individuals.

#### **3. Augmenting Epistemic Claims with Moral Commitment and Virtue Theory**

These limitations noted, I maintain that JTB is nevertheless essential to our ability to publicly and coherently justify the choices that we make for ourselves, and in our capacity as moral agents who sometimes critique, interrogate, or uphold society's actions, choices, and mandates. Science and empiricism are non-negotiable bases of the claims of medicine and public health. Their epistemic assertions are essential for assessing the legitimacy of beliefs about COVID-19 and responses to it. At the same time, if a large part of our lives is composed of encounters with truth claims and counterclaims that cannot be demonstrated in unambiguous and straightforward ways that employ the tripartite structure of arriving at JTB, and if we cannot always establish a certain ground for our truth claims, then we must shift our task away from a narrow focus on establishing simple JTBs and augment such commitments with additional tools that can help us justify our beliefs in the absence of a fully demonstrable truth. This realization is nothing new. Many concerns of practical epistemology involve accounting for moral values and ethical commitments, and these debates must go forward regardless of whether we can attain the complete and coherent

knowledge of the truth that we need. What additional considerations and tools might assist us in this endeavor?

Making the right decision is hard, and public health decisions in times of crisis reveal how intractable that process can be. Justified beliefs and actions require recourse to logic, but also consideration of our shared values that we claim are essential to life in community. Given the complexity of many decisions made in the medical and public health professions, I want to argue for a need—beyond the knowledge generated by the JTP—of moral commitments as the practical foundation for the normative claims made in the fields of ethics and public health.

There are a range of approaches to morality that might be considered for this task. Most pervasive in the literature of medicine and public health is principlism, popularized in the work of Tom Beauchamp and Jim Childress (Beauchamp and Childress 2019). Principlism judges the moral rightness or wrongness of an action by whether or not that action can be justified using one of a number of discreet and well defined substantial moral principles that possess broad appeal across various cultures and traditions. In this approach to morality, the rightness or wrongness of an action is a function not of the character of the moral actor *per se*, but of whether or not the action under analysis can be justified in a compelling way in terms of a given moral principle. Beauchamp and Childress identify four critical principles: non-maleficence, respect for autonomy, beneficence, and justice (ibid).

In spite of its comprehensiveness, coherence, relative simplicity, compatibility with our moral experience and considered intuitions, and provisional compatibility with much of the moral teaching of various religious and secular communities, principlism is an inadequate method of ethics for the project we are developing. Its weakness is that it fails to explicitly account for the need of moral actors to instantiate in their own person the substance of morality. This is particularly true in the context of public health, where the credibility of spokespersons, policy developers, agencies, and governments are crucial in establishing the trust needed in a complex, sometimes ambiguous, and politically inflected context. Because of this, we must explore an approach to ethics that can account for the considered values that we hold as important, captured in the substance of critical moral principles, but one that also informs both our view of the importance of moral agents and allows a means legitimately to assess those agents as viable and trustworthy in dealing with the important health aspects of our individual and corporate lives. In other words, we need to explore the viability of a virtue theory of morality, one that centers moral decision-making on agents and inculcates in them the characters, dispositions, motivations, and commitments needed to act effectively and in a manner in which they can establish trust and lead to good action.

Aristotle's *Nicomachean Ethics* is a good place to begin this process of exploration because of Aristotle's concurrent commitments to establishing an empirically grounded, agent-centered, psychologically aware, critically astute, and politically and culturally sensitive appreciation of how morality functions in complex situations in life. These elements are precisely the attributes that are most important as we think about what regulations or guidelines could be universalized in response to COVID-19. Aristotle developed what has become known as the *ergon* argument, which states: "[e]very art and every inquiry, and similarly every action and pursuit, is thought to aim at some good; and for this reason the good has rightly been declared to be that at which all things aim . . . the end of the medical art is health, that of shipbuilding a vessel, that of strategy victory, that of economics wealth" (Aristotle 2009, Book I, chap. 1). For something to become a rule that is meant to be binding on the individuals in a population, it has to demonstrably lead to the flourishing good of that population. Applied to our current situation, the research, production, and distribution of COVID-19 vaccines fits well in this mold of the "art" of medicine, which is to bring about good health. From the perspective of an Aristotelian construal of right action, the moral role of public health practitioners—consistent with the declared ends of public health—is to determine what steps regarding vaccine use will reduce harm and enhance individual and community health based on our knowledge and our justified beliefs (Oakley and Cocking 2001). Public health professionals, then, are called upon to embrace

the specific epistemic principles that will guide that moral function of harm reduction and health enhancement by integrating their reading of the facts of the situation, gathered data, and the best justification for their moral commitments.

Aristotle provides the rudimentary impetus for this move, and Aristotelian virtue theory, which hinges on the "ergon," or *function* of any action in pursuance of the human good, has been widely assessed and elaborated in contemporary scholarship by philosophers as various and influential as Philippa Foot (1978), Gertrude Elizabeth Margaret Anscombe (1958), Bernard Williams (1985), Alisdair MacIntyre (1985), Michael Slote (1992), and Christine Swanton (2003), all of whom help to construct the bridge between our epistemic commitments to provisional JTB and the virtue theory of role-related morality. What constitutes flourishing, including healthful flourishing, is not an *arbitrary* construct, but rather a refined assessment of the particular animal a human being is and judgment about what that being requires to participate in the good. In Aristotelian virtue ethics, opt-outs are not easily tolerated when the individual who is opting out negatively impacts the pursuit of these humanly flourishing ends in others.

If we accept the power of the Aristotelian construction of morality in role-related virtue theory and embrace our earlier commitment to empirical scientific reasoning as the basis for establishing truth claims, the task before us is to determine how best to bring these two elements together in a functional model of research, public health, and policy. The insights of three contemporary epistemologists can be invoked to elucidate the point. In *Science as Social Knowledge*, Helen Longino argues that belief justifications ought to be made based on sound scientific reasoning, even in the absence of empirical certainty (Longino 1990). "[T]o say that a theory or hypothesis was accepted on the basis of objective methods does not guarantee that it is true, but it does–if anything does–justify us in asserting that it is true" (p. 268). C.A.J. Coady's work in social epistemology grapples with the enduring dilemma that we have when faced with individuals or institutions that claim to be asserting the truth or suggesting that their pronouncements should serve as the basis for justified truth claims (Coady 1992). Coady provides various reasons for why one might or might not believe—or not be justified in believing—a person's testimony. For Coady, the trustworthiness of a testifier is supported by several conditions, including one's expertise in a given matter, whether that person has been historically reliable in truth-telling, and whether that person exhibits other traits that make someone epistemically reliable. Finally, in his insightful and synthetic *A Virtue Epistemology*, Ernest Sosa blends epistemic and normative principles to establish a functional and complex foundation for the justification of true belief (Sosa 2007). Sosa likens ethico-epistemic judgments to a skilled archer's shooting in three distinct ways. First, there is the judgment of whether the arrow hits the target—its *accuracy*. Second, there is the question of whether the archer's accurate shot makes use of his skill. This skill is what Sosa calls *adroitness*. Third, Sosa asks whether a successful shot from the archer resulted from his adroitness or mere luck. If it is skill that led to the accurate shot, this is called *aptness*.

According to all three of these thinkers, in lieu of deductive certainty, which real-world situations rarely, if ever, make available, we have a duty of intellectual honesty to tether justificatory warrants to the wealth of information that can be gleaned from past experience, often relayed through the meaningful testimony of established authorities. Experience matters a great deal in terms of establishing trust of authorities. Sosa's three principles of accuracy, adroitness, and aptness, for example, are essential to establishing and providing a test for judgment of the beliefs that we form in response to our interactions with people, facts, and events in our daily lives. To claim a belief is justified in this model, any epistemic successes must arise by way of adroitness, yet the theory also accounts for practitioners who, despite their general skill (adroitness), don't always hit the target. For example, a public health practitioner in early-stage COVID-19 might have recommended that people wear masks in public gatherings, even in airy outdoor areas with ample sunlight when gatherings were only brief. It's reasonable that, with limited information and inadequate data, the practitioner did not possess perfect knowledge of the efficacy of the normative

claims on which recommendations of provisional public policy were based. The person, generally speaking, is apt to make accurate judgments, but in that instance, missed the mark for lack of accuracy. Nonetheless, given the complexity of the task before them, they performed reasonably well and acted in a manner justified by the competing claims of epistemic coherence and moral commitment to which they are committed.

According to the functional ethico-epistemic model elaborated by Longino, Coady, and Sosa, to lay a legitimate foundation for the attainment of knowledge one must commit to scientific reasoning consistent with the scientific method, which is presumably what constitutes *scientific objectivity*. This requires one to observe, form a negative hypothesis, venture a provisional prediction, engage in experimentation, and then analyze the results either to confirm the hypothesis or advance a new testable negative hypothesis. At the same time—because many sources of prospective knowledge related to pandemic concerns are public health professionals—it is essential that any proffered testimony be trustworthy. In this context, one is typically judged trustworthy based on a track record of adroitness, but, as discussed above, with some tolerance for error in respect to accuracy. Additionally, public health officials must be correct in their judgments, but in the absence of certainty they must be adequately qualified to have made an imperfect or even flawed policy decision, and to have shown sincerity throughout the process by acknowledging the admission of failure when failure occurs. These three attributes, taken together, offer a substantive moral and epistemic groundwork for analyzing public health decisions.
