Ethics of mandatory vaccinations: Benefits may not outweigh challenges

Vaccines are one of the most effective tools for protecting people against COVID-19, according to the World Health Organization (WHO). But should vaccines be made mandatory in order to increase vaccination rates and achieve public health goals?

A new policy brief published by WHO, led by Western University’s Maxwell Smith, provides ethical guidance for countries and organizations who may be considering making COVID-19 vaccinations mandatory, and if so, under which conditions, for whom and in what contexts.

“We are in a very fortunate position with several COVID-19 vaccines that are effective in preventing severe disease, hospitalization, and death. This has caused some to consider whether vaccinations should be made mandatory, particularly in vulnerable settings like long-term care homes and hospitals, in order to increase uptake and protect the most vulnerable,” said Smith, a Western health studies professor currently serving on Ontario’s COVID-19 vaccine distribution task force.

Mandatory vaccination is unlikely to be ethically justified among the general public given limited supply and because it is unclear that a mandate is necessary to achieve public health objectives, says Smith.

Vaccination mandates rarely force individuals to be vaccinated or are accompanied by criminal penalties in the case of noncompliance. Rather, mandatory vaccination policies make vaccination a condition of, for example, attending school or working in particular industries or settings, like health care.

Smith says mandatory vaccination is not ethically justified at the moment in schools because vaccines are not currently authorized for children.

He does, however, suggest mandatory vaccination in health care settings may be ethically justified, but if vaccination is made a condition of employment, there is a possibility that this could lead to some attrition, which could threaten an already overburdened health work force.

Governments and institutional policymakers should use arguments to encourage voluntary vaccination against COVID-19 before contemplating mandatory vaccination, says Smith. A number of ethical considerations and caveats should be explicitly discussed and addressed through ethical analysis when considering whether mandatory COVID-19 vaccination is an ethically justifiable policy option.

“Making vaccination mandatory can be ethically justified. Several childhood vaccinations have been made mandatory as a condition of attending school, including in Ontario, and other vaccinations are required as a condition of employment in health care settings,” said Smith. “But, we need to think about the potential consequences of making COVID-19 vaccinations mandatory, including if this could threaten public trust or lead to reductions in our already overwhelmed health workforce.”

The policy brief, titled COVID-19 and mandatory vaccination: ethical considerations and caveats, identifies six ethical considerations that should guide decisions about whether to make COVID-19 vaccinations mandatory, including:

• Necessity and proportionality: Mandatory vaccination should be considered only if it is necessary for, and proportionate to, the achievement of an important public health goal (e.g., protecting the most vulnerable; protecting health care capacity; herd immunity).
• Sufficient evidence of vaccine safety: Data should be available that demonstrate the vaccine being mandated has been found to be safe in the populations for whom the vaccine is to be made mandatory.
• Sufficient evidence of vaccine efficacy and effectiveness: Data on efficacy and effectiveness should be available that show the vaccine is efficacious in the population for whom vaccination is to be mandated and that the vaccine is an effective means of achieving an important public health goal.
• Sufficient supply: Supply of the vaccine should be sufficient and reliable, with reasonable, free access for those for whom it is to be made mandatory.
• Public trust: Policymakers should carefully consider the effect that mandating vaccination could have on public confidence and public trust.
• Ethical processes of decision-making: Legitimate public health authorities contemplating mandatory vaccination policies should use transparent, deliberative procedures to consider these ethical issues outlined in an explicit ethical analysis.

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