Cross post: Pandemic Ethics: Should COVID-19 Vaccines Be mandatory? Two Experts Discuss

Written by Alberto Giubilini (Oxford Uehiro Centre for Practical Ethics and WEH, University of Oxford )

Vageesh Jaini (University College London)

(Cross posted with the Conversation)

 

To be properly protective, COVID-19 vaccines need to be given to most people worldwide. Only through widespread vaccination will we reach herd immunity – where enough people are immune to stop the disease from spreading freely. To achieve this, some have suggested vaccines should be made compulsory, though the UK government has ruled this out. But with high rates of COVID-19 vaccine hesitancy in the UK and elsewhere, is this the right call? Here, two experts to make the case for and against mandatory COVID-19 vaccines.

 

Alberto Giubilini, Senior Research Fellow, Oxford Uehiro Centre for Practical Ethics, University of Oxford

COVID-19 vaccination should be mandatory – at least for certain groups. This means there would be penalties for failure to vaccinate, such as fines or limitations on freedom of movement.

The less burdensome it is for an individual to do something that prevents harm to others, and the greater the harm prevented, the stronger the ethical reason for mandating it.

Being vaccinated dramatically reduces the risk of seriously harming or killing others. Vaccines such as the PfizerAstraZeneca or Moderna ones with 90-95% efficacy at preventing people from getting sick are also likely to be effective at stopping the virus from spreading, though possibly to a lower degree. Such benefits would come at a very minimal cost to individuals.

Lockdown is mandatory. Exactly like mandatory vaccination, it protects vulnerable people from COVID-19. But, as I have argued in detail elsewhere, unlike mandatory vaccination, lockdown entails very large individual and societal costs. It is inconsistent to accept mandatory lockdown but reject mandatory vaccination. The latter can achieve a much greater good at a much smaller cost.

Also, mandatory vaccination ensures that the risks and burdens of reaching herd immunity are distributed evenly across the population. Because herd immunity benefits society collectively, it’s only fair that the responsibility of reaching it is shared evenly among society’s individual members.

Of course, we might achieve herd immunity through less restrictive alternatives than making vaccination mandatory – such as information campaigns to encourage people to be vaccinated. But even if we reach herd immunity, the higher the uptake of vaccines, the lower the risk of falling below the herd immunity threshold at a later time. We should do everything we can to prevent that emergency from happening – especially when the cost of doing so is low.

Fostering trust and driving uptake by making people more informed is a nice narrative, but it’s risky. Merely giving people information on vaccines does not always result in increased willingness to vaccinate and might actually lower confidence in vaccines. On the other hand, we’ve seen mandatory vaccination policies in Italy recently successfully boost vaccine uptake for other diseases.

Mandatory seatbelt policies have proven very successful in reducing deaths from car accidents, and are now widely endorsed despite the (very small) risks that seatbelts entail. We should see vaccines as seatbelts against COVID-19. In fact, as very special seatbelts, which protect ourselves and protect others.

A protestor holding a sign that says: 'No to mandatory vaccines'Although not in the UK government’s plans, mandatory vaccines have become a focus for some protesters. EPA-EFE

 

 

 

 

 

 

 

 

 

 

 

 

Vageesh Jain, NIHR Academic Clinical Fellow in Public Health Medicine, UCL

Mandatory vaccination does not automatically increase vaccine uptake. An EU-funded project on epidemics and pandemics, which took place several years before COVID-19, found no evidence to support this notion. Looking at Baltic and Scandinavian countries, the project’s report noted that countries “where a vaccination is mandatory do not usually reach better coverage than neighbour or similar countries where there is no legal obligation”.

According to the Nuffield Council of Bioethics, mandatory vaccination may be justified for highly contagious and serious diseases. But although contagious, Public Health England does not classify COVID-19 as a high-consequence infectious disease due to its relatively low case fatality rate.

COVID-19 severity is strongly linked with age, dividing individual perceptions of vulnerability within populations. The death rate is estimated at 7.8% in people aged over 80, but at just 0.0016% in children aged nine and under. In a liberal democracy, forcing the vaccination of millions of young and healthy citizens who perceive themselves to be at an acceptably low risk from COVID-19 will be ethically disputed and is politically risky.

Public apprehensions for a novel vaccine produced at breakneck speed are wholly legitimate. A UK survey of 70,000 people found 49% were “very likely” to get a COVID-19 vaccine once available. US surveys are similar. This is not because the majority are anti-vaxxers.

Despite promising headlines, the trials and pharmaceutical processes surrounding them have not yet been scrutinised. With the first trials only beginning in April, there is limited data on long-term safety and efficacy. We don’t know how long immunity lasts for. None of the trials were designed to tell us if the vaccine prevents serious disease or virus transmission.

To disregard these ubiquitous concerns would be counterproductive. As a tool for combating anti-vaxxers – estimated at around 58 million globally and making up a small minority of those not getting vaccinated – mandatory vaccines are also problematic. The forces driving scientific and political populism are the same. Anti-vaxxers do not trust experts, industry and especially not the government. A government mandate will not just be met with unshakeable defiance, but will also be weaponised to recruit others to the anti-vaxxer cause.

In the early 1990s, polio was endemic in India, with between 500 and 1,000 children getting paralysed daily. By 2011, the virus was eliminated. This was not achieved through legislation. It was down to a consolidated effort to involve communities, target high-need groups, understand concerns, inform, educate, remove barriers, invest in local delivery systems and link with political and religious leaders.

Mandatory vaccination is rarely justified. The successful roll-out of novel COVID-19 vaccines will require time, communication and trust. We have come too far, too fast, to lose our nerve now.

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7 Responses to Cross post: Pandemic Ethics: Should COVID-19 Vaccines Be mandatory? Two Experts Discuss

  • Daniel says:

    It is also noteworthy to talk about human rights in refuting making Covid-19 vaccines necessary. This undermines people’s freedom to chose, leaning towards a socialist’s practice of distributing resources.
    Feasibility is also ambiguous in terms of carrying out compulsory vaccination. Do offenders get warned, fined, or imprisoned? How does the government recognise those who have/ haven’t got their vaccine?
    Last but not least, the extent to which the government is subsidising this scheme is also a concern. The people who can’t even afford three meals a day simply would not consider paying extra expenses.
    These points would make the argument point against stronger without merely talking about the past successful experience of combating endemic without legislation or unseriousness of Covid-19 currently.

    • Alberto Giubilini says:

      Thanks Daniel.
      Freedom to choose is not absolute and is already limited in many other cases for the sake of harm prevention or other important values and the public good. I don’t think talk of human rights would be very helpful in this case because if you introduce the concept, then you will see there are many rights at stake here and it is not clear which ones are ‘human rights’ or in any case which rights are more important than which ones. It is not too clear exactly what ‘human rights’, if any, would be violated by a policy which, say, prevented access to certain places to those who are not vaccinated (which is a form of mandatory vaccination which I would support). And in any case, the right of vulnerable people to enjoy as normal a life as possible and to feel safe in social and public spaces should also be taken into account and is likely to outweigh any right that might be violated by mandatory vaccination, whether we want to call all these rights at stake ‘human rights’ or not.
      I think your last point is very important. If vaccination is made mandatory, we need to ensure that vaccines are easily accessible to people, which includes state subsidization for those who could not afford them.

  • gilles cossette says:

    LLa photo de cette dame âgée contestant l’obligation de vaccination m’a fortement interpelé. Je suis avec elle de tout coeur et avec les millions de français, qui sont avec nous. Oui, selon l’auteur indien concerné, quand le taux de mortalité est très bas pour la pandémie Covid 19 (nous parlons des vrais cas déclarés, non les faux + ou -, les deux vaccins synthétiques (conservés à -70C) qui seront offerts généreusement par M. Trudeau, dès décembre 2020, par son bras ARMÉE aux Canadiens privilégiés.
    Je parle des vaccins expérimentaux de Pfiser et Moderna (deux vaccins déprogrammeurs de gênes, les messagers ARN fabriquant d’OGM humain), créés depuis peu dans la bousculade des brevets et pour lesquels, il y a une compétition féroce à savoir, quel gouvernement, qul parti PLTQ va l’EMPORTER dans ce bio-encan (merci Foucault).
    Eh bien, ces vaccins selon l’auteur indien, ne devraient pas être administrés aux personnes déjà en santé, qui ont déjà développé cette année une auto-immunité (il n’y a pas encore de test pour valider ce fait médical) et pour lesquels la vaccination pourrait compromettre cette inocuité naturelle. Sans créer un état de choc plus dommageable que peut l’être la pandémie covid 19 elle-même quand elle entre dans une phase descendante, du pic vers le bas. Une pelle de tracteur pour écraser une mouche, quoi!. Ils comportent des risques non reconnus d’autant plus que nous serions des cobbayes instrumentés dans cette guerre, inter-pharma, à savoir qui a le bon vaccin.
    Ce sont donc des vaccins EXPÉRIMENTAUX, qui selon la charte de Nuremberg (Me Rocco Galati), ne peuvent pas être administrés massivement sans obtenir le consentement individuel et une information juste sur ces effets nuisibles (créer un mal pire que celui qu’on veut traiter – cause Latimer); voilà ce que décrit notre médecin indien. Ils sont donc contre-indiqués et trop à risques. Pourtant selon le dr Raoult, un épidémiologue français, les vaccins traditionnels, classiques qui ont déjà fait leurs preuves dans le passé récént avec la H1, le SRAS, ta ta ta, n’ont pas ou peu d’effets secondaires. Ils n’entraînent pas une transformation du code humain d’ADN de la personne, un repliqage transmissible aux nouvelles générations.
    De plus, il sont plus sécuritaires et ils n’ont pas besoin d’être conservés dans un état de froid sibéral, ce qui entraîne des coûts considérables en conservation de stocks sanitaire de santé dans un pays qui est déjà en faillite et en forte liquidation d’emplois. Enfin j’ai appris tout cela en écoutant un couple âgé de canards du marais (qui n’ont pas encore changé de genre), discourir, très simplement, sur la stupidité des bipèdes à deux pattes que nous sommes devenus avec notre rage de tout aseptisé jusqu’à notre déficiente nature humaine. Pour eux, le saccage actuel des marais et l’abbatage des arbres a beaucoup plus d’impacts nuisibles sur notre état de santé, sur notre immunité que les traitements annonçant l’immortalité de l’homme et la fin des maladies. Avis les Martiens du Big Pharma et consorts, il faut apprendre à les reconnaître sous leurs masques d’auto-immunikté. Gilles Cossette ex-infirmier de Sacré-Coeur et de RVP.

  • Josh says:

    Even with the attempt to force mandatory vaccinations, how would it go about being regulated? What considerations would be taken into account? Would it merely be based on health records? Age? Would it even be worth the resources necessary in order to try and enforce it. If people are properly informed, then they will get vaccinated. But that’s just my take on it.

    • Alberto Giubilini says:

      Thanks Josh. Your questions actually concern 2 issues: which groups to target (you mention for example targeting on the basis of age, which is an option) and how to get people in those groups to vaccinate (e.g. through mandatory policies or less restrictive alternatives).
      At the moment most countries, including the UK, prioritize access according to age, which is taken as a reliable proxy for vulnerability, and for healthcare and care homes staff. I am not convinced that is the best strategy, but the answer is that it should be mandatory for the targeted group. Later on, as the vaccine becomes available for larger portions of the populations, it should be mandatory for the groups that will have access to it.
      As for the more practical question about how to enforce it, there are different options: one is through ‘vaccination passports’ that would not allow the non-vaccinated (unless they have medical exemptions, of course) to access certain places, as is already the case for instance is some US states with regard to children’s access to schools. Another one is having fines for non-vaccination, as is already the case for some child vaccinations in Italy. Yet another one is to withhold some state benefits for those who refuse vaccination, as is already the case for example in Australia. Some people worry that these would not work, but in the examples I have provided they do work better than the alternatives. There will be people who do not comply, as is the case with any other mandatory policy (for example, there are people who evade taxes), but that is not an argument against mandates (for example, it is not an argument against mandatory taxation), unless the policy is not effective (which is not the case for the other mandatory vaccination policies I have mentioned).
      When you say that if people are properly informed, then they will get vaccinated, you might be right, but I think you might be a bit too optimistic. If the main reason for getting vaccinated is to protect others (which will be the case when the vaccine will be made available to the young), many people would probably not do it even if informed.

      • D Manazares says:

        Hi Alberto. Re. Australia’s approach–“no jab, no pay”–this was widely perceived at the time as simply a way for the government to spend less on welfare. It also subtly intimated a UK-style approach to welfare of “give and take”–where welfare is essentially a transaction between the government and citizen, and the government has the right to set any terms it pleases (as if the choice is really free given the alternative!). This is a new political theology in Australia which was mostly foreign to us until the 2010s. The government’s decision had nothing to do with major concern about disease outbreak, and no medical organisation noted this as being an issue (and opinions re. “no jab, no pay” were therefore quite split, mostly along political lines…)

        To the point, in terms of of the effect of “no jab, no pay” on immunisation uptake, the research shows that it has little effect on uptake because parents who fail to be convinced by doctors’ attempts at suasion generally are set enough in their ways that they will forego the benefit, and slip further into poverty, because under their analysis, the vaccine risk is so substantial that any financial inducement is not sufficient. We need to carefully evaluate the reason these people acquire these views–my suspicion is that vaccines have just become an unfortunate ‘proxy’ issue for various culture war issues. As a GP I have found most parents who are sceptical of vaccines to be generally serious people, but misinformed, whose minds can be changed without much trouble, if you take the time to talk to them properly

        Moreover, it’s unclear to me why “no jab, no pay” is morally permissible but it’s not to, say, take the child from its parents arms and vaccinate them. Both are forms of coercion (coercion is not necessarily wrong, but if coercion is what we want, we must say it and open up the field of discussion).

  • J Mwanzia says:

    We know nothing about whether this vaccine prevents transmission so the argument that people are vaccinated to protect others is not valid in this case. The usual safety protocol for vaccines is 2 years safety follow up and it is way too early to know if Pfizer vaccine is safe or effective in the long term. The document Pfizer submitted to the FDA for approval states that at 2 months post vaccine only 50.6% of recipients are still being followed up in both vaccinated and placebo groups with no explanation of this high drop out rate. The mean for vaccine trials is about 17% drop out so this seems exceptionally high. If vaccines become mandated we will be vaccinating the placebo group so no long term comparison of vaccinated and placebo will be possible.

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