Making Vaccines Mandatory – An Ethical Perspective

covid vaccine

On June 28, the Madhya Pradesh Home Minister Narottam Mishra said that only those who have received two doses of vaccines will be permitted entry into theatres, multiplexes, coaching centres, and colleges.

A few days before, on June 24, the Gujarat High Court granted temporary relief to an IAF officer who received a show-cause notice from Indian Air Force over refusal to take Covid vaccine.

In March 2021, KPMG reported that 94 percent CEOs of major Indian companies plan to ask their employees to return to office only after vaccination. And state officials have been seen visiting households asking residents to vaccinate failing which water and electricity connections will be severed.

While Covid vaccination remains voluntary, state officials, agencies and organisations are acting in a manner that appears to suggest that vaccination is mandatory. Experience of countries shows that making (Covid 19) vaccination mandatory (or compulsory) requires meeting four conditions to make it ethically correct and morally sound.

One, is there a grave threat to public health? Covid 19 is admittedly a public health hazard. It is not only so in its scale, speed and spread, but by the economic and social disruption it causes. One may agree or disagree with the vaccination drive, but few will deny its gravity

Two, is the vaccine safe and effective? Vaccines are safe when they do not debilitate or cause death. In the case of Covid, a class of people has feared both and such fears have only multiplied. They see long Covid as an example of physical debility, and there is enough going around about death due to Covid 19 vaccine.   Both the central and state authorities have failed to address, adequately and squarely, such fears. The science about vaccine is very clear though. Those who succumb due to Covid are infinitesimally small. However, when people think of science of vaccination, they think in terms of cure, not numbers, averages and probabilities.

Covid vaccine has also redefined effectiveness. The popular understanding about vaccines is that they are effective against diseases. That is, once inoculated, the person will not contract them. The belief, proven by experience, is that vaccines protect.  A child vaccinated for measles or polio, for example, will not contract the disease. Such an expectation has turned out overwhelmingly true. However, in the case of coronavirus, effectiveness does not mean the same. Our housemaid who refuses to receive the Covid vaccine argues, “Why should we continue to wear masks and maintain physical distance once vaccinated? That means, vaccine by themselves do not work.”  The logic of explaining anything different to her runs up against accumulated previous experience. Is she wrong? Well, how about this: No country has ever produced a safe and effective vaccine against a coronavirus.

Three, does mandatory vaccination have a superior cost/benefit profile compared with other alternatives. This is perhaps the most relevant condition for vaccine acceptance. However, the approach relies on cognitive elaboration and the ability to think in term of utilities. For example, what is the expected utility of Covid vaccine when compared with the expected utility of relevant alternatives such as lockdown, washing hands, wearing facemasks, etc.?  Undoubtedly, Covid vaccine costs less (not just monetarily) and the benefits it offers are more lasting than any other alternative. However, such an approach, based on decision theory, requires a type of training and education among people that ought to begin before society lands in a public health emergency.

Fourth and final, is the level of coercion proportionate. In public health ethics, the concept of ‘least restrictive alternative’ informs that in order to decide which policy to implement among the potentially effective options, policymakers should ideally adopt principles of least infringement and of least restrictive alternative. In other words, an alternative is least restrictive when it achieves a given outcome with the least coercion and least restriction of liberty.

The incidents mentioned above are not only coercive but impose restrictions on individual liberty. In doing so, they give rise to two ethical dilemmas. The first relates to a conflict between individual best interest and individual autonomy. Let us understand the conflict with help of a different example. It is in individual’s best interest to marry, but to do so (or not do so) is her or his autonomous decision. Similarly, it is in individual’s best interest to vaccinate, but to vaccinate or not, is individual’s decision. The state or an institution cannot perform a paternalistic role, especially when it does not provide for vaccine injury compensation funds.

The second ethical dilemma relates to the conflict between individual autonomy and public health. The latter, by definition, is a matter of collective responsibility (think herd immunity). Where, and to what extent, does individual responsibility figure in the collective?  Parfit’s “Harmless Torturers” case captures the conflict between the two. In it, each torturer contributes only negligibly to the pain experienced by the victims, but the victims feel pain because of the contributions of a sufficiently high number of torturers. In such case, the moral obligation not to inflict pain is collective, and not individual, since each individual torturer is “harmless”. Demanding people to vaccinate captures the same dilemma.

Pradeep Krishnatray is former director, Research and Strategic Planning, Johns Hopkins Center for Communication Programs, New Delhi.



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