Prof Effy Vayena, Health Ethics and Policy Lab, Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland.
Dr Ezekiel J. Emanuel, Vice Provost for Global Initiatives, Co-Director, Healthcare Transformation Institute, Levy University Professor, Perelman School of Medicine and The Wharton School, University of Pennsylvania, Philadelphia, USA
Dr Christiane Druml, UNESCO Chair on Bioethics at the Medical University of Vienna, Ethics, Collections and History of Medicine, Medical University of Vienna, 1090, Vienna, Austria
Mr Allan Achesa Maleche, Executive Director, KELIN, Kenya
Vaccines are one of the most effective tools for protecting people against COVID-19. Consequently, some governments and institutions have made COVID-19 vaccination ‘mandatory’ to increase vaccination rates and achieve public health goals, and others may be considering doing the same. Yet, given the rapidly evolving nature of the COVID-19 pandemic and evolving evidence regarding the effectiveness of COVID-19 vaccines against novel variants of concern (e.g., Omicron), the number of doses necessary to achieve public health objectives, and durability of protection, the scientific and ethical justification for mandatory vaccination for COVID-19 is similarly shifting and may be waning. This seminar took stock of where countries find themselves with respect to the pandemic and explored this present context for evaluating the ethics of mandatory COVID-19 vaccination.
Dr Ezekiel Emanuel began the discussion by arguing that societies introduce mandates in relation to valid and valuable social goals. If voluntary compliance is unattainable, and other mechanisms have not worked, then mandates are a last-resort, and a method by which we can get a large enough proportion of the population to do something in relation to that goal. Dr Emanuel notes that society already uses mandates; for example, driving licenses, seatbelts, and car inspections are all mandatory if individuals want to drive. However, what constitutes a valuable social goal? Dr Emanuel argued that it is goal which protects the individual, society, or both. In regard to mandatory COVID-19 vaccinations, the valid social goal in this case is to limit individual sickness and hospitalisations, and limit the harm to others caused which may arise through school closures, or staff absences in key industries like healthcare. Dr Emanuel argued mandatory vaccination for COVID-19 is valid even if it doesn’t reduce transmission, but does prevent hospitalisation and death. He challenged the idea that vaccination mandates are new citing the fact that in a large number of countries children have to be vaccinated against various diseases which protect both them, and in many cases other people. Vaccination mandates work: To give an example, the influenza vaccines aren’t mandated, and therefore voluntary uptake is limited to two thirds of children and around 45% of adults. This is insufficient and the result is that there are around 30,000 to 75,000 unnecessary deaths from influenza each year. This figure would reduce if mandatory vaccinations were introduced. Dr Emanuel also confronted two accusations commonly levelled at mandatory vaccinations. The first is that it is a violation of individual liberty. However, the notion you can do whatever you want with your body even if it endangers the life, liberty or peace of someone else is simply untrue. We grant individual liberty, but this is not unlimited. Drawing on John Locke he said we must distinguish a state of liberty from a state of licentiousness; the latter of which exists in a state of nature, and leaves no room for governance. Liberty on the other hand is a system of order where individual limitations ensure others can be safe in possessions and health. The second is that this vaccination is coercive. Dr Emanuel said this is false, because coercion always means you will be worse off. However, in the case of a vaccine you are actually better off; vaccinations prevent severe illness, hospitalisation and death, while not being vaccinated is more likely to lead to the opposite.
Dr Christiane Druml followed up on this, arguing a pandemic isn’t a private matter. However, the precise formula that should be used to judge the value and validity of vaccine mandates must be proportionality. The more harmless an intervention is for the individual, the more dangerous a disease is for the health of the population, and the greater the benefit vaccination will give, the more the intervention will be justified. In this case, COVID-19 is a severe disease for some people, while COVID-19 vaccinations are safe and effective for virtually everyone, meaning mandates can be justified. In relation to COVID-19, she said the question of mandates was brought up even before the vaccines were developed, and so too the question of prioritisation. At that time, the Austrian National Bioethics Commission prioritised healthcare personnel on the basis they are responsible for the health of others. And, on that basis, those who are prioritised first, should have a professional and moral obligation to be protect themselves and others now; particularly those who are vulnerable, and in some cases can’t be vaccinated. Dr Druml reflected on the fact many people would argue COVID-19 vaccinations are new, however 7billion people have now been vaccinated, and we know they prevent serious disease, hospitalisation and death. The ethical justification for mandates is therefore taken in the present context and the wider scientific evidence which emerges in scientific peer-reviewed journals. Dr Druml concluded by arguing that while the future course of the pandemic is unknown, population immunity, is the way in which the pandemic will end. For this reason mandatory COVID-19 vaccinations can be justified.
Mr Allan Achesa Maleche took a contrary approach to Dr Emanuel and Dr Druml. He argued that while it is undeniable that vaccinations are the most valuable tool we have in fighting against COVID-19, even in the context of pandemics, we don’t suspend human rights. Mr Maleche argued the concerns about mandatory COVID-19 vaccination stems from the tension between public health and individual bodily autonomy. Now, you can have mandates in law, but you also have to justify why they are needed. In the case of COVID-19 we want to protect individuals from severe disease. However, does mandating vaccines get us closer to the end goal of getting people vaccinated? In this case, there is not enough evidence to say either way. Mr Maleche reflected on vaccine hesitancy and vaccine inequity, suggesting that the fact that only 25% of Kenyans for instance, have been vaccinated, is not necessarily because of reluctance but the inequalities present from the beginning. Should we be setting targets to vaccinate the world, when the underlying inequity remains? Other barriers include age, social status, language, and documentation. If we are unable to convey adequate information about vaccinations, vaccination side effects, and finally what treatments are available if side-effects emerge then of course there will be hesitancy. Furthermore, the process by which vaccines are actually mandated needs to be aligned to individual countries, while still operating within a global framework. Resistance is going to be expected particularly if citizens haven’t been able to share their views in civil society forums. This is therefore, a legal, human rights, and ethical issue. The best way to increase uptake is via trust, while also tackling vaccine inequity. We’ve learnt from the HIV/AIDS pandemic that communities need to be involved, and so while it’s a tough balancing act, we need to draw the line between bodily autonomy and public health; and for this you need a legal framework.
The panel then opened up to discussion, with Professor Vayena, posing two questions. Firstly, in regard to the widespread absence of trust, does enforcement bring us forward in terms of trust and addressing our social goals? Secondly, the measure of proportionality, in the case of COVID-19 is related to whether the intervention is proportional to the problem, and the way in which we intervene. However, what does that mean in reality?
Dr Druml reflected on the issue of trust arguing the proliferation of fake news through unregulated social media channels has made it difficult for the state to counter misinformation, but that we must do so anyway. Furthermore, COVID-19 has already been politicised, and the debate has moved from public health to politics with very negative results. In this context, it is not enforcement, but voluntarism which is the problem, because the latter fosters doubt. Essentially, if the vaccination health benefits were true, why would it not be required? Mr Maleche argued trust is the prerequisite for any public health campaign or measure. To create this, governments must provide accessible, real-time information which is tailored to the needs of specific communities. From his perspective, the concerns around COVID-19 vaccination must be addressed first, before society attaining adherence. Furthermore, the rush to mandates, which often places restrictions on freedom based on vaccination status, is a borderline violation of an individual’s human rights. The question then, is what do we need to do in order to build trust from the beginning in order to get people to comply? You can’t win people over with threats, but you can provide contextually-specific information to affected communities on a local level, while also increasing vaccine accessibility. Dr Emanuel challenged this argument, stating that unequal distribution is not a justification or explanation as to why there is vaccine hesitancy. Furthermore, it is not mandates which has undermined trust but misinformation promulgated through social media, and in this context, and the context of a pandemic, we simply don’t have time to build trust in the manner in which we would like.
Professor Vayena, also asked in terms of justification of vaccine mandates is there a difference between now, and the summer of 2021?
Christiane Druml again argued that the proliferation of fake news is continuing to polarise societies, and harm our understanding of the pandemic. She was pessimistic about solving some of the problems discussed, but was hopeful, COVID-19 would continue to decrease in severity, which would inevitably mean public health measures would be lifted. Mr Maleche argued mandates should be the last option rather than the first, and if they are implemented have the least restrictions. Unfortunately, governments have taken it as the first option; and therefore failed in their overarching public health objective. To increase uptake, governments must work with communities building trust, and providing accurate information to counter social media. While we are in a hurry to get rid of the pandemic we are not understanding why people are hesitant, meaning the pandemic is more likely to continue. Dr Emanuel agreed with Mr Maleche, arguing that mandates should be a last option; and to that extent removing barriers to vaccine accessibility is a priority. However, false information, travels faster than true information; we urgently need to address this, but also shape public health measures accordingly.