By Julian Savulescu.
The best chance of bringing the Coronavirus pandemic to an end with the least loss of life and the greatest return to normality seems to be the introduction of an effective vaccine. But how should such a vaccine be distributed?
To be effective, particularly in protecting the most vulnerable in the population, it would need to achieve herd immunity (the exact percentage of the population that would need to be immune for herd immunity to be reached depends on various factors, but current estimates range up to 82% of the population).
There are huge logistical issues around finding a vaccine, proving it to be safe, and then producing and administering it to the world’s population. Even if those issues are resolved, the pandemic has come at a time where there is another growing problem in public health: vaccine hesitancy.
If these results prove accurate then even if a safe and effective vaccine is produced, at best, herd immunity will be significantly delayed by vaccine hesitancy at a cost to both lives and to the resumption of normal life, and at worst, it may never be achieved.
Should it be made mandatory?
The Case in Favour of Mandatory COVID19 Vaccination
There is a strong case for making any vaccination mandatory (or compulsory) if three conditions are met:
- There is a grave threat to public health
- The vaccine is safe and effective
- Mandatory vaccination has a superior cost/benefit profile compared to other alternatives.
Each of these conditions involves value judgements.
- Grave Threat to Public Health
So far, there have been over 650, 000 deaths attributed to COVID-19 globally (as of 28 July). In the UK alone, it was predicted in influential early modelling that 500,000 would have died if nothing was done to prevent its spread. Even with the subsequent introduction of a range of highly restrictive lockdown measures, (measures which could themselves come at a cost of 200, 000 non-COVID-19 lives according to a recent government report), 45,752 (as of 27 July) have died in the UK.
The case fatality rate was originally estimated to be as high as even 11% but (as is typical with new diseases), this was quickly scaled down to 1%, or even lower. The infection fatality rate (which accounts for asymptomatic and undiagnosed cases) is lower still as it has become clear that there are a large number of asymptomatic and mild cases. For example, the Centre for Evidence Based Medicine reports that “In Iceland, where the most testing per capita has occurred, the IFR lies somewhere between 0.03% and 0.28%.”
Of course, how you define “grave” is a value judgement. One of the worst-affected countries in the world in terms of Coronavirus-attributed deaths per million is Belgium. The mortality is currently around 850 per million population, which is still under 0.1%, and has an average age of death of 80. Of course, Belgium, and most other countries have taken strict measures to control the virus and so we are not seeing the greatest possible impact the virus could have. Yet others such as Brazil and Sweden have intervened to a much lesser degree, yet (currently) have rates of 413 and 564 deaths per million respectively. Sweden’s April all-cause deaths and death rate at the peak of its pandemic so far, whilst extremely high, were surpassed by months in 1993 and 2000.
The data is complex and difficult to compare with different testing rates, and ways of assigning deaths and collecting data from country to country. Moreover, there have been huge behavioural changes even in countries without legally enforced lockdowns. Furthermore, the IFR varies wildly by age-group and other factors. Even amongst survivors, there is emerging evidence that there may be longterm consequences for those who have been infected but survived. Nevertheless, some might argue that this disease has not entered the “grave” range that would warrant mandatory vaccination. The Spanish flu killed many more (50-100 million), and it afflicted younger rather than older people, meaning even more “life years” were lost. It is not difficult to imagine a Superflu, or bioengineered bug, which killed 10% across all ages. This would certainly be a grave public health emergency where it is likely mandatory vaccination would be employed.
Deciding whether Coronavirus is sufficiently grave requires both more data than we have, and also a value judgement over the gravity that would warrant this kind of intervention. But let us grant for the sake of argument that COVID-19 is a grave public health emergency.
2. Vaccine Is Safe and Effective
What is safe or effective enough? There are community concerns about the safety of all pre-existing vaccines, including many that have been rigorously tested and employed for years.
In the case of COVID, the hesitancy may be exacerbated by the accelerated testing and approval process:
“[M]y administration cut through every piece of red tape to achieve the fastest-ever, by far, launch of a vaccine trial for this new virus, this very vicious virus. And I want to thank all of the doctors and scientists and researchers involved because they’ve never moved like this, or never even close.”
The large impact on society means the vaccine will be put to market much more quickly than usual, perhaps employing challenge studies or other innovative designs, or by condensing or running certain parts of the process in parallel (for example, creating candidate vaccines prior to its approval).
Whilst the speed is welcomed by politicians and public health professionals, the pressure to produce a candidate vaccine, and the speed at which it has been done may be also perceived to increase the likelihood of the kind of concerns that lead to vaccine hesitancy: concerns over side-effects that are unexpected or rare, or that take longer to appear than the testing process allows for, or that for another reason may be missed in the testing process. Moreover, there has never been an effective vaccine for a Coronavirus so this vaccine will be entering uncharted waters.
The job to be done will not only be to prove scientifically that the vaccine is safe and effective, but also to inform and reassure the public: especially the group who are willing to take the vaccine in theory—but only after others have tried it out first.
The question remains of how safe is safe enough to warrant mandatory vaccination? It is vanishingly unlikely that there will be absolutely no risk of harm from any biomedical intervention, and the disease itself has dramatically different risk profiles in different groups of the population. In an ideal world, the vaccine would be proven to be 100% safe. But there will likely be some risk remaining, and some risk that there are risks that have not yet been identified. Any mandatory vaccination programme would therefore need to make a value judgement about what level of safety and what level of certainty are safe enough. Of course, it would need to be very high, but a 0% risk option is very unlikely.
3. Better than the Alternatives
There are many alternatives to mandatory vaccination.
The popular position is that we don’t need mandatory vaccination because people are self-interested or altruistic enough to come forward for vaccination. We can reach herd immunity without mandatory vaccination.
If this were true, well and good. But the surveys cast doubt on this claim. Moreover, reaching herd immunity is not good enough.
Firstly, how fast we reach herd immunity is also important. In the pandemic, time is lives, lots of lives. If it takes a year to reach herd immunity, that could be thousands or tens of thousands of lives in one country. You need to get there fast.
Secondly, herd immunity is necessary because some people can’t be vaccinated for medical reasons: they have allergies, immune problems, or other illnesses. The elderly often don’t mount a strong immune response (that is why it is better to vaccinate children for flu because they are the biggest spreaders of that disease – although COVID appears different on the current evidence). And immunity wanes over time – so even people previously vaccinated may become vulnerable.
Even when national herd immunity is achieved, local areas can fall below that level over time, causing outbreaks, as happened with measles recently. So ideally we need better than herd immunity to ensure that people are protected both over time and in every place.
These are reasons to doubt whether a policy of voluntary vaccination will be good enough, though it remains to be seen.
There are other policies which might obviate the need for mandatory vaccination. South Korea has kept deaths down to about 300 with a population of 60 000 000 with a vigorous track and trace program (although it was criticised for exposing affairs and other stigmatised behaviours). Other countries have enforced quarantine with tracking devices. There could be selective lockdown of certain groups, or for intermittent periods of time.
The long term costs and benefits of such policies would have to be evaluated. How they should be evaluated is an ethical question. Should we count deaths averted (no matter how old), life years lost or lost well-being (perhaps measured by Quality Adjusted Life Years)? Should we count loss of liberty or privacy into the other side the equation?
It may be that a one-off mandatory vaccination is a significantly smaller loss of well-being or liberty than these other complex resource intensive strategies.
So we cannot say whether a mandatory policy of COVID-19 vaccination is ethically justified until we can assess the nature of the vaccine, the gravity of the problem and the likely costs/benefit of alternatives. But it is certainly feasible that it could be justified.
It is worth noting that mandatory vaccination policies are already in place in different parts of the world for certain vaccines. Australia has the “No Jab, No Pay” scheme which withholds child benefits if the child is not vaccinated, and “No Jab, No Play” which withholds childcare. Italy imposes fines. In some states of the US, children cannot attend school if they are not vaccinated.
All of these policies appear to increase vaccination rates.
Whether a particular mandatory policy is justified is determined in part by the proportionality of the penalty.
For example, penalties have been set very high even for policies that impose a high risk of physical harm and even death. In war, those who conscientiously objected to conscription went to jail or were forced to perform community service (or participate in medical research). On the other hand, the fines for not wearing a seat belt are typically small. A modest penalty for not being vaccinated in a grave public health emergency could be justifiable in certain circumstances.
Better than Coercion? Payment for Risk
Is there a more attractive alternative?
The arguments in favour of vaccination, particularly for those at low risk (children, young people and those previously infected) are typically ones of solidarity. “We are in this together”. Those at low risk are asked to do their duty to their fellow citizens, a kind of community service.
However, another way of looking at this is that those at low risk are being asked to do a job which entails some risk. So they should be paid for the risk they are taking for the sake of providing a public good. And although it may be unlikely to influence so-called ‘anti-vaxxers’, it may influence the ‘wait and see’ and don’t know’ groups of the population, accounting for 60% of American adults in this poll.
I have previously argued that we should reconceive live organ donation and participation in risky research, including challenge studies, as jobs where risk should be remunerated, much like we pay construction workers and other dangerous professions both for the job and for the risk involved.
The advantage of payment for risk is that people are choosing voluntarily to take it on. As long as we are accurate in conveying the limitations in our confidence about the risks and benefits of a vaccine, then it is up to individuals to judge whether they are worth payment.
Indeed, if a vaccine is judged to be safe enough to be used without payment, then it is safe enough to be used with payment.
A payment model could also be superior to a mandatory model. There may be considerable resistance to a mandatory model which may make it difficult, expensive and time consuming to implement, with considerable invasion of liberty. In a payment model, people are doing what they want to do.
A payment model could also be very cheap, compared to the alternatives. The cost of the UK’s furlough Scheme is estimated to reach £60 billion by its planned end in October, and the economic shut down is likely to cost many billions more, as well as the estimated 200,000 lives expected to be lost as a result. It would make economic sense to pay people quite a lot to incentivize them to vaccinate quickly.
It may be that payment is only required to incentivise certain groups. For example, it may be that young people require incentivizing because they are at lower risk from the disease itself. On the other hand justice might require payment for all taking the risk. Although the elderly and those at higher risk have more to gain personally, they are also providing a service by being vaccinated and not using limited health resources. (There is an enormous backlog of patients in the NHS – another grave threat to public health.)
One particularly difficult case is paying parents to vaccinate their children. It is one thing to pay people to take on risk for themselves; it is quite another to pay them to enable their children to take on risks, particularly when the children have little to gain as they are at lowest risk. In part, the answer to this issue is determined by how safe the vaccine is and how confident we can be in that assessment. If it were very safe, to a level that even a mandatory programme would be justified, it may be appropriate to instead incentivize parents to volunteer their children for vaccination. If safety is less certain, payment for risk in this group is more problematic.
A standard objection to paying people to do their duty, particularly civic duty, is that it undermines solidarity, trust, reciprocity and other community values. This is the argument given by Richard Titmuss for a voluntary blood donation scheme (“The Gift Relationship”).
The UK does not pay donors for blood or blood products, but does purchase blood products from other countries, including Austria where donors are paid a ‘travel allowance’ for plasma donation. In Australia, which runs a donor system, more than 50% of the plasma comes from paid donors in the US. Altruism is insufficient. Germany recently moved to paying for plasma donors. It does not appear to have undermined German society.
In the end, the policy we should adopt towards COVID vaccination will depend on the precise risks and benefits of the vaccine (and our confidence in them), the state of the pandemic, the nature of the alternatives and particularly public appetite for a vaccine.
In the right circumstances, mandatory vaccination could be ethically justified, if the penalty is suitably proportionate.
Payment for vaccination, perhaps, has even more to be said for it.
For those attached to the gift of altruism, the vaccinated could be offered the opportunity to donate their fee back to the NHS (or similar health service provider). This combined “payment-donation” model would be a happy marriage of ethics and economics. It would give altruists a double chance to be altruistic: first by vaccinating and second by donating the fee. It would couple self-interest with morality for free-riders, and it would give those who face obstacles to vaccination an additional reason to overcome these.
Of course, benefits can come in cash or kind. An alternative “payment” model is to pay those who vaccinate in kind. This could take the form of greater freedom to travel, opportunity to work or socialise. We have given similar arguments in favour of immunity passports.
One attractive benefit would be the freedom to not wear a mask in public places if you carried a vaccination certificate, and not to socially distance. Currently, everyone has to wear a mask and practise social distancing. Relaxing this requirement for those who have been vaccinated (or have otherwise immunity) would be an attractive benefit. Moreover, it would help ameliorate the risks the unvaccinated would pose to others.
Some might object that this is shaming the non-vaccinators (some of whom might be excluded from vaccination for health reasons), just as presenting those who evaded conscription with a white feather was a method of shaming perceived free-riders. But there is a good reason to require the non-vaccinated to continue to wear masks and practice social distancing: they do represent a threat to others, a direct threat.
It is quite possible that some mixture of altruism, financial and non-financial benefits will obviate the need to introduce mandatory vaccination. It is better that people voluntarily choose on the basis of reasons to act well, rather than being forced to do so. Structuring the rewards and punishments in a just and fair way is one way of giving people reasons for action.
Author: Julian Savulescu1, 2, 3
1: Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK.
2: Murdoch Children’s Research Institute, Melbourne, Australia.
3: Melbourne Law School, University of Melbourne.
Competing interests: None
Social media account: @juliansavulescu