In 2019, the World Health Organisation named vaccine hesitancy as one of the top ten gravest threats to global health. With well over two million deaths due to COVID-19, the question of mandatory vaccination is increasingly being discussed.
Evidence of the effectiveness and safety of vaccinations is resounding. Public Health England (PHE) estimates that the measles vaccine has prevented 20 million cases of measles and saved 4,500 lives. In terms of improving global public health, vaccination is second only to clean drinking water.
And yet, research published recently by the London Assembly Health Committee has found that one in four Londoners are ‘Unlikely to’ or ‘Definitely won’t’ get a COVID-19 vaccine.
People refuse to be vaccinated for a wide variety of reasons. These include a distrust of drug companies and the government, medical and religious reasons, inclination towards believing incorrect information about the safety of vaccines (such as the Wakefield study linking the MMR vaccine to autism), or the belief herd immunity will be achieved without them having to take on the small risks of vaccination.
Undoubtedly, it would be a safer and healthier world if everyone agreed to be vaccinated. However, the ethical implications concerning mandatory vaccination are numerous and notoriously difficult to resolve. There is a complex interaction and conflict between four ethical principles: autonomy, utilitarianism, the harm principle and preventing harm to individuals.
Autonomy is the capacity to make choices that are consistent with one’s values and goals.
Ensuring everyone has autonomy is often at the heart of any ethical discussion that strives to be anti-paternalistic. However, there are hundreds of laws that restrict our autonomy in society and dictate what we can and cannot do. The key ethical consideration is deciding when it is permissible to infringe on our liberty.
J S Mill argued in On Liberty that ‘the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient warrant.’
Many take Mill’s argument to be the basis of deciding when it is permissible to restrict autonomy: when your choices will harm another person. This has come to be known as the harm principle and is used to justify various infectious disease control interventions – including vaccinations.
When herd immunity is reached, vaccines protect not only those who are vaccinated, but also those who cannot be vaccinated. Thus, when parents choose not to vaccinate their children, it puts the most vulnerable in the community at increased risk of contracting diseases. Vaccine refusal therefore risks harming innocent bystanders.
Dr Jessica Flangian has argued that compulsory vaccination is justified just as other kinds of harmful conduct are rightly prohibited. She compares not getting vaccinated to someone sitting on their porch and randomly firing their gun in the air. We want to say that this is wrong because the bullet could land on someone, but the shooter could equally say that it is their house, their gun and their right to do what they please. Flanigan argues that someone who refuses to be vaccinated is like the person firing the gun, rendering the issue not of a paternalistic nature, but a question of harming others.
There have been various rebuttals to Flanigan’s argument. Anti-vaxxers often claim they are not intending to harm anyone – but can you be culpable without intention? To not get vaccinated is not an action, it is failure to act. Surely, then, the distinction between allowing and doing matters? Furthermore, the risk to the community due to not getting vaccinated is very small. So do we really want to say it is the same as harming someone else?
There are other considerations to take into account, particularly from a utilitarian perspective.
Utilitarianism is based on the ideology that actions are “right” to the extent that they produce the best consequences for the greatest number of people. Utilitarianism and the promotion of public health provide an ethical justification for vaccine mandates: even if mandates do infringe upon liberty, they undoubtedly make us (as a community) better off than we otherwise would be in their absence.
Often, the number of people who refuse to get vaccinated is small enough that herd immunity can still be achieved.
Whilst this may not seem to be a problem, there are still ethical concerns with this situation as it seems to be an instance of free-riding. It seems unfair that those who choose not to be vaccinated still enjoy the benefits of an immunised society, without having taken on any of the risks (albeit very small) that vaccinated people have done. Preventing free-riding as an argument to justify compulsory vaccination complicates the anti-paternalism picture, because it suggests a second reason to interfere with individuals’ choices.
Even if we were to reach the conclusion that preventing harm to others and making society fairer justifies interference with liberty, we must consider when there are exemptions to be made.
Opting out is justified if compliance is expected to cause harm or illness to the individual, such as when an immune-compromised person is at genuine risk of becoming ill following vaccination.
However, the reality is that many opt out of vaccination when there is no risk to them or their children. This is partly due to poor communication among public bodies: websites such as the US National Vaccine Information Center claim that vaccines cause great harm, despite the American Academy of Paediatricians, the American Medical Association and the American Public Health Association expressing support of vaccination programs.
Is it justified to override someone’s decision because they have been misled? Should we make exemptions for religious or moral beliefs? What counts as a truly justified exemption?
Ultimately, ethical contention boils down to scientific evidence in favour of vaccination existing in conflict with a strong, anti-paternalistic reluctance to restrict our autonomy. There seems to be something particularly troubling to us as a society with compulsory medical intervention.
It is unlikely that there will ever be mandatory vaccination, as it is a foundational principle of medical ethics that consent must be given for any procedure. The decision to make vaccination mandatory is therefore a decision to impose some form of penalty on those who do not vaccinate either themselves or their children, as has been enforced in other countries for some years.
A common such penalty is to exclude unvaccinated children from schools. This has been the case in the United States since 1980, and has proven effective: between 2013 and 2017 the proportion of unvaccinated children attending kindergarten in California halved. Australia, France and Italy have taken similar action since.
Australia also introduced legislation in 2015 that withholds financial child support from the parents of unvaccinated children without medical exemptions. This ‘No Jab, No Pay’ legislation coincided with full immunization rates rising by around 3%.
However, there are drawbacks to these mandates. Many argue that punitive mandates lead to disadvantaged groups bearing the brunt of social and financial penalties. In Australia, for example, mandates aimed to target the middle class demographic who lodged non-medical exemptions.
However, the largest group not being vaccinated actually comprised those who could not access health services because of socioeconomic factors. Denying financial support and educational opportunities to those who are already experiencing difficulty accessing health care only increases health disparities.
Perhaps penalties need not be so stringent. Dr Josephine Sauvage, a GP at the City Road medical practice, has suggested that a mandate could record a child’s vaccination status and require anyone who declines immunizations to register a conscientious objection. This would seem to be a satisfactory ethical middle ground: anti-vaxxers still have their right to refuse to be vaccinated, but their risk of harming others is somewhat minimised.
However, again, allowing parents the right to refuse their child to be vaccinated raises the question of when it is ethically permissible for governments to infringe on parental rights. Do we want to allow a parent to be able to decide that their child should not go to school because they won’t vaccinate them?
Clearly, the very heart of the ethical issues surrounding mandatory vaccination is how much power we want to give our governments to infringe on our autonomy.
Ideally, everyone would choose to be vaccinated at every opportunity, unless there was a legitimate medical concern. The reality is not so simple. Mandates are not as neat a solution as policy makers hope they are. The factors driving low immunisation rates vary dramatically across the world, and governments must frame their policy-making decisions with careful analysis of the situation – it cannot purely be an ethical discussion.
Although there are specific factors in each country that require tailored approaches, globally we require better education and communication. Communicating with vaccine-hesitant families in a way that addresses their concerns for their autonomy, whilst simultaneously conveying the importance of vaccination has proven to be incredibly challenging.
It is therefore time to reconsider how health care practitioners and policy makers approach vaccine education.