By Leo Lam and Taylor Nichols.

The COVID-19 pandemic has greatly disrupted the operation of our society. To cope with a novel virus to which humans had no immunity, public health authorities took a multitude of actions such as lockdowns, mandates on non-pharmaceutical interventions such as masks, and later on vaccines in specific circumstances to protect the population. Naturally, whenever mandatory actions are enforced, ethical questions regarding liberty and the question of choice arise and the answers are not always clear.

One way to help guide us through such an ethical dilemma is to perform a risk and benefit analysis on the individuals and the community affected by these actions. This is also not a simple task as some risks/benefits may be superficially qualitative and as such, quantitative comparisons must be formulated carefully to avoid bias and therefore skewing the outcome of the analysis. Ethical positions must be informed by scientifically justifiable facts, not cherry-picked values that support preconceived notions.

In another word, the risk profiles for the risk and benefit must be closely matched for the analysis to be fair, defensible, and scientifically justifiable. Without this consideration, merely comparing numbers may create an illusion that sways the argument one way or the other, while the actions that optimally benefit society and individuals languish in the noise.

Vaccine mandates, especially those that apply to college campuses, have been a point of contention among experts and general society because the risk and benefit analysis is not as clear cut for the college-aged population as, for example, those who are over 65. The college-aged group does not get as sick when infected, and the death rate is lower. Yet regardless of age, some risks do exist and such risks must be carefully balanced against the perceived lowering benefit as we progress down the age groups.

To perform a robust analysis for this younger age group, details matter when it comes to examining the risk profiles. On the benefit side for this age group in decreasing severity, vaccines reduce the number of deaths, reduce the number of cases of severe diseases that require resource-intensive hospitalizations, reduce the overall number of cases, and lower the chance of Long COVID even for mild cases. Each one of these benefits reflects different levels of resource consumption for treatments and individual suffering with long-term and short-term implications. It is also clear that there are public health benefits that affect other age groups when this group is vaccinated. On the negative side, receiving the vaccines comes with risks such as Severe Adverse Events (SAEs), reactogenicity, and myocarditis, especially for the males in the group. Each one of these risks also requires the consumption of resources to treat and represent varying levels of personal suffering.

For example, using the number of cases to quantify the risk of SAEs seems straightforward, but the severity of such SAEs would determine which benefits should be compared. The SAEs reported in the Pfizer vaccine trial were “moderate persistent tachycardia, moderate transient elevated hepatic enzymes, and mild elevated hepatic enzymes” all of which were reported to be transient, self-resolved events that did not require hospitalization in the trial. It would be, therefore, inappropriate to compare this low level of severity to death or even to hospitalized cases of COVID given the differential in treatment resources and suffering. While still imperfect, it would be more reasonable to compare it to the number of COVID cases prevented. There is a spectrum of severity in COVID cases, some resources are still needed to treat on average, and with Long COVID being a non-insignificant possible outcome, the risk profile of a COVID case is still higher than the reported SAEs. Here, the precautionary principle applies, and erring on underestimating the benefits is not unreasonable to prevent harm.

Our paper that examines the ethics of college vaccine mandates uses the same process to identify the correct comparison pairs for SAEs, reactogenicity, and the chance of myocarditis. It can be demonstrated that the resources saved via vaccine mandates far exceed the resources needed to treat the risks and that the population in that age group benefits from vaccination far more than the risk they are exposed to from vaccination when risk profiles on both sides are carefully balanced. Attending college is also a privilege, not a right. We concluded that the vaccine mandates carry more benefits than risks on both an individual level and on a societal scale on quantifiable grounds. And thus, college mandates are ethical.

Paper title: The ethics of college vaccine mandates, using reasonable comparisons

Authors: Leo Lam, Taylor Nichols

Affiliations: University of Washington, University of San Francisco

Competing interests: None

Social media accounts of post authors: @SeattleiteLeo @tnicholsmd