From an ethical perspective, resource limitations provide a challenge for healthcare providers. Handling disclosure of the financial details of treatment options in a way that empowers patients, even in the face of extreme poverty, requires careful consideration of the personal preferences and motivations of each patient. This article will consider the high costs of dialysis for patients experiencing extreme poverty in light of various ethical principles, including informed consent and truth-telling. It will conclude that a graduated method of disclosing the physical and financial burdens of each treatment option is the best way forward, particularly for healthcare workers engaged in resource-limited settings.

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Photo by National Cancer Institute on Unsplash “An expert is someone who knows some of the worst mistakes that can be made in his subject, and how to avoid them.” ― Werner Heisenberg INTRODUCTION Bioethicists have long debated the question of expertise in clinical ethics and who gets a say in bedside clinical ethics consults.[1] From Seattle’s famous God Committee that decided on the allocation of kidneys, to clinical ethicists at a suburban hospital in Ohio, clinical ethics ‘experts’ have been central to bioethics and its development.[2] However, it is time to question what expertise in clinical ethics means, and if there can ever be such an expert. Does expertise mean proficiency in clinical care or the ethics part of clinical ethics? Should professionals who are not healthcare practitioners be involved in clinical ethics discussions? In this paper, I argue that clinical ethics consults involving non-clinicians should be done away with for two reasons:  first, they lack clinical medical experience to properly analyze the ethical issues, and second, moral expertise should give way to medical expertise. Although clinical ethics consultants might venture into areas of clinical expertise with a bona fide intention of helping patients or surrogates, their judgment is often based on knowledge of ethical theories.[3] However, bioethicists have cautioned against a casuistic method and signaled for clinical ethicists to have clinical experience and medical education.[4] While it is perfectly possible to familiarize oneself with the law and ethics, I argue that it is not possible to appreciate the complexity of certain medical decisions entirely without medical experience.[5] Bedside ethical conundrums are unique and impact every patient differently. Thus, when an ethics consultant or a healthcare practitioner draws on a single bedside dilemma and applies the knowledge gained from it to a different patient or a different dilemma, they may find themselves creating bad rules and ignoring autonomy. As non-clinicians who sit on ethics committees have no bedside clinical experience, their magnitude of transformative experiences (experiences that give the subject knowledge that would otherwise be otherwise unavailable)[6] is limited. The clinicians develop such experiences over time giving care. The ethics committee members do not have a similar way to gain experience. This also speaks to the importance of a phenomenological reading of clinical ethics decisions. Specifically, clinical ethics consultants without sufficient medical expertise may fail to guide patients in the best way possible in making medical decisions. A confined and parochial, or purely philosophical, approach that non-clinicians often use might not be in the best interests of the particular patient. If they were to venture into clinical situations to comment on the ethical aspect, they could step into matters they know little about which might end up causing harm to the patient. We, as bioethicists, would be doing a disservice to patients if we let non-clinicians claim the moral high ground in the face of medical advice. As Scofield puts it, “(Clinical) Ethics consultation is and can only be what it purports not to be—a moral, if not an ethics, disaster. It has acted unprofessionally because … of its failure to do what a profession worthy of the name would do.”[7] l.     Medical Expertise May Be More Appropriate than Moral Expertise An idea that a clinical ethics consult should be conducted by clinicians themselves comports with the makeup of clinical ethics committees. They are usually comprised primarily of medical professionals, but increasingly hospitals are attracting more ethics professionals who are not healthcare practitioners. As Hauschildt and De Vires note, “a closer examination suggests that clinical ethicists are likely to be clinicians themselves and that clinical considerations are often the ultimate authority in defining what is, and is not, determined to be ethical.”[8] In cases that are reported to ethics consults, 63 percent show a disagreement between the patient and the doctor about the course of treatments.[9] Those disagreements speak to ethical issues. For example, if a doctor recommends palliative care and patient wants to pursue an aggressive course of treatment, the ethical dilemma is built into the clinical care decision. While we would like to think that ethicists on hospital ethics committees deliberate on philosophical nuances of treatment (or the lack thereof), I argue that clinical ethics consults focus on resolving clinical ambiguities and reaching consensus, which ultimately relies on clinical judgment. An ethics consultant may not be able to appreciate the medical nuances of the situation. Studies conducted have clearly demonstrated that most ethics consults are called in when there is a lack of communication.[10] What would serve the patients, in this case, is perhaps investing the money that is spent in training and employing non-clinician consultants into teaching doctors and nurses how to communicate better. ll.     Authoritarian Ethics Consults As with healthcare workers delving into ethics advice, in clinical ethics consults, there is a risk that the consultant might adopt an “authoritarian approach”[11] and impose his or her values, priorities, and/or religious convictions on the patients and their families. It is inevitable that in the work of bioethics, the personal meets the professional. Even if they do not mean to impose their values on the patients, there is strong empirical data to suggest that in most clinical ethics consults, patients end up following recommendations of the ethics committees. For example, in a study conducted of 229 clinical ethics consults, approximately 88 percent of the recommendations were followed. Certain types of consults such as initiating a palliative care treatment or proceeding with life-sustaining intervention had a 100 percent compliance rate with the ethics committee’s advice.[12] Additionally, studies have shown that clinicians frame consults in a way that nudges the patients in making decisions that maximize their welfare and is seen as an acceptable form of paternalism.[13] Yet, patients likely do not appreciate paternalistic nudges. In the studies, most questions were about futility or the withdrawal of life-sustaining treatment. Arguably, these questions require clinical expertise and not ethical expertise. A clinician or a nurse may be better suited to help guide the patient’s family because they would be able to comprehend and explain the complexity of the clinical case to the family better. If the idea of a clinical ethics consult is to further patient autonomy, it is failing. lll.     Addressing Counterarguments Two arguments may challenge a proposal as radical as kicking all the ethics consultants who are not also medical professionals or healthcare practitioners out of clinical ethics consults or committees: first, the argument that a broader variety of professionals should have a say in bioethics; and second, that ethics committee members may relate to patients more effectively than some physicians and other healthcare workers do. Yet, these claims are not strong rebuttals. As bioethics developed within philosophy, it may have lost sight of the day-to-day ethical issues that arise in the clinic. Komesaroff argues that the task of handling clinical ethics consults is only one that clinicians can handle, and there is a need to separate bioethics from clinical ethics. He suggests that the time is ripe for clinical ethics to be considered through the lens of micro-ethics and established as an area of research distinct from bioethics.[14] I agree and assert that there is a need to distinguish the broader ethical debate from the work of everyday clinical practice, a work where clinicians are best suited to handle the issues, perhaps a subcategory of bioethics. This will involve the need for redefining the relationship between the macro ethical work of bioethics, and the micro ethical work of everyday medical/clinical ethics which happens at the bedside.[15] What is required in a clinical ethics setting, in my opinion, is for the doctor not to frame the issue in terms of bioethical or large philosophical concepts such as autonomy or deontology, but to talk to the patient and more importantly, listen to the patient. A smooth communication structure, if put in place, would help alleviate fear and establish a common ground on which decisions can be reached in clinical settings. That is, I see clinical ethics as also not necessary to the doctor-patient relationship but argue that better communication would help patients make important decisions. The ethics ultimately would belong to the patient, with the clinician providing necessary data that will help guide patient decision making and do no more. The second issue is relatability. Clinicians are often constrained by their vocabulary and medical expertise and may not be able to break down the complex pathology of a disease to the patients. Thus, some may argue that non-clinicians, not held back by the jargon, would be able to relate to the patient. As I proposed earlier, the money spent hiring and training clinical ethics consultants could be redirected to teaching doctors how to be more effective communicators. That would perhaps further patient autonomy. Nurses may also make effective interlocutors between patients and doctors in cases where the doctor cannot get through to the patient. Nurses are often involved more in the day-to-day dealing with the patient and thus know the patient and their families closely. Secondly, they possess the requisite medical knowledge to help the patients through decision-making processes. Yet the current shortage of nurses also poses issues in this realm. Some doctors and nurses make a point to get to know the patients, their beliefs, and their goals of care and could thus be better at helping patients arrive at decisions by using open jargon-free communication. CONCLUSION Much of this paper stems from my experiences as a Master of Bioethics candidate at Harvard Medical School. As a non-clinician who studied clinical ethics for a semester, under excellent guidance, I often found myself turning to friends who had clinical experience with questions about the medical aspects of case discussions. More often than not, the clinical insight that they gave me helped me better understand the choices that were before me as a purported expert in simulations. I have been plagued with the question-- would I be qualified to consult in clinical ethics, after a Master of Bioethics degree at Harvard Medical School? My answer would be an unequivocal NO. While I expect to be highly qualified to weigh in at the policy level and I have been provided the skillset necessary for in-depth philosophical analysis of complex bioethical issues, I have not become, and I suggest others are not as well, a moral expert (if there is such a thing). The hubris of a bioethicist should not get in the way of patient care. I do not mean to say through this paper, that non-clinicians are to be brushed aside is bioethical discussions. Lawyers, ethicists, chaplains, and the diverse set of people that are attracted to the work of bioethics provide an incredibly diverse set of skills, knowledge, and views that the clinicians often miss. They discuss and bring in perspectives from a variety of vantage points which have been instrumental in furthering the debates in bioethics. But as I have argued, they need not populate clinical ethics committees where they are at risk of exerting moral expertise, especially as their ethics position on a case may not be grounded in a deep enough understanding of the medical issues at hand. Instead, they should be used in broad policy-making decisions, framing issues, debating in print and digital media, and on IRBs. Bioethics is “everyone’s business,”[16] but clinical ethics should not be. - [1] Jan Crosthwaite, ‘In Defence of Ethicists. A Commentary on Christopher Cowley’s Paper’ (2005) 8 Medicine, Health Care and Philosophy 281 <http://link.springer.com/10.1007/s11019-005-0085-6> accessed 11 December 2021, Jukka Varelius, ‘Is Ethical Expertise Possible?’ (2008) 11 Medicine, Health Care and Philosophy 127 <http://link.springer.com/10.1007/s11019-007-9089-8> accessed 11 December 2021, Christopher Cowley, “A New Rejection of Moral Expertise,” Medicine, Health Care and Philosophy 8, no. 3 (November 2005): 273–79, https://doi.org/10.1007/s11019-005-1588-x.Ana S. Iltis and Lisa M. Rasmussen, “The ‘Ethics’ Expertise in Clinical Ethics Consultation,” Journal of Medicine and Philosophy 41, no. 4 (August 2016): 363–68, https://doi.org/10.1093/jmp/jhw013. [2] Albert R. Jonsen, “The God Squad and the Origins of Transplantation Ethics and Policy,” Journal of Law, Medicine & Ethics 35, no. 2 (2007): 238–40, https://doi.org/10.1111/j.1748-720X.2007.00131.x. [3] Albert R. Jonsen, “Casuistry as Methodology in Clinical Ethics,” Theoretical Medicine 12, no. 4 (December 1991): 295–307, https://doi.org/10.1007/BF00489890. [4] Matthew A. Butkus, “The Necessity of Clinical Experience in Medical Ethics Expertise,” in Moral Expertise: New Essays from Theoretical and Clinical Bioethics, ed. Jamie Carlin Watson and Laura K. Guidry-Grimes (Cham: Springer International Publishing, 2018), 227–44, https://doi.org/10.1007/978-3-319-92759-6_13. [5] Butkus. [6] L. A. Paul, “What You Can’t Expect When You’re Expecting,” Res Philosophica 92, no. 2 (2015): 149–70, https://doi.org/10.11612/resphil.2015.92.2.1. [7] Giles R. Scofield, “What Is Medical Ethics Consultation?” Journal of Law, Medicine & Ethics 36, no. 1 (2008): 95–118, https://doi.org/10.1111/j.1748-720X.2008.00241.x. [8] Katrina Hauschildt and Raymond De Vries, “Reinforcing Medical Authority: Clinical Ethics Consultation and the Resolution of Conflicts in Treatment Decisions,” Sociology of Health & Illness 42, no. 2 (February 2020): 307–26, https://doi.org/10.1111/1467-9566.13003. [9] Katrina Hauschildt and Raymond De Vries, ‘Reinforcing Medical Authority: Clinical Ethics Consultation and the Resolution of Conflicts in Treatment Decisions’ (2020) 42 Sociology of Health & Illness 307 <https://onlinelibrary.wiley.com/doi/10.1111/1467-9566.13003> accessed 12 December 2021, G DuVal, ‘What Triggers Requests for Ethics Consultations?’ (2001) 27 Journal of Medical Ethics 24 <https://jme.bmj.com/lookup/doi/10.1136/jme.27.suppl_1.i24> accessed 12 December 2021. [10] Raymond De Vries, “Regarding Bioethics: A Sociology of Morality,” Perspectives in Biology and Medicine 60, no. 1 (2017): 74–92, https://doi.org/10.1353/pbm.2017.0020. [11] H. Tristram Engelhardt, “Core Competencies for Health Care Ethics Consultants: In Search of Professional Status in a Post-Modern World,” HEC Forum: An Interdisciplinary Journal on Hospitals’ Ethical and Legal Issues 23, no. 3 (September 2011): 129–45, https://doi.org/10.1007/s10730-011-9167-4. [12] Jessica Richmond Moeller et al., “Functions and Outcomes of a Clinical Medical Ethics Committee: A Review of 100 Consults,” HEC Forum 24, no. 2 (June 2012): 99–114, https://doi.org/10.1007/s10730-011-9170-9. [13] Ajay Aggarwal, Joanna Davies, and Richard Sullivan, “‘Nudge’ in the Clinical Consultation – an Acceptable Form of Medical Paternalism?,” BMC Medical Ethics 15, no. 1 (December 2014): 31, https://doi.org/10.1186/1472-6939-15-31. [14] Paul A. Komesaroff, “From Bioethics to Microethics: Ethical Debate and Clinical Medicine,” in Troubled Bodies, ed. Paul A. Komesaroff (Duke University Press, 1995), 62–86, https://doi.org/10.1215/9780822379782-004. [15] Robert Sokolowski, Moral Action: A Phenomenological Study (Bloomington: The Catholic University of America Press, 2017). [16] Amy Gutmann, Everybody Wants to Go to Heaven but Nobody Wants to Die: Bioethics and the Transformation of Health Care in America, First Edition (New York: Liveright Publishing Corporation, 2019).

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Photo by Mufid Majnun on Unsplash INTRODUCTION In 2007, the Nuffield Council of Bioethics introduced the “Intervention ladder” as a guiding framework[1] to evaluate the impact on individual liberty of various public health measures. One criticism of the ladder is that it reflects a narrow view of liberty, yet other researchers adapted the intervention ladder to incorporate a more autonomy-based view. Recently, academics and public health officials have used intervention ladders as guides in framing policies, particularly COVID-19 pandemic policies.[2] Analyzing the Indian COVID-19 vaccination drive under these two ladders can illuminate the concepts of liberty underlying those ladders and help determine the best framework on a philosophical basis. ANALYSIS l.     Case Study: The Indian COVID-19 Vaccination Drive On January 16, 2021, India attempted a public vaccination drive.[3] The drug regulatory body Central Drugs Standards Control Organization (CDSCO) approved two vaccines, Covishield and Covaxin, for emergency use.[4] The approval was granted despite a clear lack of phase 3 clinical trial data for both of these vaccines.[5] Covishield, produced by the Serum Institute of India, is the Indian variant of the  Astra-Zeneca vaccine that has shown an average efficiency of 70.4 percent after trials in the UK.[6] Covaxin, manufactured by Bharat Biotech in collaboration with the Indian Council of Medical Research (ICMR) National Institute of Virology, was developed and manufactured in India. [7] Covishield relied on the safety and efficacy data from large trials conducted in Brazil, South Africa, and the UK with 24,000 participants and a small cohort for the Indian study.  Covaxin was given approval based only on phase-1 trial data. [8] An article published in The Lancet called for further efficacy data from the Covaxin study.[9] The officials associated with Bharat Biotech, as well as the Indian Council of Medical Research, maintained that fast production of the vaccine does not indicate a compromise in safety, even though they had little data to produce.[10] However, transparency is key to vaccination policy, which requires public participation. The media reported that the Covaxin clinical trials compromised research integrity by providing a monetary incentive of around 7 euros, to research subjects. People’s University, a private medical college, and hospital, recruited survivors of the Bhopal Gas tragedy for the Covaxin study. The participants were told that they were being provided a vaccine against COVID-19 without clarifying that data was being collected for their clinical study. There was no record of informed consent from these participants for the Covaxin study.[11]   The media reported the death of a 42-year-old individual who received his first dose on December 23, 2020. [12]  Although it was reported that the cause of death was not linked to the vaccine, the death added to vaccine hesitancy. The vaccines were provided for free to the frontline healthcare workers with no choice on which vaccine the recipients would receive.[13] Similarly, in the US, some people do not have a choice between Pfizer or Moderna. In the UK and the US, data from phase 3 trials are known with a periodic follow-up after the administration of the second dose.[14] The WHO developed a tracking system for COVID-19 vaccine recipients which was updated on March 19, 2021, to reflect the results of Covaxin phase 3 trials.[15] India eliminated choice although the two vaccines approved for emergency use did not have the depth of research that those used elsewhere had.  The intervention ladder, discussed below, which uses proportionality and the harm principle to justify the lack of choice between the vaccines in the UK and the US, should not be applied to India’s vaccination policy. ll.     The Nuffield Intervention Ladder The foundational principle underlying the Nuffield Intervention Ladder is Mill’s conception of individual liberty from the prominent work, On Liberty.[16] However, the Council recognizes that the intervention ladder is conceived on a broader interpretation of Mill’s liberty, using the principle of proportionality as a tool for justification i.e., the desired effect from the intervention is proportional to the loss incurred in liberty.[17]  As shown in Table 1, an ideal intervention that is least infringing would then be no intervention at all. An intervention that would be more difficult to justify would be one that significantly restricts individual liberty.  Intuitively, eliminating occupies the topmost rung on the ladder. The metaphor of the ladder suggests that as one climbs up the rungs of the ladder, stronger justifications would be required. Table 1: Examples of interventions at each level of the intervention ladder adapted and improvised from the Nuffield Council of Bioethics Report, 2007. A voluntary vaccination policy is one public health intervention that is acceptable and justifiable in terms of the principle of proportionality as well as Mill’s Harm Principle, with emphasis on diminishing individual liberties when actions might result in harm to others.[18] Although a vaccination policy in the context of a global pandemic seems justifiable through the lens of the intervention ladder, the Indian modus operandi is unique because of inherent problems with the original conception of the intervention ladder. By pausing to elaborate and reflect on the Indian context as a case study, we can demonstrate that individual liberty should not be the sole variable in framing justifiability. lll.     Critiquing the Nuffield Intervention Ladder & Adding a Precautionary Approach In his paper, ‘Snakes and Ladders: State Interventions and the Place of Liberty in Public Health Policy’, Angus Dawson criticizes the intervention ladder’s focus on individual liberty,.[19]  and its inability to account for the different treatment of incentives and disincentives and the role of information. Public health institutions require public participation to restrict the infectious spread of COVID-19. The lack of transparency and minimal information surrounding the vaccines have been a major hurdle in increasing public participation. It is contradictory to think that the public does not require information about interventions and have the ability of self-determination to guide them, when in fact self-determination presupposes possession of relevant information. A voluntary vaccination policy can be seen as sitting on either the lowest rung (providing information) or the rung of enabling choice, as a vaccination campaign does both. However, in India, the precautionary principle should also be applied as providing the choice should not permit ‘harm’. The precautionary principle holds that anything that poses a risk to human health or the environment should be avoided or accompanied by precautionary measures.  In India, because the clinical trials were smaller and there is less proof of safety and efficacy, a vaccination requirement, or a public health campaign to encourage vaccination violates the principle. The proportionality principle governing the intervention ladder only requires that the benefits of the intervention justify the restrictions on liberty. The intervention ladder should prevent requiring healthcare worker vaccination without a choice of vaccine because a free choice requires transparency and more information than is available from the small early-stage clinical trials. Actions surrounding the vaccines in India do not reflect proper precaution or a proportionate and thus acceptable restriction on liberty. If there is no ability to choose between the two possible vaccines, then they should not be mandatory for healthcare workers. The Indian government and its officials have urged healthcare worker compliance by invoking the seriousness of the pandemic and the alarming rates of mortality rather than providing transparent data pursuant to the regulatory mechanisms of the vaccine clinical trial. For a healthcare worker, the duty to provide service and a stronger obligation to do so in the time of a pandemic already imposes certain restrictions on their liberty. The lack of choice in opting for a preferred vaccine puts it on a higher rung on the intervention ladder and thus requires stronger justifications. This case study reveals how the same public health intervention falls on different rungs of the intervention ladder depending on the target group in consideration. Or to put this simply, choice is contextual. Table 2: The ethical values at stake when it comes to “choice” lV.     An Autonomy-Based Intervention Ladder Liberty and autonomy differ slightly: liberty revolves around the constraints on the ability to act, whereas autonomy stresses on the independence and the authenticity of the willingness to act.[20] It is thus possible for an individual to be autonomous but unfree, as can be seen from the inability to opt for a preferred vaccine.[21] Figure 1 shows an adapted schematic of an autonomy-based intervention ladder as proposed by Griffiths et al. Figure 1: An adapted schematic of the autonomy-based intervention ladder proposed by Griffiths, P.E and West, C. In comparing the original intervention ladder with their proposal, we see that the autonomy-based model allows for a negative scale in terms of its effects on autonomy. Thus, on this ladder, actions can be autonomy-enhancing or autonomy-diminishing. Such a model challenges the one-directional view of the ladder and rearranges interventions on a scale that ranges from negative to positive. A few interventions that were shown to have restrictive effects on liberty now have reinforcing effects when viewed through the lens of autonomy. Thus, providing information and educating can be seen as positive reinforcements for autonomous choice rather than infringing on individual liberty. The autonomy-based intervention ladder requires the State to implement interventions and design policies in a manner that reinforces autonomy. Information and education allow individuals to be free and equal participants in public health discourses. As seen in the original intervention ladder restricting choice, as well as eliminating it, still fall in the negative, autonomy-infringing side of the ladder. Thus, requiring stronger justifications for their implementation. The only difference between the two is the manner in which the new model ensures the availability of a choice when the precautionary, as well as the proportionality principle, have not been met to a sufficient extent. Ensuring choice and exercising it becomes much more relevant in making people autonomous. The frontline worker thus can opt for a vaccine they prefer. Thereby, helping them navigate the moral conundrum of opting to get vaccinated, easing their moral burden. It also places strict vigilance over regulatory mechanisms that are involved in clinical trials since the burden of proof now involves providing information as a clear operational motive. This ameliorates public tendencies of hesitancy can be alleviated in this respect. An autonomy-based intervention ladder is not in conflict with Mill’s conception of liberty since Mill himself does not automatically assume a cost to liberty when the State seems to employ public education campaigns to inform the public.[22] CONCLUSION The original intervention ladder was conceived to remedy the hurdles that a traditional liberal landscape brings in implementing a public health intervention and to protect individual liberties. The intervention ladder assumes an inverse relationship between public health and freedom. Rethinking the intervention ladder from a different perspective allows a proper role of the dissemination of information, recognizing that consent relies on information. An autonomy ladder acts as a starting point for rethinking public health and how it can foster autonomy as well as impede it. By focusing on autonomy, the benefits that can be gained from educational and informational campaigns are viewed as reinforcing autonomy.  Autonomy is vital to liberty. COVID-19 has brought a unique set of ethical issues that have questioned conventionally accepted frameworks and calls for a substantive, alternative approach to public health ethics. [1] Nuffield Council on Bioethics, “Public Health: Ethical Issues.” Nuffieldbioethics.org, Nov 13, 2007. www.nuffieldbioethics.org/publications/public-health. Accessed 9 May 2021. [2] Giubilini A, The Ethics of Vaccination [Internet]. Cham (CH): Palgrave Pivot; 2019. Chapter 3, “Vaccination Policies and the Principle of Least Restrictive Alternative: An Intervention Ladder.” 2018 Dec 29, 2018.  www.ncbi.nlm.nih.gov/books/NBK538385/. [3] Dash, Sachinta. “India Begins Its COVID-19 Vaccination Drive — Here’s a Look at How the World’s Largest Vaccine Rollout Is Set to Take Place.” Business Insider India, January 16, 2021, www.businessinsider.in/india/news/india-will-begin-its-covid-19-vaccination-drive-tomorrow-heres-everything-you-need-to-know/articleshow/80281740.cms. Accessed 9 May 2021. ‌ [4] Special Correspondent, “Coronavirus | India Approves COVID-19 Vaccines Covishield and Covaxin for Emergency Use,” The Hindu, January 3, 2021, www.thehindu.com/news/national/drug-controller-general-approves-covishield-and-covaxin-in-india-for-emergency-use/article33485539.ece. Accessed 9 May 2021. ‌ [5] Thiagarajan, Kamala, “Covid-19: India Is at Centre of Global Vaccine Manufacturing, but Opacity Threatens Public Trust.” BMJ, January 28, 2021. www.bmj.com/content/372/bmj.n196, 10.1136/bmj.n196. [6] Thiagarajan, Kamala. [7] Bharat Biotech, “COVAXIN - India’s First Indigenous Covid-19 Vaccine | Bharat Biotech.” www.bharatbiotech.com/covaxin.html. [8] Prasad, R. “Coronavirus | Vaccine Dilemma — to Take or Not to Take Covaxin.” The Hindu, January 15, 2021, www.thehindu.com/sci-tech/health/vaccine-dilemma-to-take-or-not-to-take-covaxin/article33577223.ece. [9] Ella, Raches, et al. “Safety and Immunogenicity of an Inactivated SARS-CoV-2 Vaccine, BBV152: A Double-Blind, Randomised, Phase 1 Trial.” The Lancet Infectious Diseases, vol. 21, no. 5, January 21, 2021, pp. 637–646, www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30942-7/fulltext, 10.1016/S1473-3099(20)30942-7. [10] Thiagarajan, Kamala. [11] Thiagarajan, Kamala.  ‌ [12] Nichenametla, Prasad. “Bhopal Volunteer’s Death Unrelated to Covaxin, Says Bharat Biotech.” Deccan Herald, 9 Jan. 2021, www.deccanherald.com/national/bhopal-volunteers-death-unrelated-to-covaxin-says-bharat-biotech-937199.html. [13] Thiagarajan, Kamala. ‌ [14] Thiagarajan, Kamala. ‌ [15] World Health Organization, “Draft Landscape of COVID-19 Candidate Vaccines.” www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines. Accessed 9 May 2021. ‌ [16] John Stuart Mill. On Liberty. 1859. S.L., Arcturus Publishing Ltd, 1859. [17] Nuffield. “Public Health: Ethical Issues.” [18] John Stuart Mill. On Liberty. p 13. [19] Dawson, Angus J. “Snakes and Ladders: State Interventions and the Place of Liberty in Public Health Policy.” Journal of Medical Ethics, vol. 42, no. 8, May 23, 2016, pp. 510–513, 10.1136/medethics-2016-103502. [20] Griffiths, P.E., and C. West. “A Balanced Intervention Ladder: Promoting Autonomy through Public Health Action.” Public Health, vol. 129, no. 8, August 2015, pp. 1092–1098, pubmed.ncbi.nlm.nih.gov/26330372/, 10.1016/j.puhe.2015.08.007 [21] Thaler, Richard H, and Cass R Sunstein. Nudge: Improving Decisions about Health, Wealth, and Happiness. London, Penguin Books, 2008. ‌ [22] Griffiths, P.E., and C. West.