DMEJ

   Duke Medical Ethics Journal   

Vaccine Ethics: Mandatory Vaccine Programs and Individual Liberty

By: Michelle Huang (Duke University) & Radheesh Ameresekere (University of Toronto)

1. Introduction

 

In the face of the COVID-19 pandemic, vaccines have become a contentious topic – this section examines both sides of that contention. On one hand, much of the existing academic literature on vaccination illustrates clear and predictable empirical benefits, including but not limited to immunization, transmission prevention, symptom mitigation, and herd immunity. In particular, herd immunization and decrease in overall disease morbidity and mortality – given their relevance to public safety and social harm prevention – are the benefits most often cited by public health institutions. In other words, advocates of mandatory vaccine programs contend that vaccinations are at the forefront of combating viruses like COVID-19 and promoting public health and safety. It is precisely these findings – and the broader body of scientific literature – that underpin the justifications for mandatory vaccine programs. On the other hand, despite the evidence in existing academic literature supporting vaccine efficacy in preventing harm, some object to their use, claiming inefficacy, disproportionate side-effects, lack of research, etc. Furthermore, many objectors – including typical advocates of vaccines – consider mandatory vaccine programs to be an infringement of civil liberties and/or individual freedoms, namely, the freedom to make autonomous medical decisions such as taking or refusing vaccination while still benefiting from seperate societal resources.

Huang - Writer’s Piece Graphic 2.JPG

In trying to develop sound ethical criteria for mandatory vaccination programs, this paper strives to recognize both the empirical good of mass-vaccination for public health and the inviolability of individual freedom and liberty. The former requires establishing the empirically proven benefits of vaccinations with relevant evidence and literature, as without a firm scientific justification for the alleged public health benefits, there are no legitimate scientific grounds to justify these programs. The latter requires nuancing some major axiological positions about freedom and individual liberty, and examining why preserving them is a serious ethical concern. The paper will then effectively mediate both these paradigms.

“Any limitation of positive liberty violates the unalienable will of the individual, whereas negative liberty suffices to promote public health while still nonetheless respecting the autonomy of the individual to refuse vaccination.”

II. Vaccine Benefits

As stated in Section I, we must first establish the empirically proven benefits of vaccination. Specifically, it is necessary to (i) ensure that vaccines cause no harm to the individuals that receive them, and (ii) provide evidence that they are medically beneficial to the public. The former echoes the basic ethical commitments of the Hippocratic oath that in turn underpins all medical commitments, whereas the latter substantiates the justifications usually cited by mandatory vaccination programs.

In regard to the former, a substantial amount of rigorous testing and empirical data support the beneficial effects of vaccines decreasing COVID-19 transmission and severity while only causing minimal symptoms and negative effects, despite the short amount of time in which they were developed. All available COVID-19 vaccines have been subject to diligent testing in accordance with the standard three-phase vaccine trial procedure, which involved tens of thousands of volunteers of different ages, races, and ethnicities to ensure all side effects are recorded and no adverse outcomes are observed before proceeding with public distribution., With global effort and funding, the trial phases were conducted in tandem, and the experimental phase was safely expedited and monitored after eight weeks to prove vaccine reliability, ensuring that each vaccine will do no significant harm to the individual.5 Against virtually every empirical standard of safety, COVID-19 has proven safe beyond any reasonable scientific doubt.

The most common objection to this position is that ‘COVID-19 vaccines have had dangerous and unpredictable side-effects.’ In other words, the research often cited is insufficient in anticipating potentially severe side-effects. In reply, it should be considered that any physical reactions to each COVID-19 vaccine have been extensively documented, with the large majority of the population experiencing negligible temporary effects that pale in comparison to actual COVID-19 symptoms. Cost-benefit analysis is key to refuting these alleged-criticisms. Myths that the mRNA vaccine produces the virus, alters genetic material, or changes the magnetic qualities of your body have all been proven undeniably false. In reality, minimal side effects such as fever, fatigue, and pain are merely signs of immune system activation used to build protection against the threat of the real disease. Serious vaccine complications like myocarditis, anaphylaxis and thrombosis are extremely rare, with a probability of less than one in one hundred thousand recipients.5 On the other hand, the mortality rate and aftereffects of the COVID-19 virus itself are much more serious and prevalent, with over 4.5 million total deaths from the disease.

In regard to the latter, not only is the vaccine provably safe for widespread usage, but also prevents harm at two levels: the individual level, and the collective level. The COVID-19 vaccine has been proven to provide protection against COVID-19 hospitalization, with an effectiveness of 94% among adults who were fully vaccinated, and prevent mortality of vulnerable individuals.3 However, the crucial benefit is not immunity at the level of particular individuals. The widespread use of the COVID-19 vaccine would allow for herd immunity, which is when the decrease of virus transmission rates makes the spread of disease from person to person unlikely. As a result, the whole community becomes protected — not just those who are immune or received the vaccine. With herd immunity, even vulnerable individuals like children, the immunocompromised, the elderly, and those who cannot receive the vaccine can be protected from the virus in the population. The vaccine provides crucial defense against the COVID-19 virus to every member of the population, furthering public health and improving health outcomes for the vulnerable. Starkly reducing fatal cases, debilitating symptoms, rapid transmissions, etc. all of which bolster social wellbeing, vaccines are simply the vanguard of public health and safety.

Huang - Writer’s Piece Graphic 1.JPG

III. Individual Liberty

While we have thus shown the empirical efficacy of vaccinations and the necessity of them for public health, preserving individual liberty is still necessary to develop an ethical framework for vaccine mandates. ​​In the last three or so decades, medical ethics has become increasingly concerned with autonomy. Autonomy has become largely synonymous with dignity. Echoing these developments, we contend that individual patients ought to possess the freedom to act upon their own will, as in the case of medical autonomy. In other words, individuals ought to be free to act without coercion or limitation of their wills, including making medical decisions that pertain to the health of their persons. Considering the matter at hand, this also includes the right to refuse vaccination. This is broadly called the right to individual liberty, and specifically called the right to medical autonomy in this case. However, as shown above, infectious diseases such as COVID-19 also pertain to public health and safety, inasmuch as individual decisions impact the broader population. These mandatory vaccine programs are, in turn, matters of public policy. To even attempt to reconcile these paradigms, we must first examine when – if ever – institutions are justified in limiting individual liberty, and ethical ways they can do so.

Generally speaking, there are two possible cases for limiting individual liberty. (i) Limiting individual liberties for the sake of the individual, and/or (ii) limiting individual liberties for the sake of the many. We criticize the former limitation as paternalistic, wherein institutions commandeer the autonomy of the individual and violate their right to individual liberty. These are cases where the state presumes to know what is best for the individual, and limits their liberty in pursuance of this end. This methodology has regularly been applied and abused in authoritarian states and dictatorial regimes, resulting not only in the violation of individual liberty, but the violation of the individual themselves as a dignified free agent. Therefore, institutions cannot legitimately mandate vaccine programs for the sake of any one individual. In other words, institutions cannot force individuals to take vaccines for their own benefit – the state may not presume to know what is best for individuals and mandate action on these terms, lest they violate the inviolable autonomy and dignity of agents.

However, the autonomy and dignity of one person can never violate the inviolable autonomy and dignity of another – this would be paradoxical moral reasoning. In other words, one cannot exercise their autonomy at the expense of other people. This would violate the very autonomy that free action hinges upon in the first place. Therefore, the only time an individual’s autonomy can be legitimately limited is if and only if the exercise of their autonomy infringes on another person’s. This principle was developed by John Stuart Mill in On Liberty, and is widely-considered the most non-invasive ethical principle. It states: “The only purpose for which power can rightfully be exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient warrant.” In other words, the only time a state can justifiably limit individual liberty is if that individual’s liberty infringes on another individual’s or group of individuals inviolate right to life, liberty, property and health in turn. This methodology has two key benefits absent in the first, authoritarian case. This allows institutions to indeed (i) prevent harm to those they are required to protect, while (ii) only limiting individual liberty in cases where other individuals are placed at risk by the relevant action. How does this pertain to vaccines? As proven in Section I, refusal to take vaccinations does harm to the broader community by (i) increasing transmission and (ii) decreasing herd immunity. Marcuse and Diekema echo that, because vaccination bolsters herd immunity, unvaccinated individuals are harming other individuals at a causal level. Therefore, given Mill’s principle, vaccine mandates can be exercised to prevent harm to others.

However, some may still object that these limitations are merely authoritarian justifications to violate individual liberty under the guise of some “greater good”. To this, we reply by nuancing two kinds of liberty: Positive liberty and Negative liberty. Positive liberty, broadly, concerns the individual's capacity to act upon their own will/freedom. Negative liberty on the other hand, broadly, concerns freedom from external restraints on their desired outcomes. We concede that limiting the individual’s ability to act (e.g., forcibly administering vaccines) would be a violation of the individual will itself, and thereby a massive abuse of power. This would again fall victim to the objection of authoritarianism. However, mandatory vaccine programs only limit negative liberty. These programs do not forcibly administer vaccines to members of society, but rather prevent their access to certain services if they do not take the vaccines. These programs de facto separate unvaccinated individuals from vaccinated individuals, thereby preventing transmission by relegating them from accessing public services and spaces. This is essentially a limitation of negative liberty; the power for individuals to act (i.e., refuse vaccines) is not limited, but they face external restraints and barriers. These kinds of barriers exist throughout social settings. One can refuse to get a driver's license (viz. positive liberty), but cannot drive without one (viz. negative liberty). Therefore, these limitations nonetheless preserve the inviolable will of the individual and their patient-autonomy – namely, their right to refuse care – while placing restraints in pursuance of public health as to prevent harm.

IV. Ethical Conclusions

In summation, mandatory vaccination programs must operate in consideration of the following ethical conclusions:

  1. Any vaccines administered, COVID-19 or otherwise, must be empirically proven beyond reasonable scientific doubt to promote public health and must do no harm to whomever they are administered to. Rigorous testing and empirical data must support their effectivity, namely in relation to public health, given that:

  2. Mandatory vaccination programs must only be administered for the promotion of public health, not the promotion of individual health. While institutions may be inclined to protect particular individuals from infectious diseases - despite their own inclinations - via mandatory vaccination programs, such implements are paternalistic and authoritarian. Alternatively, these such programs must be implemented (only) to prevent harm and further public health, as not to lead to contradictions in moral reasoning about individual liberty. 

  3. To truly ethically accommodate (2), mandates must never infringe positive liberty (i.e., by forcefully vaccinating individuals), but may only limit negative liberty (i.e., employing social barriers and deterrents for vaccine refusal). Any limitation of positive liberty violates the unalienable will of the individual, whereas negative liberty suffices to promote public health while still nonetheless respecting the autonomy of the individual to refuse vaccination.

Review Editor: Laura Wang
Design Editor: AJ Kochuba
References
  1. Alan, Jordan et al. “Coronavirus In The U.S. : Latest Map And Case Count.” New York Times. Last modified November 12, 2021. https://www.nytimes.com/interactive/2021/us/covid-cases.html.

  2. Centers For Disease Control And Prevention. “COVID-19 Vaccination". Accessed November 12, 2021. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/distributing/steps-ensure-safety.html.

  3. Diekema, Douglas and E.K. Marcuse. “Ethical Issues in the Vaccination of Children.” in Public Health Ethics: Theory, Policy and Practice. Edited by Ronald Bayer, Lawrence Gostin, Bruce Jennings, and Bonnie Steinbeck. New York: Oxford University Press, 2007.

  4. Mayo Clinic. “Herd Immunity And COVID-19 (Coronavirus): What You Need To Know.” Accessed November 12, 2021. 

  5. Kant, Immanuel. Metaphysics of Morals. Edited by Lara Denis. Translated by Mary Gregor. Cambridge: Cambridge University Press, 2017.

  6. Mill, John Stuart. On Liberty. Kitchener: Batoche Books, 2001.

  7. Randolph, Haley E., and Luis B. Barreiro. “Herd Immunity: Understanding COVID-19.” Immunity 52, no. 5 (2021): 737-741. doi:10.1016/j.immuni.2020.04.012.

  8. Sharma, Omna, Ali A. Sultan, Hong Ding, and Chris R. Triggle. “A Review Of The Progress And Challenges Of Developing A Vaccine For COVID-19.” Frontiers In Immunology 11 (2020): online print only. doi:10.3389/fimmu.2020.585354.

  9. Tenforde, Mark W. et al. “Effectiveness Of Pfizer-Biontech And Moderna Vaccines Against COVID-19 Among Hospitalized Adults Aged ≥65 Years — United States, January–March 2021.” Morbidity and Mortality Weekly Report 70, no. 8 (2021): online print. doi: 10.15585/mmwr.mm7018e1.