Why A Universal COVID-19 Vaccine Mandate Is Ethical Today – Health Affairs

Many organizations and individuals are calling for the mandatory vaccination of all Americans against COVID-19. But others have objected to vaccine mandates, calling them unethical. As members of the Association of Bioethics Program Directors (an organization representing more than 90 bioethics centers in the US and Canada), we’ve had vigorous debates on these issues. We have concluded that broad vaccine mandates for COVID-19 are ethically justified at this time.

Of course, any mandate should exempt people who cannot receive the vaccine for medical reasons, but this is remarkably rare. And there are legitimate practical arguments about the impact of mandating vaccination for individuals with documented prior infection or who can prove some level of prior immunity, which we will not take up here. More commonly, those opposed to vaccination mandates have argued that they are unethical because they might infringe on personal liberties or because they violate religious freedom. We argue that avoiding mandates to uphold the ideals of personal and religious freedom is not worth the risk to others that would ensue in the current environment; imposing risk on others can justify enforcing limits to personal decision making.

Counterpoints To Common Arguments Against Vaccine Mandates

Personal Liberty Objections

What makes any public health mandate ethical, whether it’s for mask-wearing, social distancing, or vaccination? Answering this question, especially in the US context, requires us to start with our foundational commitment to the value of individual liberty. Liberty is grounded in the ethical concept of autonomy—or self-rule—and it is the primary value that guides medical practice in normal times.

Even in normal times, of course, choices have consequences. In particular, some personal choices have the potential to harm others. When one person’s choice might harm others, it can be ethical for that choice to be limited. That’s why we have speed limits and stop signs; both limit your right to drive as you might wish, but they are necessary for public safety. If you choose to drive recklessly and put others at risk, you should expect to pay a fine, possibly lose your license to drive, or maybe even go to jail. Other examples include laws about smoking in airplanes, firing a gun in an urban area, or shouting “Fire!” in a crowded theater and causing a panic.

It is the risk of harm to others—impinging on their liberty to be safe while driving, breathe clean air, or not be shot or trampled—that makes it ethical to place limits on personal choices. Limiting personal freedom when it is necessary to prevent harm to others is widely agreed to be ethical under a wide variety of secular and religious worldviews and traditions.

In terms of limiting people’s choices about vaccination during the COVID-19 pandemic, we must consider whether one person going unvaccinated today is likely to cause harm to other people. Nearly all people interact and come into physical contact with others on a daily basis, and a person with COVID-19 can infect several others even before showing symptoms. The risk of one person harming many others, even inadvertently, provides ethical justification for limiting the choice to go unvaccinated during a pandemic.

While mitigation strategies—masking, social distancing, hand washing—are effective in slowing the spread of COVID-19, such measures carry their own harms and are much less appealing as long-term strategies. Only vaccines are capable of halting viral transmission to the degree of stopping COVID-19 from continuing as a pandemic-level threat. Herd immunity for COVID-19 will only occur through vaccination.

The choice of too many individuals to go unvaccinated has already resulted in the worsening of the pandemic and the COVID-19 virus itself. The best current estimates are that 80–90 percent of people need to be immune to reach herd immunity—that is, the point at which the COVID-19 virus will stop circulating widely and be prevented from mutating into more infectious and deadlier forms. The failure to quickly achieve herd immunity after COVID-19 vaccines became available allowed it to mutate into the Delta variant, which has now spread across the United States, killing many thousands of people and harming untold numbers more. The Delta variant has even infected some vaccinated people. Many states have been forced to go back to requiring mask-wearing and social distancing in public, practices that inhibit personal freedom and have socioeconomic repercussions. 

While the COVID-19 vaccines have been shown to be safe and effective for the vast majority of people who have gotten them, there are still some people who cannot get vaccinated or who have responded poorly to vaccination, including those who are immunocompromised and children for whom COVID-19 vaccines are yet approved. There is nothing tyrannical about mandating vaccination for everyone who can safely take the vaccine to allow those who cannot get vaccinated to live without fear of catching COVID. Allowing some people the choice to remain unvaccinated severely limits the mobility and threatens the safety of other people, which makes the availability of that choice both unfair and dangerous for those who are especially vulnerable and who may not have other options to protect themselves.

Because autonomy is a very important value, authorities should use the least restrictive means possible to achieve the goal of minimizing the harms of COVID-19. While voluntary vaccination is preferable because of this, education and incentives have not worked to increase COVID-19 vaccination rates. Mandatory vaccination, therefore, is now the least restrictive way to minimize the virus’s damage.

For some, being mandated to take a vaccine might seem to be more of a restriction on personal liberty than other existing measures, including mandates to wear a face mask in public, stay at home, or stand six feet away from others. Yet, the harmful effects that these other measures have had on the economy, effective education, and mental health all indicate that mandatory vaccination is a less harmful way of minimizing death and destruction from COVID-19 than other strategies for limiting its spread. Vaccination carries a very small risk of serious negative reactions, and it frequently produces minor short-term side effects. Is it ethical to require people to take on this risk, however small, if it is mainly to protect others?

Major secular and religious worldviews and traditions—including Islam, Judaism, and Christianity—support individuals being required to accept some risk or sacrifice of personal comfort or well-being to help others. Indeed, the responsibility to help others who are more vulnerable is a central tenet in many religious traditions. One secular tradition speaks directly to the need for individuals to accept restrictions on some of their freedoms to protect the safety and well-being of their community: democracy. In a democracy, the people or their elected representatives are specifically authorized to pass laws and enact regulations that limit individual freedoms. People who disagree can pursue legitimate ways to protest and get laws changed. Many Americans presumably agree that a democracy, even if it’s not perfect, is still the best system for making decisions about the collective good. Even those who are disillusioned, frustrated, or disengaged from the principles of democracy still have an obligation to live by the norms and laws of their society.  

Religious Objections

Most mandates from employers are legally required to allow exemptions for people with “sincerely held” religious objections to vaccination, as long as accommodating these employees doesn’t cause “undue hardship” on the employer. The US Supreme Court has ruled that a sincerely held religious belief can seem illogical or unreasonable to others, it can even be entirely false, and does not have to be tied to a major religion, but it cannot solely be a cover for political or social beliefs. More importantly, from an ethical standpoint, even if a religious belief against vaccination is sincerely held, it does not create the right to place other people in harm’s way. Religious freedom is a very important value in the US, but it is not the only value at stake in making public policy decisions.

All major religions, including those that emphasize faith-healing, permit vaccination under at least some circumstances. During the pandemic, religious leaders of the major faiths, including Christian, Jewish, Islamic, and Mormon, have openly encouraged members to get vaccinated against COVID-19. Pope Francis has gone so far as to say that it would be “suicidal” not to be vaccinated in the current environment, and that being vaccinated is an “act of love” and a moral obligation.

Some oppose COVID-19 vaccines out of the mistaken belief that they were created using recently aborted fetal tissue. Factually, this is not the case. No abortions have been performed to create vaccines, and no fetal cells are in any COVID-19 vaccines.

It is true that some COVID-19 vaccines were developed or tested using “immortal” cell lines, and some of these cell lines are connected to miscarriages or abortions that happened decades ago. Some people claim to have a sincerely held religious objection to using anything developed using cell lines connected to abortions; however, at least one major religious tradition opposed to abortion has definitively stated that any of the COVID-19 vaccines may be taken in good conscience.

These cell lines are also regularly used in the development of many processed food additives and over-the-counter medications. According to the Conway Regional Health System, examples of products developed using these cell lines include Tylenol, Pepto Bismol, aspirin, Tums, ibuprofen, Maalox, Benadryl, Sudafed, albuterol, Preparation H, Claritin, Zoloft, Prilosec OTC, azithromycin, and many others. It is unlikely that most people who say they object to COVID-19 vaccines for this reason also avoid using all of these other common products, and it is ethically justified for employers to question whether one’s belief is sincere if it is inconsistently applied.

We conclude that many of those seeking religious exemptions to vaccine mandates are likely exploiting these exemptions as cover for personal, political, or social beliefs or fears about the safety of the vaccine. But even for those for whom their religious beliefs against vaccination are sincere, the harms to others associated with having unvaccinated individuals in close contact creates an undue burden on the organizations and communities in which these individuals live, work, worship, and play. For example, the sincerity of a religious belief that promoted public intoxication would not make that belief ethically or legally allowed because of the potential harms that would be caused if people acted on that belief.

Why Vaccine Mandates Are Ethical In This Moment

Mandates should only be used if they are needed. Individuals should first be educated about vaccination and its effectiveness—along with any potential risks—and then be encouraged to get voluntarily vaccinated. Incentives to encourage voluntary vaccination should also be tried.

A public health mandate should also only be instituted after robust public debate, in which there has been an opportunity for all people to voice their opinions. This has already happened. Indeed, social media have enabled all voices to be amplified and heard, sometimes over and over again. Those who prefer to remain unvaccinated will be disappointed to feel the pressure of a mandate. Not getting your way when you live in a democracy, however, does not mean you were excluded from the deliberative process.

Unfortunately, public debate and voluntary means have not been enough. When education, encouragement, prodding, and even incentivization have failed, and when harms from outbreaks are ongoing, then coercion in the form of mandates is ethically justifiable.

By “coercion,” we do not mean that anyone is going to be strapped down and jabbed with a needle against their will, or that this should happen. There is still a choice not to be vaccinated, but because that choice imposes substantial burdens, risks, and possible harm to others, it is reasonable for it to carry significant costs. For some, choosing not to be vaccinated will mean not holding a certain job, not enrolling in a school, or not being allowed to attend a public event. These implications are admittedly coercive, but coercion is justified when we are facing a terrible public health threat that involves many people getting infected and dying every day.

Authors’ Note

All of the authors are members of the Association of Bioethics Program Directors (APBD) (Jason T. Eberl is an officer of the APBD board). The authors wish to thank Barbara Juknialis, MA, for editorial assistance.

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