Should a Covid-19 Vaccine Be Mandatory?

In August 2020, Australia’s Prime Minister was asked whether any future coronavirus vaccine would be made mandatory. His reply was “I would expect it to be as mandatory as you can possibly make it”, with exemptions on medical grounds only. After drawing considerable attention, these comments were quickly walked back by the Prime Minister and other senior members of government, all seeking to reassure that a vaccine would not be made “compulsory” after all. Instead, the government would rely on “a lot of encouragement and measures to get as high a rate of acceptance as usual”, citing Australia as having “one of the best records in the world of getting high rates of immunisation”.

Offhand, it is not immediately obvious why the Prime Minister should have backtracked. One powerful intuition is that coercion, particularly of adults by their government, is likely to violate individual rights. On the other hand, it may be that a very high uptake of the vaccine is needed to secure herd immunity. This is the case with some existing vaccines, such as the 95% uptake needed to generate herd immunity against measles, though current estimates place the threshold for immunity to COVID-19 at lower levels. And for some existing vaccines, many governments do in fact follow a policy of mandatory uptake. In an era of fake news, conspiracy theories, and influential ‘anti-vaxxer’ movements, the prospect of very high voluntary uptake is by no means guaranteed. All of this may seem to count somewhat in favour of the Prime Minister’s initial position.

We might first wonder exactly what is meant by “as mandatory as you can make it”. Really there are a range of different ways in which governments can use their powers to get citizens to do things, including receive a vaccine. The most radical approach would be to make it a crime to not get vaccinated, backed by a threat of legal punishment. Some countries have gone so far as to issue fines to citizens found to have failed to get vaccinated against certain diseases. A more moderate approach, typically preferred by governments where existing vaccines are concerned, is to withhold certain benefits until evidence of vaccination can be provided. For example, a condition of getting one’s child placed in a state childcare facility in Australia is to provide evidence that they have been immunised against the various diseases for which there are established vaccines.

In the literature on vaccine ethics, it is customary to talk of ‘coercive’ vaccine policy when the approach is of the more radical punitive sort. The term ‘mandatory’ is often used to refer to the more moderate practice of withholding benefits, though this still counts as coercion insofar as it involves the government attaching credible threats to vaccine refusal. (In saying “there are no compulsory vaccines in Australia” the Prime Minister’s remarks avoided explicitly ruling out this weaker approach.) Whether a radical or moderate approach is justified in the case of a COVID vaccine depends partly on what the status quo is like in the country in question, particularly the impact of the pandemic and the efforts being put in place to address it until a vaccine becomes available. The fact that we are dealing with the most lethal pandemic in living memory would seem to count in favour of taking seriously proposals that might normally be rejected.

[I]f we think there is a moral problem with government coercion, we may think that coercing people to accept a vaccine is in fact the lesser evil compared to the status quo.

While the pandemic is tremendously serious in terms of the lives it has taken (not to mention the lives it is still yet to take), so too are measures being used by governments to address it. The pandemic has triggered a slew of coercive policies already, which in many countries are at a level of severity not seen since the second world war. Governments have taken such steps as commanding shutdowns of entire industries, restricting mass gatherings – including very personally significant ones like weddings and funerals – postponing medical treatment for non-pandemic conditions, imposing quarantines and curfews, sealing international borders and have even prevented people from leaving their own towns or neighbourhoods. On any plausible view about how to measure the severity of state coercion, a mandatory vaccine surely makes for a weaker instance of coercion than the sort of things just mentioned, even in cases where governments have only pursued some of the measures listed. So, if we think there is a moral problem with government coercion, we may think that coercing people to accept a vaccine is in fact the lesser evil compared to the status quo. And this may be true without even taking into account the benefits of removing the disease.

The permissibility of coercive policies depends not just on whatever measure can be taken of their ‘overall’ severity, but also on how they distribute burdens across a population. It is worth noting that state coercion tends to be less morally controversial when the benefits it delivers are guaranteed, immediate and evenly distributed. This is often true for coercive solutions to coordination problems, like laws instructing us to drive on the left or right side of the road. Even though the punishments for breaking traffic laws can be harsh and there is room for disagreement about what’s proportionate, it is almost unheard of for anyone to suggest that the state has no business making and enforcing such laws. Certainly nobody would suggest that the government should aim to back off from using coercion in favour of relying on ‘voluntary’ compliance with a law to drive on the left side of the road.

It is clear that the various coercive policies used to combat the pandemic have costs that are unequally distributed, and which often exacerbate prior inequalities. The white collar worker whose industry can operate with staff working from home is in a much superior position to the minimum-wage hospitality worker reliant on causal contracts whose industry has been effectively shut down for the foreseeable future. Those who have suddenly had to educate their children at home while schools are closed have been burdened in ways that those without school-aged children have not. While help may be given to citizens in their home countries, other citizens are left stranded overseas, often with no help from the government of their host country, with the best option being an enormously expensive ticket for one of the few flights home. So long as there is no vaccine and governments have to pursue policies that maintain social distancing, such inequalities will likely continue. But a vaccine is not really like this. Assuming it is safe, the costs of uptake are more or less the same for everyone. Even if coercion is used, a requirement to accept a vaccine may be much like a requirement to obey traffic laws in terms of its minimal tendency to generate an unequal distribution of burdens.

It is clear that the various coercive policies used to combat the pandemic have costs that are unequally distributed, and which often exacerbate prior inequalities.

So, it may seem like a mandatory (or coercive) vaccine is both less coercive and more equally coercive than the coercion from which it actually provides relief. But of course this only establishes, at most, that it may be relatively easy to justify forcing people to take a vaccine if this is necessary. If people could be induced to take the vaccine in sufficient numbers voluntarily, then the same benefits would be secured as if people had been forced to do so. The fact that the vaccine provides a way out of the large and unequally distributed burdens of the pandemic may seem not to count in favour of making it mandatory at all.

Even if voluntary uptake is sufficient to secure herd immunity, then there might still be a moral problem with the fact that there’s been no coercion. The fact remains that, while herd immunity has been produced (thanks to a sufficient number of volunteers), there are some who will then consume the benefits of this immunity having refused to contribute to its production. This may be unjust in the way that free-riding on the production of other public goods is unjust. Philosopher Alberto Giubilini (2020), for example, likens refusal to take a vaccine as akin to tax evasion, which is indeed a criminal offence in most countries. Such considerations show that there might still be an ethical case for coercive vaccination even if it is not strictly necessary to achieve herd immunity.

It may be that the case for mandatory vaccination is stronger in some countries than others. The Australian Prime Minister leads a country that is fortunate enough to currently enjoy near-zero community transmission of COVID-19 (though his remarks in favour of mandatory vaccination were made when parts of Australia were still struggling to bring community transmission under control). While there are still measures that need to be in place to maintain these conditions, not least closed international borders, other restrictions have been much relaxed in Australia, and are now far less severe than the measures that other country’s governments need to use. While the situation could easily change and community outbreaks are likely to happen between now and the vaccine’s arrival, the current low levels of transmission mean a vaccine is basically less urgent than in other countries. This lack of urgency may be a moral reason to at least begin with voluntary uptake and see how it goes.

It goes without saying that rapid vaccine uptake could prevent tens of thousands of deaths, plus the considerable suffering associated with non-fatal cases, in many countries, including ones where a mandatory vaccination program might seem quite feasible. What factors might decide whether the approach taken should be based on the withholding of benefits, or on the more radically coercive model of actually attaching material punishment to refusals to take the vaccine? In part, the answer depends on where the threshold for herd immunity lies, and whether the effectiveness of the early vaccines is long-lasting. These facts, particularly the latter, will become better known over time. It is also possible that the early vaccines will be superseded by later vaccines that are better performers, not just in terms of effectiveness but also ease of distribution and storage. When this happens, herd immunity might be easier to generate and maintain. But such improvements may be some way off.

But a high level of urgency does not put the case for mandatory vaccination beyond dispute. One of the popular rejoinders to mandatory programs is that they breed distrust and resentment within the population. In part this is a claim about feasibility – distrust and resentment might induce a level of civic resistance that the state finds it can’t overpower and herd immunity can’t be secured. But it is also a claim, perhaps, about the longer-term social cost to a society that feels unhappy about how it has been treated by its government. On any interpretation, predictions about the civic reaction to coercive policies involve empirical claims not really amenable to philosophical analysis. Levels of (dis)trust in government may in any case be somewhat pre-established factors, which might not be changed much by how the government seeks to promote vaccine uptake. Indeed, a tradition of mandatory vaccination in Australia seems correlated with relatively high levels of public compliance, and trust in government at least where public health is concerned. Such attitudes seem to have held up during the pandemic and may help account for why Australia is now in such a good position. It’s unclear why a mandatory COVID-19 vaccine would jeopardise this.

If a mandatory approach is indeed what it takes to generate herd immunity in the shortest time possible, then it is likely on balance to be justified in countries where great costs must be absorbed by certain individuals in the meantime.

There remains the question of which sorts of benefits should be withheld. Since the goal is to vaccinate the adult population, withholding access to childcare will not be enough. It is possible that the private sector will be happy to cooperate. Airlines and hotels might refuse to issue bookings to customers who cannot upload evidence of having been vaccinated. Even if not legally required, such measures may make good business sense if it is what the majority of customers welcome. But the range of possibilities that exist may also indicate that it is easier to enforce a ‘merely’ mandatory approach based on withholding benefits, than the more aggressive ‘coercive’ alternative on which the government must find a way to actually track down and punish those who have not received a vaccine.

I have tried to convey a brief impression of the various considerations that bear for and against a program of mandatory versus voluntary vaccination. There is much that must be weighed up. The answer may vary according to the circumstances that a country is in, both regarding how badly impacted it has been by the pandemic, and how its population tends to respond to being coerced. With these variations in mind, let me offer what I take to be a plausible (if qualified) general conclusion.

Many governments are currently telling subsets of their populations that they need to absorb the cost of lost earnings while their industry is suspended for the sake of social distancing, or that they cannot visit a family member in aged care, or that their hip replacement operation will be postponed for some indefinite period, or that they must remain stranded overseas. These are large burdens, and ones that many other members of the population simply don’t have to absorb, and which are sometimes easily forgotten. Given this, a large burden of justification attaches to any claim that it is morally wrong for the government to require all members of its population to absorb the small and more or less equal cost of receiving a vaccination, so that these other burdens can be lifted as soon as possible. If a mandatory approach is indeed what it takes to generate herd immunity in the shortest time possible, then it is likely on balance to be justified in countries where great costs must be absorbed by certain individuals in the meantime.

References

Giubilini, Alberto (2020) “An Argument for Compulsory Vaccination: The Taxation Analogy” Journal of Applied Philosophy 37(3): 446-466.

Disclaimer: Any views or opinions expressed on The Public Ethics Blog are solely those of the post author(s) and not The Stockholm Centre for the Ethics of War and Peace, Stockholm University, the Wallenberg Foundation, or the staff of those organisations.