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The Ethics of Selective Mandatory Vaccination for COVID-19

The Ethics of Selective Mandatory Vaccination for COVID-19 Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 PUBLIC HEALTH ETHICS VOLUME 15 ISSUE 1 2022 74–86 74 • • • The Ethics of Selective Mandatory Vaccination for COVID-19 1,2 1 2 Bridget M. Williams *, Oxford Uehiro Centre for Practical Ethics, Oxford, UK, Center for Population-Level Bioethics, Rutgers University, New Brunswick, USA *Corresponding author: Bridget M. Williams, Oxford Uehiro Centre for Practical Ethics, Littlegate House, 16-17 St Ebbe’s St, Oxford OX1 1PT, UK. Tel.: þ44 (0)1865 286893; Email: Bridget.williams@pmb.ox.ac.uk With evidence of vaccine hesitancy in several jurisdictions, the option of making COVID-19 vaccination mandatory requires consideration. In this paper I argue that it would be ethical to make the COVID-19 vaccination mandatory for older people who are at highest risk of severe disease, but if this were to occur, and while there is limited knowledge of the disease and vaccines, there are not likely to be sufficient grounds to mandate vaccination for those at lower risk. Mandating vaccination for those at high risk of severe disease is justified on the basis of the harm principle, as there is evidence that this would remove the grave public health threat of COVID-19. The risk– benefit profile of vaccination is also more clearly in the interests of those at highest risk, so mandatory vaccination entails a less severe cost to them. Therefore, a selective mandate would create fairness in the distribution of risks. The level of coercion imposed by a mandate would need to be proportionate, and it is likely that multiple approaches will be needed to increase vaccine uptake. However, a selective mandate for COVID-19 vaccines is likely to be an ethical choice and should be considered by policy-makers. indeed been implemented for certain workers in the USA Introduction (The White House, 2021). Savulescu et al. (2021)have The emergence of coronavirus disease 2019 (COVID-19) considered the ethics of mandating vaccines in children; has resulted in substantial harm across the world, both as a however, the possibility of implementing a selective man- direct result of the disease and indirectly as a result of the date aimed at those at highest risk of severe COVID-19 has, socio-economic impacts of its change on behaviour and thus far, received little attention. In this paper I argue that policies used to achieve disease control. Several highly ef- it would be ethical to make the COVID-19 vaccination fective COVID-19 vaccines have been developed (Folegatti mandatory for those at highest risk of severe disease, but, et al.,2020; National Institutes of Health, 2020; Pfizer, while there is limited knowledge of the disease and vac- 2020) and roll-out of these vaccines is well underway in cines, there likely are not sufficient grounds to mandate many countries (Mathieu, 2021). Rapid resolution of the vaccination for those at lower risk if those at higher risk COVID-19 crisis is important, both for mitigating the dir- were protected. I offer several considerations for the po- ect harms of the disease and for allowing socio-economic tential role of selective mandate in COVID-19 vaccination recovery to begin. Therefore, a range of policy options to strategies and defend this proposal from two objections: achieve rapid vaccine uptake should be considered. With that any mandate risks worsening vaccine hesitancy and evidence of vaccine hesitancy in several jurisdictions, vol- that selective mandate is unjustly discriminatory. untary uptake alone may not lead to the vaccine coverage levels required for epidemic control. Indeed, a recent re- What Is Mandatory Vaccination and port has estimated the mortality impact of the pandemic to be eight times higher over two years in countries with When Should It Be Considered? higher vaccine hesitancy (Mesa et al.,2021). As such, the Mandates are a form of government coercion; that is, they option of making COVID-19 vaccination mandatory limit the autonomy of an individual to make a free per- requires consideration. sonal choice by threatening punishment for non- It has been suggested that a COVID-19 vaccine mandate is likely to be appropriate and legally enforceable in the compliance. The level of coercion can vary, from the im- USA (Reiss and Caplan, 2020), and vaccine mandates have position of bureaucratic hurdles to large fines, community doi:10.1093/phe/phab028 Advance Access publication on 15 December 2021 V C The Author(s) 2021. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 SELECTIVE MANDATORY VACCINATION FOR COVID-19 75 service, restriction on freedom of movement or, in extreme the first 12 months of the pandemic, in the UK, over cases, forced vaccination. Although the terms mandatory 100,000 people had died and had COVID-19 on their and compulsory are often used interchangeably, following death certificate (Public Health England, 2021) and Navin and Largent (2017), I will use mandatory to refer to modelling suggests unmitigated epidemic would result measures that do not involve the criminalization of refusal. in hundreds of thousands of deaths in the country Implementing a vaccine mandate makes it clear that (Ferguson et al., 2020; Ragonnet et al., 2020). Aside vaccination is not a personal choice, but rather some- from this direct mortality impact, many survivors will thing expected as a member of a population, similar to suffer significant morbidity, and an unmitigated epi- taxes (Giubilini, 2020). Mandates are generally aimed at demic would likely overwhelm health care services, jeop- those who are vaccine-hesitant rather than those who are ardizing health more broadly (Ferguson et al., 2020). At staunchly opposed to vaccination (Pierik, 2018). By gen- least in the UK and nations like it, COVID-19 does seem erating a social norm of vaccination, making vaccine to present a grave public health threat. refusal costly or inconvenient, and by providing assur- Vaccine development has been faster than many ini- ance that others are also making their contribution, tially predicted, and several vaccines were developed mandates can improve vaccine uptake rates. Several during 2020. Although some vaccines have been associ- studies in different settings have shown mandates to be ated with rare side effects (discussed further below), the effective in increasing vaccination uptake (Robbins et al., risks of the vaccines are low, and they have been author- 1981; Orenstein and Hinman, 1999; D’Ancona et al., ized for use in many countries and by the World Health 2019; Le ´ vy-Bruhl et al., 2019). Organization (2021). In many settings voluntary Mandatory vaccination exists in some form in most COVID-19 vaccine uptake has been high. Within the countries, most commonly for childhood vaccine pre- first 6 months of vaccine availability, the proportion ventable diseases (Gravagna et al., 2020). For childhood of people over the age of 65 who received at least one vaccines, mandates have taken the form of requiring dose of vaccine was>90% in the UK (Office for National vaccination for the receipt of some welfare benefits (in Statistics, 2021) and >85% in the USA (US Centers for Australia), attendance at state-run school or childcare Disease Control, 2021a) and several European countries centres (the USA and Italy). In adults, instances of man- (European Center for Disease Control, 2021). However, datory vaccines have included requiring health care vaccine uptake among high-risk groups has been much workers to receive certain vaccines in order to work slower in some locations, and this rate of uptake is im- with patients (Field, 2009). portant for minimizing the overall harms of the pan- The Nuffield Council on Bioethics’ 2007 report on demic. There is heterogeneity in uptake within ethical issues in public health suggests that when consid- countries, with uptake being well below average in ering whether directive vaccine policies are acceptable, some areas, leaving some communities vulnerable to on- the following should be taken into account: the serious- going outbreaks which may threaten local health care ness of the threat to the population, and the risks asso- systems. Indeed, in September 2021, 10 months after ciated with the disease and vaccination itself (Nuffield vaccines became available, some areas of the USA were Council on Bioethics, 2007). The report suggests that reported to be rationing health care due to COVID-19 ‘quasi-mandatory’ policies are more likely to be appro- surges (Boone, 2021). In October 2021, in 26% of US priate for diseases that are highly contagious and serious, counties, fewer than 70% of people aged 65 years and and diseases where eradication may be possible. More over had received at least one vaccine dose. In 10% of recently, Julian Savulescu has argued that mandatory counties fewer than 30% of this age group had received at vaccination may be permissible when four conditions least one vaccine dose (US Centers for Disease Control, are met: (i) that the disease is a grave public health threat, 2021b). (ii) that there is a safe and effective vaccine, (iii) manda- Slow vaccine uptake has seen several states in the USA tory vaccination has a superior cost/benefit profile com- implement incentives for vaccinations, such as cash or pared with other alternatives and (iv) the level of lotteries (Knutson, 2021). Strategies to increase vaccine coercion is proportionate (Savulescu, 2020). uptake are clearly needed, and may be even more im- portant for booster vaccinations. Given that the longer the COVID-19 pandemic continues, the greater the Mandatory Vaccination in COVID-19 harms caused, taking an approach of ‘waiting and seeing’ It seems relatively clear that COVID-19 poses a serious whether vaccines are taken up sufficiently rapidly volun- threat to the health of many countries’ populations. In tarily may carry significant costs. The potential health Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 76 WILLIAMS gains of a selective mandate provide a strong argument Although it is possible that new variants may, in the for consideration in policy. future, change the epidemiological features of COVID- One important feature of COVID-19 is the heterogen- 19, at this point in time there is no evidence to suggest eity in disease severity across population groups. While a that new variants have substantially changed the demo- variety of factors influence risk of severe COVID-19, the graphic patterns of disease severity or transmissibility greatest risk comes with older age (Williamson et al., (Lewis, 2021). Therefore, the following argument pro- 2020). The infection mortality ratio for SARS-CoV-2 ceeds with the assumptions that age is a particularly im- (the causative pathogen of COVID-19) is lowest in portant risk factor for disease severity and that there is no young children, with median estimates between 0.01% demographic group that is particularly important for and 0.001% for those aged 5–9 years (Brazeau et al., transmission. However, changes in these epidemiologic- 2021), but rises in a log-linear pattern among people al features, should they occur, will alter the applicability aged 30 years and over. For those aged over 80 it is of this argument. estimated to be 8.29% (O’Driscoll et al., 2020), although even in this group the risk continues to increase dramat- Optimizing Outcomes and ically with age, with one estimate putting the risk at around 5% for those aged 80–84 and 17% for those Removing the Grave Public 90 years and older (Brazeau et al., 2021). A modelling Health Threat analysis (Ragonnet et al., 2020) has suggested that if those at highest risk of disease could be effectively iso- One of the reasons to consider mandatory vaccination is lated, then even if infection were allowed to occur in the potential health and well-being gains it might pro- younger people, the mortality costs of the pandemic duce. Indeed, the Nuffield Council’s reference to the would be drastically reduced. Of course, this does not ‘seriousness of the threat to the population’ and take into account health impacts apart from mortality, Savulescu’s reference to ‘grave public health threat’ ap- but morbidity from COVID-19 is also higher among peal to the magnitude of health and well-being that is at older people, with long-term harms correlated with dis- risk without vaccination. ease severity, and long-covid also more likely among Ultimately, vaccinating the entire population against those who are older (Sudre et al., 2021). This heterogen- COVID-19 would best minimize direct COVID-19 mor- eity in risk of harm is relevant to discussions of manda- bidity and mortality. This would protect those who can- tory vaccination. It suggests that vaccinating this high- not be vaccinated, and better protect those at risk of risk subset of the population may cause disproportion- severe disease, as no vaccine is 100% effective. It would ate public health benefit and that the risk–benefit profile also protect the younger population. Although the mor- of vaccination will be different for different groups. As tality risk is relatively low for this group, it is not zero. such, it may be the case that mandatory vaccination is COVID-19 also poses health risks apart from death, only appropriate for high-risk age groups. including the harm of the acute illness, long-Covid, This paper explores the idea of selective mandatory and possibly unknown long-term effects. All else equal, vaccination in the setting of COVID-19. In future pan- it is better for everyone to avoid contracting COVID-19. demics the characteristics of the disease in the popula- However, time is crucially important in the COVID- tion may be different, and it may be different groups that 19 pandemic, and vaccines cannot be produced and dis- have higher risk of severe disease. For example, in the tributed to everyone immediately. Strategies need to take 1918 influenza pandemic it was younger adults (aged into account what will lead to the best outcomes given 25–40) who were at highest risk of severe disease the immediate constraints on vaccine distribution. (Liang et al., 2021). Rather than disease severity, trans- Modelling studies have suggested that in this condition missibility may be the key factor that varies among of scarcity, prioritizing the elderly for vaccination is groups. In previous influenza pandemics children have most likely to minimize COVID-19 mortality (Hogan been significant vectors for transmission, and it has been et al., 2020; Bubar et al., 2021; Moore et al., 2021). This argued that a COVID-19 vaccine mandate for children is unsurprising given that those aged over 65 account for may be permissible if it were the case that children are the majority of COVID-19 deaths: 92.5% in England particularly important vectors for transmission (Office for National Statistics, 2020). Choices around (Savulescu et al., 2021). The groups targeted by selective vaccination programs may be influenced by several dif- mandate may therefore be different depending on char- ferent values, including saving lives, saving life years, acteristics of the disease in a population. saving quality-adjusted life years, protecting the health Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 SELECTIVE MANDATORY VACCINATION FOR COVID-19 77 care system or restoring the normal functioning of soci- While the harm principle provides an effective basis for when it may be ethical to override a person’s auton- ety (Giubilini et al., 2021). It is therefore not clear that the goal of a vaccination program ought to be minimiz- omy, judgement is required to determine circumstances where this is proportionate. Many things we do pose a ing the number of deaths. However, it is likely that pro- tecting those most at risk of severe disease would risk of harming others, for example driving a car poses a risk to other motorists and pedestrians. So, it must be minimize the mortality burden in terms of both number of deaths and years of life lost. As this group is also the shown that the risk of harm is sufficiently high, and the cost of removing it proportionately low. Building on most likely to require health care resources, this would Flanigan’s analogy, Giubilini points out that when a also be likely to most effectively prevent the health care population is close to herd immunity for a particular system from being overwhelmed. This also suggests that disease, an individual failing to vaccinate only adds a the ‘grave public health threat’ would be substantially minor risk of harm to others. As he says, in such cases reduced, and possibly eliminated, if this group were pro- mandatory vaccination may be more like preventing tected with an efficacious vaccine. From a population someone from firing a gun when everyone is wearing health perspective ensuring rapid uptake of the vaccine bulletproof vests (Giubilini, 2020). In this instance, the in this group, and others at high risk, should be an im- argument from the harm principle is not as strong. In the mediate priority. case of COVID-19, if those at high risk were already vaccinated, then vaccinating people at low risk would Justifying Mandatory Vaccination: be like preventing them firing a gun whose bullets only harm a subset of the population, and that subset are The Harm Principle wearing bulletproof vests. If those at high risk from Even if mandatory vaccination were only considered for COVID-19 were all protected through vaccination, the those most at risk and who would clearly receive sub- argument that others remaining unvaccinated poses sig- stantial individual benefit from COVID-19 vaccination, nificant harm is weakened. a justification still needs to be provided as to why their On the other hand, the harm principle does support autonomy can be overridden. People often choose mandatory vaccination of those who are at high risk of options that may not seem to be best from them, and severe COVID-19. As mentioned, the indirect harms this freedom to choose is highly valued in many societies. caused by the COVID-19 epidemic are substantial, Here John Stuart Mill’s suggestion that the state can only both through disruption to health services and the lim- restrict a person’s liberty to prevent them from causing itations on public movement. Analyses have suggested harm to another (Mill, 2011) has been influential. substantial harms from disrupted cancer screening serv- Indeed, existing discussion of mandatory vaccination ices (Maringe et al., 2020) and from school disruption commonly appeals to this ‘harm principle’. Vaccination (Christakis et al., 2020), as well as mental illness exacer- not only protects the vaccinated individual but also pre- bated by lockdown measures (Pierce et al., 2020). In the vents them directly harming others by passing on infec- UK, population movement restrictions have been justi- tion, and indirectly harming others by unnecessarily fied by appealing to the need to save lives and protect the requiring health care resources. Giubilini and National Health Service (NHS). The same justification Savulescu (2019) liken the duty to vaccinate oneself to applies to vaccination, especially for those at risk of se- the duty to wear a seatbelt. In both cases the action vere disease that puts greater strain on the NHS. For prevents direct harm (to other vehicle occupants or to those at risk of severe disease, the harm principle sug- people to whom an infection may be transmitted), as gests that it is permissible to override their autonomy on well as indirect harm to other health care service users, the decision of whether to receive the COVID-19 vac- and this risk of harm overrides the individual’s auton- cine, as their risk of infection carries a risk of using health omy to choose the riskier option for themselves. care services unnecessarily, and prolonging socio- Similarly, Flanigan (2014) describes mandatory vaccin- economic disruption with its attendant health costs. ation as akin to forcibly preventing someone from firing In instances where one group is a particularly import- a gun into a crowd. She suggests that in the same way that ant vector for transmission then this increased risk of we think it is permissible to override a person’s auton- harming others (and thereby also indirectly contributing omy to prevent them from firing a gun and risking harm to health care systems becoming overwhelmed) would to others, we should consider it permissible to override be a relevant feature for considering the permissibility of autonomy to ensure people are vaccinated to prevent a vaccine mandate. The magnitude of the risk posed by them harming others. this group may be sufficient to implement a mandate, Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 78 WILLIAMS where it may not be warranted in others who pose a be an instance of paternalistic vaccination, as the deci- sion is made by someone other than the vaccinee and the lower risk of transmission. Thus far, no particular demo- graphic group has been identified to be particularly key vaccinee is the primary beneficiary of the vaccine. However, even though the vaccinee does receive a large transmitters of COVID-19, but it is possible that such a benefit from the vaccine, the reason to coerce them to group would be identified in the future. Mandating vac- vaccinate is actually to protect the interests of others by cination for this group may be justifiable given certain removing the public health threat and thereby prevent- conditions, but further ethical analysis would be ing the societal harms of an uncontrolled epidemic. So, required. this is either an instance of what Kraaijeveld calls indirect vaccination (where someone other than the vaccinee Fair Contribution to a Public Good makes the decision to vaccinate for the purpose of bring- ing about benefit to others), or the scenario may fall Another consideration of any public health policy op- outside the scope of Kraaijeveld’s framework. It is not tion is the implications for fairness. Giubilini (2020) paternalism, but rather contribution to the common suggests that mandatory vaccination to achieve herd im- good and prevention of indirect harms to others, that munity in childhood diseases may be justified by appeals is the motivation for the mandate. to fairness, rather than simply appealing to harms. By For most adults, a COVID-19 vaccine is very clearly in likening vaccination to taxation, he suggests that popu- their interests. Whatever small risks the vaccine may lation immunity is a public good and the measures taken have, these are vastly outweighed by the reduction of to reach this public good should be fairly distributed. In risk from COVID-19 that the vaccine provides. the case of COVID-19, given immediate vaccine scarcity However, at this relatively early stage of the vaccine’s the most important public good from vaccination is use, for some younger age groups, we cannot be so con- rapid epidemic control and removal of the grave public fident that the risk–benefit profile of the COVID-19 vac- health threat, rather than herd immunity. cine leads to vaccination being clearly in the individual’s Here again the heterogeneity in risk for COVID-19 clinical interest. This is highlighted by several countries has implications, as the risk–benefit profile of vaccin- introducing limits on the type of vaccine used in younger ation compared to the risk of the disease is different age groups (Gallagher, 2021; Olsen, 2021). Vaccines for different groups. It is less costly for those who are often can cause short-lived adverse effects such as fa- most at risk of COVID-19 to be vaccinated, as the risk– tigue, malaise and pain, but also carry a small risk of benefit profile of individual vaccination is more clearly more severe side effects, including anaphylaxis and other in favour of vaccination. For those at lower risk of severe complications. The phenomenon of vaccine-induced disease vaccination asks them to accept a less favourable immune thrombotic thrombocytopenia, and more re- risk–benefit profile. cently evidence suggesting a link between myocarditis in This difference in risk–benefit profiles is important, as younger males and some mRNA vaccines, has high- it affects the level of burden that an individual is being lighted how the risk–benefit profile of a vaccine can asked to take on as a contribution to the public good of vary depending on demographic features (Greinacher removing the public health threat of COVID-19. et al., 2021; Vogel, 2021; Winton Centre for Risk and Although for people at high risk of severe COVID-19 Evidence Communication, 2021). It has also highlighted vaccination is very clearly in their interests, the reason how vaccines (and other medical interventions) can have to implement a mandate is not to force people to protect unexpected risks that may not be detected in clinical themselves for their own sake, but rather is to reduce the trials. This highlights the importance of another feature risk of their illness contributing to overwhelming the that distinguishes COVID-19 from other vaccine pre- health care system and/or requiring prolonged ventable diseases—its novelty, and the uncertainty in population-movement restrictions. So even though disease and vaccine risk profile that entails. Studies they are the primary beneficiary of the vaccine, rather assessing childhood vaccines have not found evidence than being coerced to vaccinate for their own benefit, of long-term harms (Pittman et al., 2004), but there is they are being coerced to vaccinate for the public good. a risk that new vaccines may have unexpected harms. For Kraaijeveld (2020) has developed a framework for differ- example, a vaccine developed for the 2009 influenza pan- entiating types of vaccination based on who makes the demic was associated with a small risk of developing decision to vaccinate and who is the primary beneficiary narcolepsy in children (Miller et al., 2013). For most of the vaccine. On this framework, a COVID-19 vaccine vaccines there is a long history of use and substantial mandate for those at highest risk might initially seem to data monitoring for long-term harms, which allows us Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 SELECTIVE MANDATORY VACCINATION FOR COVID-19 79 to make confident statements on the nature of their risks, Folegatti et al., 2020; Pfizer, 2020). So current evidence such as this from the UK’s NHS: ‘vaccines get safety suggests that the elderly will have substantial protection tested for years before being introduced—they’re also from being vaccinated themselves. Although the role of monitored for any side effects’ (National Institutes of children in transmission remains an area of uncertainty, Health, 2020). This statement cannot be made for any the evidence that is available does not suggest that chil- COVID-19 vaccine. These possible risks of long-term dren are a particularly important vector for COVID-19 harm are also more important for younger people than transmission (Dattner et al., 2021; Munro and Faust, older people, as few safety trials have involved young 2020). Combined with the uncertain risk–benefit profile people (children and adolescents), and because the to low-risk individuals and the uncertain effect of young can expect to live longer to experience them if COVID-19 vaccination on transmission risk, it is less they do occur, and for their effects to affect a greater clear that the small level of additional protection for portion of their life. This inability to provide confidence the elderly arising from vaccinating low-risk people jus- in the risk–benefit profile, particularly for those at low tifies the infringement of autonomy and small risk im- risk from COVID-19, makes vaccination a comparative- position required by mandatory vaccination. ly greater cost to people at lower risk, especially younger It may also be argued that, although the clinical risk– people, than it does to older people at higher risk of benefit profile of vaccination may not be clearly favour- disease. able for younger people, the indirect benefits from the If it were the case that the most effective way to remove resolution of the COVID-19 crisis will tip the balance to the public health threat of a disease was to target those be clearly in favour of vaccination for younger people as who are most likely to transmit the disease, rather than well. Indeed, it might be suggested that younger people those most at risk of severe disease, then appealing to the stand to gain more from removing the public health idea of fair contribution to a public good will be more threat of COVID-19 than do older people, as they may complicated. Consideration of fairness may instead be a suffer more due to the pandemic’s socio-economic reason against pursuing that approach if it asks those effects, which will likely persist for many years into the who can contribute most to removing the public health future. Concern for fair contribution to a public good threat to take on an overly large burden. However, given might then suggest that younger people ought to take on modelling has consistently recommended vaccinating more of the burden of achieving epidemic control, even those who are most vulnerable to severe COVID-19 first, though their clinical risk–benefit profile is lower, as they in this situation efficiency and fairness coincide, and stand to gain more from this good. However, making consideration of fairness adds to the argument to this comparison of who stands to gain more from rapid mandate a vaccine for those at highest risk of resolution of the crisis is difficult. It could equally be severe COVID-19. argued that older people have a greater interest in achiev- In some instances it may be appropriate to ask people ing rapid resolution of the pandemic as they have fewer to accept an unfavourable risk–benefit profile for the years remaining, so it matters more to them how much purposes of protecting others. Previously it has been of the next few years are spent with restrictions. These argued that children should be vaccinated against influ- sorts of considerations also raise difficult and controver- enza for the primary purpose of protecting the elderly sial philosophical questions on the nature of personal (although in this case the risk–benefit profile clearly identity and how this persists through time. favours vaccination for children as well) (Bambery Considering the clinical risk–benefit profile of vaccin- et al., 2018). However, much of the strength of the argu- ation provides a clear idea of who is being asked to take ment rests on the vaccine not providing substantial pro- on what degree of risk. tection directly to the elderly, and children being an Furthermore, if, as the modelling suggests, the fastest especially important vector for transmission. It has path to resolving the crisis is through vaccinating those also been argued that should these conditions hold for at highest risk of severe disease, then we ought to take COVID-19, then it would likely be ethically acceptable to this path, which involves minimizing the number of vaccinate children against COVID-19 in order to protect people who are asked to accept a less clearly favourable older people, provided that the risk of vaccination is clinical vaccination risk–benefit profile. In a setting of sufficiently small (Giubilini et al., 2020; Savulescu global vaccine scarcity, removing the grave public health et al., 2021). However, we now have more information threat everywhere should be the immediate priority, ra- on COVID-19 and vaccines. The evidence suggests that ther than reaching herd immunity in a few settings. COVID-19 vaccines have comparable efficacy across age Globally, at least initially, COVID-19 vaccines are going groups, including older adults (Anderson et al., 2020; to be a scarce resource. So, if one country was in a Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 80 WILLIAMS position to procure a greater portion of the global vac- too carries risk that the payment will not be a sufficient incentive to achieve rapid uptake. Use of local data and cine stock for their population, a strategy that relies on larger quantities of vaccine will delay the access of an- community involvement may help to determine the role other country to the vaccine, costing lives there. This of a selective mandate in a vaccination plan, and the best suggests that achieving epidemic control through rapid option for implementation, to ensure fairness, effective- vaccination of those at highest risk, rather than waiting ness and respect for the population. It would also be for population immunity to develop through voluntary important to establish a compensation mechanism for vaccination is also a matter of global justice. those who suffered adverse events as a result of manda- tory vaccination (Savulescu et al., 2021). Proportionality and Considerations Objections for Policy I have thus far argued that mandatory COVID-19 vac- I have thus far argued that a selective mandate could be cination for those at high risk of severe disease may result an ethical policy choice. However, the form of the man- in substantial welfare gains and is justified by the harm date would need to maintain respect for, and limit the principle and the value of fairness. However, it could be burden imposed on, the individual, and prevent argued that mandating vaccines risks strengthening anti- population-level harms from the mandate itself. The vaccine sentiments, and that selective vaccination is dis- costs imposed by the mandate should act as sufficient criminatory. I will respond to these objections now. disincentive to non-compliance, so that vaccination for these groups is seen as something expected, rather than Does Mandatory Vaccination Risk Strengthening an option that is the decision of the individual alone. The the Anti-Vaccine Movement? form of the mandate, and the level of coercion involved, needs to be proportionate. It has been suggested that mandatory vaccination carries As mentioned, mandatory vaccination does not imply risks of undermining public trust in vaccines (Omer criminalization of vaccine refusal (Navin and Largent, et al., 2019). Given the high profile of the COVID-19 2017) but may involve other measures like fines, com- vaccine, any adverse events in vaccine recipients are like- munity service or movement restrictions. For example, ly to be highly publicized. As vaccines do carry small people at high-risk of COVID-19 who refuse vaccination risks, there will be (and have already been) cases of ser- could be required to remain in isolation (or otherwise ious adverse events. Furthermore, it is also likely that have their freedom of movement restricted) until epi- there will be instances of people suffering an acute health demic control is achieved, to reduce their risk in another emergency shortly after receiving the vaccine, and even if way. If there were concerns that even this level of cost this is not due to the vaccine, it will be difficult to sep- would unduly burden some people (for example resi- arate the events in the eyes of a sceptical public. dents of nursing homes who are often already deprived On the background of this scrutiny, mandated vac- of social contact), then exemptions could be included. cination may have the potential to further undermine Alternatively, the cost of non-compliance could be public confidence in vaccines. However, the risk seems reduced even further, so that the mandate only created lower if vaccination were only mandated in those at a minor inconvenience (e.g. completing and submitting highest risk. The most outrage-inducing scenario would forms for exemptions). The purpose of the mandate is to be a young person, at low risk of COVID-19, who suffers, make non-compliance costly, so that more of those who or appears to suffer, an adverse event due to a mandated are hesitant end up being vaccinated, rather than enforc- vaccine. If an older person at higher risk of COVID-19 ing compliance among the entire population. However, were to suffer an unexpected adverse event it would still reducing the cost, or increasing the number of people be tragic, but a mandate would be more easily justified who are exempt, would reduce the effectiveness of the due to their higher ex-ante risk of COVID-19. If an eld- mandate. A choice would need to be made on how to erly person were to suffer an unrelated health event soon trade off effectiveness with a level of cost that seems pro- after their vaccination, it would also be less likely to be portionate and unlikely to cause excessive harms. mistakenly attributed to the vaccine, as such events are Alternatives should also be considered, including a not as unexpected in older age. payment model, which has been suggested by The risk of undermining public confidence in vaccines Savulescu (2020). This may be a better option in some needs to be balanced against the harm of a longer settings. However, like the ‘wait and see’ approach, this COVID-19 pandemic. Mandatory vaccination of only Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 SELECTIVE MANDATORY VACCINATION FOR COVID-19 81 those at highest risk of severe disease seems to strike the raise further important ethical problems than have been right balance between these two risks: avoiding the risk considered here, and may lead to important negative of the most outrage-inducing scenario, while also pro- consequences such as heightening racism in medicine, viding the majority of the public health benefit of rapid reducing trust in medical institutions, increasing racial vaccine uptake. tensions and augmenting inequalities. Introducing man- dates on the basis of race would also be practically diffi- cult, given the variation in racial identities that exist. Is a Selective Mandate Discriminatory? Although ageism exists in society, a mandate based on It may be argued that the selective mandate I have pro- age would be less fraught with social tensions. There are posed constitutes unjust discrimination on the basis of many precedent examples of selective public health age. However, as Savulescu and Cameron (2020) have measures based on age; most vaccine schedules are based argued, risk of severe disease, which in the case of on age, as are many screening interventions such as COVID-19 correlates with age, is a morally relevant fac- breast or bowel cancer screening. Furthermore, ageing tor in health policy. To discriminate on the basis of a is a universal experience, so although birth cohorts can morally irrelevant factor would be unjust. But discrim- be distinguished, all of us (unless we die prematurely) inating on the basis of a factor that has significant impli- will experience ageing, meaning that measures based on cations for the public health utility of the measure, as age involve less inequality when considering the course well as the individual’s own capacity to benefit, is not of a life. A mandate using age would also be practically unjust. To borrow an example from Savulescu and easier, given the clear availability of age data in most Cameron, offering breast cancer screening to women settings. and not men doesn’t constitute unjust discrimination on the basis of sex, as women are much more likely to benefit from breast cancer screening. Conclusion More recently, Cameron et al. (2021) have argued that Rapid uptake of a safe and effective COVID-19 vaccine selective liberty restrictions may be appropriate when in those at highest risk of severe disease will be important such restrictions would bring benefits for both the popu- to mitigating the impact of the pandemic. Although vac- lation and the individual, are designed to protect those cination is likely to be in the interests of most people, most at risk of disease, and are no more than is necessary. making a vaccine mandatory involves impositions on They also specify that differences that arise due to social autonomy which need to be justified. The infringement disadvantage itself ought not to be the basis for discrim- of autonomy of those at high risk of severe COVID-19 is inatory health measures. This is designed to promote justified on grounds of the harm principle and also pro- respect for, and protect the interests of, the individual motes fairness. However, if those at high risk were pro- as well as promote the interests of the population. tected, there is little grounds to justify mandating In the case of COVID-19, as well as age, race has also vaccination for those at lower risk of severe COVID- been correlated with disease severity (Sze et al., 2020). 19, particularly in the early stages of vaccine use. For example, in the USA, Black and Hispanic ethnicity Although a selective mandate may be an ethical choice, has been associated with substantially greater risk of the form of the mandate would need to be proportionate death from COVID-19 (Ford et al., 2020). However, and avoid being overly costly for individuals or worsen- there is evidence that the discrepancies are largely due ing inequality. Imposition or prolongation of movement to social disadvantage, rather than race per se, as in some restrictions may be an appropriate measure. Whether a analyses, when discrepancies in access to health care and selective mandate should form part of a COVID-19 vac- social disadvantage are taken into account there is no cination plan, and if so, the form that it takes, is a larger significant difference in mortality outcomes due to race (Iacobucci, 2020; Lopez et al., 2021). In this case a question that may have different answers depending on mandate on the basis of race would be roughly approx- context. A mandate alone is unlikely to be the best ap- proach, with attention needing to be paid to communi- imating a mandate on the basis of social disadvantage, which generates new ethical problems. Even if race were cation strategies, and identifying and eliminating an independent contributor to risk, there are other rea- barriers to vaccine uptake. However, based on current evidence of disease risk and transmission, a selective sons why a selective mandate on the basis of race would be ethically problematic. On a background of historic mandate for the COVID-19 vaccine on the basis of age and ongoing racism in medicine (Nuriddin et al., is likely to be ethically justifiable and, in the face of real 2020), mandating vaccination on the basis of race would and important harms from vaccine hesitancy, Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 82 WILLIAMS policymakers should give careful thought to the role it Infection Fatality Ratio: Estimates from Seroprevalence, available from: https://doi.org/10. may play in vaccination strategies. 25561/83545 [accessed 7 June 2021]. Bubar, K. M., Reinholt, K., Kissler, S. M., Lipsitch, M., Acknowledgements Cobey, S., Grad, Y. H., and Larremore, D. B. (2021). I am grateful to Julian Savulescu, Kwamina Orleans- Model-Informed COVID-19 Vaccine Prioritization Pobee, two anonymous reviewers, and an associate edi- Strategies by Age and Serostatus. Science, 371, tor of Public Health Ethics whose feedback greatly 916–921. improved this paper. Cameron, J., Williams, B., Ragonnet, R., Marais, B., Trauer, J., and Savulescu, J. (2021). Ethics of Selective Restriction of Liberty in a Pandemic. Funding Journal of Medical Ethics, 47, 553–562. Christakis, D. A., Van Cleve, W., and Zimmerman, F. J. No specific grant was received for this research. BW (2020). Estimation of US Children’s Educational receives funding from the Forethought Foundation for Attainment and Years of Life Lost Associated with Global Priorities Research to support her graduate Primary School Closures during the Coronavirus studies. Disease 2019 Pandemic. JAMA Network Open, 3, e2028786. Conflict of Interest D’Ancona, F., D’Amario, C., Maraglino, F., Rezza, G., and Iannazzo, S. (2019). The Law on Compulsory None declared. Vaccination in Italy: An Update 2 Years after the Introduction. 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The Ethics of Selective Mandatory Vaccination for COVID-19

Williams, Bridget M
Public Health Ethics , Volume 15 (1): 13 – Jun 11, 2022
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Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 PUBLIC HEALTH ETHICS VOLUME 15 ISSUE 1 2022 74–86 74 • • • The Ethics of Selective Mandatory Vaccination for COVID-19 1,2 1 2 Bridget M. Williams *, Oxford Uehiro Centre for Practical Ethics, Oxford, UK, Center for Population-Level Bioethics, Rutgers University, New Brunswick, USA *Corresponding author: Bridget M. Williams, Oxford Uehiro Centre for Practical Ethics, Littlegate House, 16-17 St Ebbe’s St, Oxford OX1 1PT, UK. Tel.: þ44 (0)1865 286893; Email: Bridget.williams@pmb.ox.ac.uk With evidence of vaccine hesitancy in several jurisdictions, the option of making COVID-19 vaccination mandatory requires consideration. In this paper I argue that it would be ethical to make the COVID-19 vaccination mandatory for older people who are at highest risk of severe disease, but if this were to occur, and while there is limited knowledge of the disease and vaccines, there are not likely to be sufficient grounds to mandate vaccination for those at lower risk. Mandating vaccination for those at high risk of severe disease is justified on the basis of the harm principle, as there is evidence that this would remove the grave public health threat of COVID-19. The risk– benefit profile of vaccination is also more clearly in the interests of those at highest risk, so mandatory vaccination entails a less severe cost to them. Therefore, a selective mandate would create fairness in the distribution of risks. The level of coercion imposed by a mandate would need to be proportionate, and it is likely that multiple approaches will be needed to increase vaccine uptake. However, a selective mandate for COVID-19 vaccines is likely to be an ethical choice and should be considered by policy-makers. indeed been implemented for certain workers in the USA Introduction (The White House, 2021). Savulescu et al. (2021)have The emergence of coronavirus disease 2019 (COVID-19) considered the ethics of mandating vaccines in children; has resulted in substantial harm across the world, both as a however, the possibility of implementing a selective man- direct result of the disease and indirectly as a result of the date aimed at those at highest risk of severe COVID-19 has, socio-economic impacts of its change on behaviour and thus far, received little attention. In this paper I argue that policies used to achieve disease control. Several highly ef- it would be ethical to make the COVID-19 vaccination fective COVID-19 vaccines have been developed (Folegatti mandatory for those at highest risk of severe disease, but, et al.,2020; National Institutes of Health, 2020; Pfizer, while there is limited knowledge of the disease and vac- 2020) and roll-out of these vaccines is well underway in cines, there likely are not sufficient grounds to mandate many countries (Mathieu, 2021). Rapid resolution of the vaccination for those at lower risk if those at higher risk COVID-19 crisis is important, both for mitigating the dir- were protected. I offer several considerations for the po- ect harms of the disease and for allowing socio-economic tential role of selective mandate in COVID-19 vaccination recovery to begin. Therefore, a range of policy options to strategies and defend this proposal from two objections: achieve rapid vaccine uptake should be considered. With that any mandate risks worsening vaccine hesitancy and evidence of vaccine hesitancy in several jurisdictions, vol- that selective mandate is unjustly discriminatory. untary uptake alone may not lead to the vaccine coverage levels required for epidemic control. Indeed, a recent re- What Is Mandatory Vaccination and port has estimated the mortality impact of the pandemic to be eight times higher over two years in countries with When Should It Be Considered? higher vaccine hesitancy (Mesa et al.,2021). As such, the Mandates are a form of government coercion; that is, they option of making COVID-19 vaccination mandatory limit the autonomy of an individual to make a free per- requires consideration. sonal choice by threatening punishment for non- It has been suggested that a COVID-19 vaccine mandate is likely to be appropriate and legally enforceable in the compliance. The level of coercion can vary, from the im- USA (Reiss and Caplan, 2020), and vaccine mandates have position of bureaucratic hurdles to large fines, community doi:10.1093/phe/phab028 Advance Access publication on 15 December 2021 V C The Author(s) 2021. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 SELECTIVE MANDATORY VACCINATION FOR COVID-19 75 service, restriction on freedom of movement or, in extreme the first 12 months of the pandemic, in the UK, over cases, forced vaccination. Although the terms mandatory 100,000 people had died and had COVID-19 on their and compulsory are often used interchangeably, following death certificate (Public Health England, 2021) and Navin and Largent (2017), I will use mandatory to refer to modelling suggests unmitigated epidemic would result measures that do not involve the criminalization of refusal. in hundreds of thousands of deaths in the country Implementing a vaccine mandate makes it clear that (Ferguson et al., 2020; Ragonnet et al., 2020). Aside vaccination is not a personal choice, but rather some- from this direct mortality impact, many survivors will thing expected as a member of a population, similar to suffer significant morbidity, and an unmitigated epi- taxes (Giubilini, 2020). Mandates are generally aimed at demic would likely overwhelm health care services, jeop- those who are vaccine-hesitant rather than those who are ardizing health more broadly (Ferguson et al., 2020). At staunchly opposed to vaccination (Pierik, 2018). By gen- least in the UK and nations like it, COVID-19 does seem erating a social norm of vaccination, making vaccine to present a grave public health threat. refusal costly or inconvenient, and by providing assur- Vaccine development has been faster than many ini- ance that others are also making their contribution, tially predicted, and several vaccines were developed mandates can improve vaccine uptake rates. Several during 2020. Although some vaccines have been associ- studies in different settings have shown mandates to be ated with rare side effects (discussed further below), the effective in increasing vaccination uptake (Robbins et al., risks of the vaccines are low, and they have been author- 1981; Orenstein and Hinman, 1999; D’Ancona et al., ized for use in many countries and by the World Health 2019; Le ´ vy-Bruhl et al., 2019). Organization (2021). In many settings voluntary Mandatory vaccination exists in some form in most COVID-19 vaccine uptake has been high. Within the countries, most commonly for childhood vaccine pre- first 6 months of vaccine availability, the proportion ventable diseases (Gravagna et al., 2020). For childhood of people over the age of 65 who received at least one vaccines, mandates have taken the form of requiring dose of vaccine was>90% in the UK (Office for National vaccination for the receipt of some welfare benefits (in Statistics, 2021) and >85% in the USA (US Centers for Australia), attendance at state-run school or childcare Disease Control, 2021a) and several European countries centres (the USA and Italy). In adults, instances of man- (European Center for Disease Control, 2021). However, datory vaccines have included requiring health care vaccine uptake among high-risk groups has been much workers to receive certain vaccines in order to work slower in some locations, and this rate of uptake is im- with patients (Field, 2009). portant for minimizing the overall harms of the pan- The Nuffield Council on Bioethics’ 2007 report on demic. There is heterogeneity in uptake within ethical issues in public health suggests that when consid- countries, with uptake being well below average in ering whether directive vaccine policies are acceptable, some areas, leaving some communities vulnerable to on- the following should be taken into account: the serious- going outbreaks which may threaten local health care ness of the threat to the population, and the risks asso- systems. Indeed, in September 2021, 10 months after ciated with the disease and vaccination itself (Nuffield vaccines became available, some areas of the USA were Council on Bioethics, 2007). The report suggests that reported to be rationing health care due to COVID-19 ‘quasi-mandatory’ policies are more likely to be appro- surges (Boone, 2021). In October 2021, in 26% of US priate for diseases that are highly contagious and serious, counties, fewer than 70% of people aged 65 years and and diseases where eradication may be possible. More over had received at least one vaccine dose. In 10% of recently, Julian Savulescu has argued that mandatory counties fewer than 30% of this age group had received at vaccination may be permissible when four conditions least one vaccine dose (US Centers for Disease Control, are met: (i) that the disease is a grave public health threat, 2021b). (ii) that there is a safe and effective vaccine, (iii) manda- Slow vaccine uptake has seen several states in the USA tory vaccination has a superior cost/benefit profile com- implement incentives for vaccinations, such as cash or pared with other alternatives and (iv) the level of lotteries (Knutson, 2021). Strategies to increase vaccine coercion is proportionate (Savulescu, 2020). uptake are clearly needed, and may be even more im- portant for booster vaccinations. Given that the longer the COVID-19 pandemic continues, the greater the Mandatory Vaccination in COVID-19 harms caused, taking an approach of ‘waiting and seeing’ It seems relatively clear that COVID-19 poses a serious whether vaccines are taken up sufficiently rapidly volun- threat to the health of many countries’ populations. In tarily may carry significant costs. The potential health Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 76 WILLIAMS gains of a selective mandate provide a strong argument Although it is possible that new variants may, in the for consideration in policy. future, change the epidemiological features of COVID- One important feature of COVID-19 is the heterogen- 19, at this point in time there is no evidence to suggest eity in disease severity across population groups. While a that new variants have substantially changed the demo- variety of factors influence risk of severe COVID-19, the graphic patterns of disease severity or transmissibility greatest risk comes with older age (Williamson et al., (Lewis, 2021). Therefore, the following argument pro- 2020). The infection mortality ratio for SARS-CoV-2 ceeds with the assumptions that age is a particularly im- (the causative pathogen of COVID-19) is lowest in portant risk factor for disease severity and that there is no young children, with median estimates between 0.01% demographic group that is particularly important for and 0.001% for those aged 5–9 years (Brazeau et al., transmission. However, changes in these epidemiologic- 2021), but rises in a log-linear pattern among people al features, should they occur, will alter the applicability aged 30 years and over. For those aged over 80 it is of this argument. estimated to be 8.29% (O’Driscoll et al., 2020), although even in this group the risk continues to increase dramat- Optimizing Outcomes and ically with age, with one estimate putting the risk at around 5% for those aged 80–84 and 17% for those Removing the Grave Public 90 years and older (Brazeau et al., 2021). A modelling Health Threat analysis (Ragonnet et al., 2020) has suggested that if those at highest risk of disease could be effectively iso- One of the reasons to consider mandatory vaccination is lated, then even if infection were allowed to occur in the potential health and well-being gains it might pro- younger people, the mortality costs of the pandemic duce. Indeed, the Nuffield Council’s reference to the would be drastically reduced. Of course, this does not ‘seriousness of the threat to the population’ and take into account health impacts apart from mortality, Savulescu’s reference to ‘grave public health threat’ ap- but morbidity from COVID-19 is also higher among peal to the magnitude of health and well-being that is at older people, with long-term harms correlated with dis- risk without vaccination. ease severity, and long-covid also more likely among Ultimately, vaccinating the entire population against those who are older (Sudre et al., 2021). This heterogen- COVID-19 would best minimize direct COVID-19 mor- eity in risk of harm is relevant to discussions of manda- bidity and mortality. This would protect those who can- tory vaccination. It suggests that vaccinating this high- not be vaccinated, and better protect those at risk of risk subset of the population may cause disproportion- severe disease, as no vaccine is 100% effective. It would ate public health benefit and that the risk–benefit profile also protect the younger population. Although the mor- of vaccination will be different for different groups. As tality risk is relatively low for this group, it is not zero. such, it may be the case that mandatory vaccination is COVID-19 also poses health risks apart from death, only appropriate for high-risk age groups. including the harm of the acute illness, long-Covid, This paper explores the idea of selective mandatory and possibly unknown long-term effects. All else equal, vaccination in the setting of COVID-19. In future pan- it is better for everyone to avoid contracting COVID-19. demics the characteristics of the disease in the popula- However, time is crucially important in the COVID- tion may be different, and it may be different groups that 19 pandemic, and vaccines cannot be produced and dis- have higher risk of severe disease. For example, in the tributed to everyone immediately. Strategies need to take 1918 influenza pandemic it was younger adults (aged into account what will lead to the best outcomes given 25–40) who were at highest risk of severe disease the immediate constraints on vaccine distribution. (Liang et al., 2021). Rather than disease severity, trans- Modelling studies have suggested that in this condition missibility may be the key factor that varies among of scarcity, prioritizing the elderly for vaccination is groups. In previous influenza pandemics children have most likely to minimize COVID-19 mortality (Hogan been significant vectors for transmission, and it has been et al., 2020; Bubar et al., 2021; Moore et al., 2021). This argued that a COVID-19 vaccine mandate for children is unsurprising given that those aged over 65 account for may be permissible if it were the case that children are the majority of COVID-19 deaths: 92.5% in England particularly important vectors for transmission (Office for National Statistics, 2020). Choices around (Savulescu et al., 2021). The groups targeted by selective vaccination programs may be influenced by several dif- mandate may therefore be different depending on char- ferent values, including saving lives, saving life years, acteristics of the disease in a population. saving quality-adjusted life years, protecting the health Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 SELECTIVE MANDATORY VACCINATION FOR COVID-19 77 care system or restoring the normal functioning of soci- While the harm principle provides an effective basis for when it may be ethical to override a person’s auton- ety (Giubilini et al., 2021). It is therefore not clear that the goal of a vaccination program ought to be minimiz- omy, judgement is required to determine circumstances where this is proportionate. Many things we do pose a ing the number of deaths. However, it is likely that pro- tecting those most at risk of severe disease would risk of harming others, for example driving a car poses a risk to other motorists and pedestrians. So, it must be minimize the mortality burden in terms of both number of deaths and years of life lost. As this group is also the shown that the risk of harm is sufficiently high, and the cost of removing it proportionately low. Building on most likely to require health care resources, this would Flanigan’s analogy, Giubilini points out that when a also be likely to most effectively prevent the health care population is close to herd immunity for a particular system from being overwhelmed. This also suggests that disease, an individual failing to vaccinate only adds a the ‘grave public health threat’ would be substantially minor risk of harm to others. As he says, in such cases reduced, and possibly eliminated, if this group were pro- mandatory vaccination may be more like preventing tected with an efficacious vaccine. From a population someone from firing a gun when everyone is wearing health perspective ensuring rapid uptake of the vaccine bulletproof vests (Giubilini, 2020). In this instance, the in this group, and others at high risk, should be an im- argument from the harm principle is not as strong. In the mediate priority. case of COVID-19, if those at high risk were already vaccinated, then vaccinating people at low risk would Justifying Mandatory Vaccination: be like preventing them firing a gun whose bullets only harm a subset of the population, and that subset are The Harm Principle wearing bulletproof vests. If those at high risk from Even if mandatory vaccination were only considered for COVID-19 were all protected through vaccination, the those most at risk and who would clearly receive sub- argument that others remaining unvaccinated poses sig- stantial individual benefit from COVID-19 vaccination, nificant harm is weakened. a justification still needs to be provided as to why their On the other hand, the harm principle does support autonomy can be overridden. People often choose mandatory vaccination of those who are at high risk of options that may not seem to be best from them, and severe COVID-19. As mentioned, the indirect harms this freedom to choose is highly valued in many societies. caused by the COVID-19 epidemic are substantial, Here John Stuart Mill’s suggestion that the state can only both through disruption to health services and the lim- restrict a person’s liberty to prevent them from causing itations on public movement. Analyses have suggested harm to another (Mill, 2011) has been influential. substantial harms from disrupted cancer screening serv- Indeed, existing discussion of mandatory vaccination ices (Maringe et al., 2020) and from school disruption commonly appeals to this ‘harm principle’. Vaccination (Christakis et al., 2020), as well as mental illness exacer- not only protects the vaccinated individual but also pre- bated by lockdown measures (Pierce et al., 2020). In the vents them directly harming others by passing on infec- UK, population movement restrictions have been justi- tion, and indirectly harming others by unnecessarily fied by appealing to the need to save lives and protect the requiring health care resources. Giubilini and National Health Service (NHS). The same justification Savulescu (2019) liken the duty to vaccinate oneself to applies to vaccination, especially for those at risk of se- the duty to wear a seatbelt. In both cases the action vere disease that puts greater strain on the NHS. For prevents direct harm (to other vehicle occupants or to those at risk of severe disease, the harm principle sug- people to whom an infection may be transmitted), as gests that it is permissible to override their autonomy on well as indirect harm to other health care service users, the decision of whether to receive the COVID-19 vac- and this risk of harm overrides the individual’s auton- cine, as their risk of infection carries a risk of using health omy to choose the riskier option for themselves. care services unnecessarily, and prolonging socio- Similarly, Flanigan (2014) describes mandatory vaccin- economic disruption with its attendant health costs. ation as akin to forcibly preventing someone from firing In instances where one group is a particularly import- a gun into a crowd. She suggests that in the same way that ant vector for transmission then this increased risk of we think it is permissible to override a person’s auton- harming others (and thereby also indirectly contributing omy to prevent them from firing a gun and risking harm to health care systems becoming overwhelmed) would to others, we should consider it permissible to override be a relevant feature for considering the permissibility of autonomy to ensure people are vaccinated to prevent a vaccine mandate. The magnitude of the risk posed by them harming others. this group may be sufficient to implement a mandate, Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 78 WILLIAMS where it may not be warranted in others who pose a be an instance of paternalistic vaccination, as the deci- sion is made by someone other than the vaccinee and the lower risk of transmission. Thus far, no particular demo- graphic group has been identified to be particularly key vaccinee is the primary beneficiary of the vaccine. However, even though the vaccinee does receive a large transmitters of COVID-19, but it is possible that such a benefit from the vaccine, the reason to coerce them to group would be identified in the future. Mandating vac- vaccinate is actually to protect the interests of others by cination for this group may be justifiable given certain removing the public health threat and thereby prevent- conditions, but further ethical analysis would be ing the societal harms of an uncontrolled epidemic. So, required. this is either an instance of what Kraaijeveld calls indirect vaccination (where someone other than the vaccinee Fair Contribution to a Public Good makes the decision to vaccinate for the purpose of bring- ing about benefit to others), or the scenario may fall Another consideration of any public health policy op- outside the scope of Kraaijeveld’s framework. It is not tion is the implications for fairness. Giubilini (2020) paternalism, but rather contribution to the common suggests that mandatory vaccination to achieve herd im- good and prevention of indirect harms to others, that munity in childhood diseases may be justified by appeals is the motivation for the mandate. to fairness, rather than simply appealing to harms. By For most adults, a COVID-19 vaccine is very clearly in likening vaccination to taxation, he suggests that popu- their interests. Whatever small risks the vaccine may lation immunity is a public good and the measures taken have, these are vastly outweighed by the reduction of to reach this public good should be fairly distributed. In risk from COVID-19 that the vaccine provides. the case of COVID-19, given immediate vaccine scarcity However, at this relatively early stage of the vaccine’s the most important public good from vaccination is use, for some younger age groups, we cannot be so con- rapid epidemic control and removal of the grave public fident that the risk–benefit profile of the COVID-19 vac- health threat, rather than herd immunity. cine leads to vaccination being clearly in the individual’s Here again the heterogeneity in risk for COVID-19 clinical interest. This is highlighted by several countries has implications, as the risk–benefit profile of vaccin- introducing limits on the type of vaccine used in younger ation compared to the risk of the disease is different age groups (Gallagher, 2021; Olsen, 2021). Vaccines for different groups. It is less costly for those who are often can cause short-lived adverse effects such as fa- most at risk of COVID-19 to be vaccinated, as the risk– tigue, malaise and pain, but also carry a small risk of benefit profile of individual vaccination is more clearly more severe side effects, including anaphylaxis and other in favour of vaccination. For those at lower risk of severe complications. The phenomenon of vaccine-induced disease vaccination asks them to accept a less favourable immune thrombotic thrombocytopenia, and more re- risk–benefit profile. cently evidence suggesting a link between myocarditis in This difference in risk–benefit profiles is important, as younger males and some mRNA vaccines, has high- it affects the level of burden that an individual is being lighted how the risk–benefit profile of a vaccine can asked to take on as a contribution to the public good of vary depending on demographic features (Greinacher removing the public health threat of COVID-19. et al., 2021; Vogel, 2021; Winton Centre for Risk and Although for people at high risk of severe COVID-19 Evidence Communication, 2021). It has also highlighted vaccination is very clearly in their interests, the reason how vaccines (and other medical interventions) can have to implement a mandate is not to force people to protect unexpected risks that may not be detected in clinical themselves for their own sake, but rather is to reduce the trials. This highlights the importance of another feature risk of their illness contributing to overwhelming the that distinguishes COVID-19 from other vaccine pre- health care system and/or requiring prolonged ventable diseases—its novelty, and the uncertainty in population-movement restrictions. So even though disease and vaccine risk profile that entails. Studies they are the primary beneficiary of the vaccine, rather assessing childhood vaccines have not found evidence than being coerced to vaccinate for their own benefit, of long-term harms (Pittman et al., 2004), but there is they are being coerced to vaccinate for the public good. a risk that new vaccines may have unexpected harms. For Kraaijeveld (2020) has developed a framework for differ- example, a vaccine developed for the 2009 influenza pan- entiating types of vaccination based on who makes the demic was associated with a small risk of developing decision to vaccinate and who is the primary beneficiary narcolepsy in children (Miller et al., 2013). For most of the vaccine. On this framework, a COVID-19 vaccine vaccines there is a long history of use and substantial mandate for those at highest risk might initially seem to data monitoring for long-term harms, which allows us Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 SELECTIVE MANDATORY VACCINATION FOR COVID-19 79 to make confident statements on the nature of their risks, Folegatti et al., 2020; Pfizer, 2020). So current evidence such as this from the UK’s NHS: ‘vaccines get safety suggests that the elderly will have substantial protection tested for years before being introduced—they’re also from being vaccinated themselves. Although the role of monitored for any side effects’ (National Institutes of children in transmission remains an area of uncertainty, Health, 2020). This statement cannot be made for any the evidence that is available does not suggest that chil- COVID-19 vaccine. These possible risks of long-term dren are a particularly important vector for COVID-19 harm are also more important for younger people than transmission (Dattner et al., 2021; Munro and Faust, older people, as few safety trials have involved young 2020). Combined with the uncertain risk–benefit profile people (children and adolescents), and because the to low-risk individuals and the uncertain effect of young can expect to live longer to experience them if COVID-19 vaccination on transmission risk, it is less they do occur, and for their effects to affect a greater clear that the small level of additional protection for portion of their life. This inability to provide confidence the elderly arising from vaccinating low-risk people jus- in the risk–benefit profile, particularly for those at low tifies the infringement of autonomy and small risk im- risk from COVID-19, makes vaccination a comparative- position required by mandatory vaccination. ly greater cost to people at lower risk, especially younger It may also be argued that, although the clinical risk– people, than it does to older people at higher risk of benefit profile of vaccination may not be clearly favour- disease. able for younger people, the indirect benefits from the If it were the case that the most effective way to remove resolution of the COVID-19 crisis will tip the balance to the public health threat of a disease was to target those be clearly in favour of vaccination for younger people as who are most likely to transmit the disease, rather than well. Indeed, it might be suggested that younger people those most at risk of severe disease, then appealing to the stand to gain more from removing the public health idea of fair contribution to a public good will be more threat of COVID-19 than do older people, as they may complicated. Consideration of fairness may instead be a suffer more due to the pandemic’s socio-economic reason against pursuing that approach if it asks those effects, which will likely persist for many years into the who can contribute most to removing the public health future. Concern for fair contribution to a public good threat to take on an overly large burden. However, given might then suggest that younger people ought to take on modelling has consistently recommended vaccinating more of the burden of achieving epidemic control, even those who are most vulnerable to severe COVID-19 first, though their clinical risk–benefit profile is lower, as they in this situation efficiency and fairness coincide, and stand to gain more from this good. However, making consideration of fairness adds to the argument to this comparison of who stands to gain more from rapid mandate a vaccine for those at highest risk of resolution of the crisis is difficult. It could equally be severe COVID-19. argued that older people have a greater interest in achiev- In some instances it may be appropriate to ask people ing rapid resolution of the pandemic as they have fewer to accept an unfavourable risk–benefit profile for the years remaining, so it matters more to them how much purposes of protecting others. Previously it has been of the next few years are spent with restrictions. These argued that children should be vaccinated against influ- sorts of considerations also raise difficult and controver- enza for the primary purpose of protecting the elderly sial philosophical questions on the nature of personal (although in this case the risk–benefit profile clearly identity and how this persists through time. favours vaccination for children as well) (Bambery Considering the clinical risk–benefit profile of vaccin- et al., 2018). However, much of the strength of the argu- ation provides a clear idea of who is being asked to take ment rests on the vaccine not providing substantial pro- on what degree of risk. tection directly to the elderly, and children being an Furthermore, if, as the modelling suggests, the fastest especially important vector for transmission. It has path to resolving the crisis is through vaccinating those also been argued that should these conditions hold for at highest risk of severe disease, then we ought to take COVID-19, then it would likely be ethically acceptable to this path, which involves minimizing the number of vaccinate children against COVID-19 in order to protect people who are asked to accept a less clearly favourable older people, provided that the risk of vaccination is clinical vaccination risk–benefit profile. In a setting of sufficiently small (Giubilini et al., 2020; Savulescu global vaccine scarcity, removing the grave public health et al., 2021). However, we now have more information threat everywhere should be the immediate priority, ra- on COVID-19 and vaccines. The evidence suggests that ther than reaching herd immunity in a few settings. COVID-19 vaccines have comparable efficacy across age Globally, at least initially, COVID-19 vaccines are going groups, including older adults (Anderson et al., 2020; to be a scarce resource. So, if one country was in a Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 80 WILLIAMS position to procure a greater portion of the global vac- too carries risk that the payment will not be a sufficient incentive to achieve rapid uptake. Use of local data and cine stock for their population, a strategy that relies on larger quantities of vaccine will delay the access of an- community involvement may help to determine the role other country to the vaccine, costing lives there. This of a selective mandate in a vaccination plan, and the best suggests that achieving epidemic control through rapid option for implementation, to ensure fairness, effective- vaccination of those at highest risk, rather than waiting ness and respect for the population. It would also be for population immunity to develop through voluntary important to establish a compensation mechanism for vaccination is also a matter of global justice. those who suffered adverse events as a result of manda- tory vaccination (Savulescu et al., 2021). Proportionality and Considerations Objections for Policy I have thus far argued that mandatory COVID-19 vac- I have thus far argued that a selective mandate could be cination for those at high risk of severe disease may result an ethical policy choice. However, the form of the man- in substantial welfare gains and is justified by the harm date would need to maintain respect for, and limit the principle and the value of fairness. However, it could be burden imposed on, the individual, and prevent argued that mandating vaccines risks strengthening anti- population-level harms from the mandate itself. The vaccine sentiments, and that selective vaccination is dis- costs imposed by the mandate should act as sufficient criminatory. I will respond to these objections now. disincentive to non-compliance, so that vaccination for these groups is seen as something expected, rather than Does Mandatory Vaccination Risk Strengthening an option that is the decision of the individual alone. The the Anti-Vaccine Movement? form of the mandate, and the level of coercion involved, needs to be proportionate. It has been suggested that mandatory vaccination carries As mentioned, mandatory vaccination does not imply risks of undermining public trust in vaccines (Omer criminalization of vaccine refusal (Navin and Largent, et al., 2019). Given the high profile of the COVID-19 2017) but may involve other measures like fines, com- vaccine, any adverse events in vaccine recipients are like- munity service or movement restrictions. For example, ly to be highly publicized. As vaccines do carry small people at high-risk of COVID-19 who refuse vaccination risks, there will be (and have already been) cases of ser- could be required to remain in isolation (or otherwise ious adverse events. Furthermore, it is also likely that have their freedom of movement restricted) until epi- there will be instances of people suffering an acute health demic control is achieved, to reduce their risk in another emergency shortly after receiving the vaccine, and even if way. If there were concerns that even this level of cost this is not due to the vaccine, it will be difficult to sep- would unduly burden some people (for example resi- arate the events in the eyes of a sceptical public. dents of nursing homes who are often already deprived On the background of this scrutiny, mandated vac- of social contact), then exemptions could be included. cination may have the potential to further undermine Alternatively, the cost of non-compliance could be public confidence in vaccines. However, the risk seems reduced even further, so that the mandate only created lower if vaccination were only mandated in those at a minor inconvenience (e.g. completing and submitting highest risk. The most outrage-inducing scenario would forms for exemptions). The purpose of the mandate is to be a young person, at low risk of COVID-19, who suffers, make non-compliance costly, so that more of those who or appears to suffer, an adverse event due to a mandated are hesitant end up being vaccinated, rather than enforc- vaccine. If an older person at higher risk of COVID-19 ing compliance among the entire population. However, were to suffer an unexpected adverse event it would still reducing the cost, or increasing the number of people be tragic, but a mandate would be more easily justified who are exempt, would reduce the effectiveness of the due to their higher ex-ante risk of COVID-19. If an eld- mandate. A choice would need to be made on how to erly person were to suffer an unrelated health event soon trade off effectiveness with a level of cost that seems pro- after their vaccination, it would also be less likely to be portionate and unlikely to cause excessive harms. mistakenly attributed to the vaccine, as such events are Alternatives should also be considered, including a not as unexpected in older age. payment model, which has been suggested by The risk of undermining public confidence in vaccines Savulescu (2020). This may be a better option in some needs to be balanced against the harm of a longer settings. However, like the ‘wait and see’ approach, this COVID-19 pandemic. Mandatory vaccination of only Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 SELECTIVE MANDATORY VACCINATION FOR COVID-19 81 those at highest risk of severe disease seems to strike the raise further important ethical problems than have been right balance between these two risks: avoiding the risk considered here, and may lead to important negative of the most outrage-inducing scenario, while also pro- consequences such as heightening racism in medicine, viding the majority of the public health benefit of rapid reducing trust in medical institutions, increasing racial vaccine uptake. tensions and augmenting inequalities. Introducing man- dates on the basis of race would also be practically diffi- cult, given the variation in racial identities that exist. Is a Selective Mandate Discriminatory? Although ageism exists in society, a mandate based on It may be argued that the selective mandate I have pro- age would be less fraught with social tensions. There are posed constitutes unjust discrimination on the basis of many precedent examples of selective public health age. However, as Savulescu and Cameron (2020) have measures based on age; most vaccine schedules are based argued, risk of severe disease, which in the case of on age, as are many screening interventions such as COVID-19 correlates with age, is a morally relevant fac- breast or bowel cancer screening. Furthermore, ageing tor in health policy. To discriminate on the basis of a is a universal experience, so although birth cohorts can morally irrelevant factor would be unjust. But discrim- be distinguished, all of us (unless we die prematurely) inating on the basis of a factor that has significant impli- will experience ageing, meaning that measures based on cations for the public health utility of the measure, as age involve less inequality when considering the course well as the individual’s own capacity to benefit, is not of a life. A mandate using age would also be practically unjust. To borrow an example from Savulescu and easier, given the clear availability of age data in most Cameron, offering breast cancer screening to women settings. and not men doesn’t constitute unjust discrimination on the basis of sex, as women are much more likely to benefit from breast cancer screening. Conclusion More recently, Cameron et al. (2021) have argued that Rapid uptake of a safe and effective COVID-19 vaccine selective liberty restrictions may be appropriate when in those at highest risk of severe disease will be important such restrictions would bring benefits for both the popu- to mitigating the impact of the pandemic. Although vac- lation and the individual, are designed to protect those cination is likely to be in the interests of most people, most at risk of disease, and are no more than is necessary. making a vaccine mandatory involves impositions on They also specify that differences that arise due to social autonomy which need to be justified. The infringement disadvantage itself ought not to be the basis for discrim- of autonomy of those at high risk of severe COVID-19 is inatory health measures. This is designed to promote justified on grounds of the harm principle and also pro- respect for, and protect the interests of, the individual motes fairness. However, if those at high risk were pro- as well as promote the interests of the population. tected, there is little grounds to justify mandating In the case of COVID-19, as well as age, race has also vaccination for those at lower risk of severe COVID- been correlated with disease severity (Sze et al., 2020). 19, particularly in the early stages of vaccine use. For example, in the USA, Black and Hispanic ethnicity Although a selective mandate may be an ethical choice, has been associated with substantially greater risk of the form of the mandate would need to be proportionate death from COVID-19 (Ford et al., 2020). However, and avoid being overly costly for individuals or worsen- there is evidence that the discrepancies are largely due ing inequality. Imposition or prolongation of movement to social disadvantage, rather than race per se, as in some restrictions may be an appropriate measure. Whether a analyses, when discrepancies in access to health care and selective mandate should form part of a COVID-19 vac- social disadvantage are taken into account there is no cination plan, and if so, the form that it takes, is a larger significant difference in mortality outcomes due to race (Iacobucci, 2020; Lopez et al., 2021). In this case a question that may have different answers depending on mandate on the basis of race would be roughly approx- context. A mandate alone is unlikely to be the best ap- proach, with attention needing to be paid to communi- imating a mandate on the basis of social disadvantage, which generates new ethical problems. Even if race were cation strategies, and identifying and eliminating an independent contributor to risk, there are other rea- barriers to vaccine uptake. However, based on current evidence of disease risk and transmission, a selective sons why a selective mandate on the basis of race would be ethically problematic. On a background of historic mandate for the COVID-19 vaccine on the basis of age and ongoing racism in medicine (Nuriddin et al., is likely to be ethically justifiable and, in the face of real 2020), mandating vaccination on the basis of race would and important harms from vaccine hesitancy, Downloaded from https://academic.oup.com/phe/article/15/1/74/6462569 by DeepDyve user on 19 July 2022 82 WILLIAMS policymakers should give careful thought to the role it Infection Fatality Ratio: Estimates from Seroprevalence, available from: https://doi.org/10. may play in vaccination strategies. 25561/83545 [accessed 7 June 2021]. Bubar, K. M., Reinholt, K., Kissler, S. M., Lipsitch, M., Acknowledgements Cobey, S., Grad, Y. H., and Larremore, D. B. (2021). I am grateful to Julian Savulescu, Kwamina Orleans- Model-Informed COVID-19 Vaccine Prioritization Pobee, two anonymous reviewers, and an associate edi- Strategies by Age and Serostatus. Science, 371, tor of Public Health Ethics whose feedback greatly 916–921. improved this paper. Cameron, J., Williams, B., Ragonnet, R., Marais, B., Trauer, J., and Savulescu, J. (2021). Ethics of Selective Restriction of Liberty in a Pandemic. Funding Journal of Medical Ethics, 47, 553–562. Christakis, D. A., Van Cleve, W., and Zimmerman, F. J. No specific grant was received for this research. BW (2020). Estimation of US Children’s Educational receives funding from the Forethought Foundation for Attainment and Years of Life Lost Associated with Global Priorities Research to support her graduate Primary School Closures during the Coronavirus studies. Disease 2019 Pandemic. JAMA Network Open, 3, e2028786. Conflict of Interest D’Ancona, F., D’Amario, C., Maraglino, F., Rezza, G., and Iannazzo, S. (2019). The Law on Compulsory None declared. Vaccination in Italy: An Update 2 Years after the Introduction. 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Public Health Ethics – Oxford University Press

Published: Jun 11, 2022

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