Are mandatory vaccinations ethical?

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KCRW’s Joanthan Bastian talks with philosopher Julian Savulescu about the anti-vax movement, personal liberty, and the ethics of mandatory vaccinations. 

The following interview excerpts have been abbreviated and edited for clarity. 

KCRW: As a philosopher and a medical doctor, what do you say when the government says that we're going to need to vaccinate as many people as possible?  

Julian Savulescu: “The question for a philosopher is when is coercion justified? When can the state limit our freedom? In The UK we're already in a new lockdown with three different tiers of restriction of liberty. So we've already had our liberty restricted in unprecedented ways effectively for periods where we were under house arrest. So the question arises, when is it legitimate to use coercion? 

I've written a paper on mandatory vaccinations in which I argue that you can make vaccines mandatory if four conditions are met. The first is if there's a grave public health problem, The second is there's a safe and effective vaccine. Thirdly, that mandatory vaccination is better than any other alternative, either voluntary or incentivized. And lastly, that the costs are reasonable and proportionate. 

So it's certainly possible to make vaccines mandatory, just as it's possible to make quarantine and isolation mandatory. In the US, California has mandatory vaccination in that children can't enter school unless they're vaccinated. Italy has fines. Australia withholds financial benefits - a ‘no jab, no pay’ policy. So one of the issues is deciding whether coercion is justified or not. 

One of the other big problems is that we already have an extraordinary lockdown, which itself is costing lives and devastating the economy. The UK has already racked up a bill of over 250 billion pounds and that's rising. But people are still dying from cancer. So 

it's about balancing COVID versus non-COVID lives. It's about balancing health and well-being versus freedom. These sorts of balancing acts are fundamentally ethical and there is no scientific fact about whether vaccination should be made mandatory or not it’s about weighing different values.”

Do the conditions exist right now to justify coercion or a mandatory vaccine?

Savulescu: “I don't think so. I don't think COVID-19 is severe enough. That it might sound a strange thing to say but the risk in the under 50 year olds is very small. If a vaccine were to be made mandatory, it should be made mandatory for people over the age of 65 because they’re at the increased risk of dying. Somebody who's 30 has the same chance of dying of COVID-19 as dying in a car accident.

Secondly if it were to be made mandatory, it should be made mandatory for older people. And I think the safety profile is inevitably going to be less certain than vaccines like measles or diphtheria or conventional polio, that have been around for decades. This is a new virus, and both the mRNA and the adenovirus vaccine are new kinds of vaccines. There’s never been a vaccine against the coronavirus, it’s a very unusual virus and so it’ll take a year or two years to see what sorts of rare side effects, if any emerge. So I do think that the safety profile is necessarily going to be different to other vaccines that we're more familiar with.” 

If we need to vaccinate 70 to 80% of the population to reach herd immunity that would mean not just the elderly need to get vaccinated? 

Savulescu: “There's a lot of uncertainty. Some people say a little as 50% of the population needs to be vaccinated for herd immunity. So again, it will depend on how long immunity lasts, which again, we don't know. So it may be that repeated vaccination of lots of age groups is necessary to control the virus and when people say we shouldn't have mandatory vaccination, you've got to remember that the comparison at the moment is to this mandatory lockdown. You also have to consider unemployment and economic devastation, and not getting other diseases treated, so you have to balance any vaccination policy against the other sort of problems that we're facing.

There's a huge elephant in the room that hasn't been discussed in terms of COVID-19 and that is ‘how do we value life? Are all lives equally worth saving? And how much should we spend to save a life?’ The governor of New York said, we should spend any amount of money necessary to save a life. That's nonsense, there are always limits. 

What's distinctive about COVID-19 are the huge stratifications in risk. If you're over 80, the chance of dying of COVID-19 is somewhere between 7 and 14%. If you're 10 years old, the chance of dying of COVID-19 is less than dying of chickenpox. So if the risks are very different and there hasn't been a direct confrontation of the issue that different people will have different chances of survival and what factors should we take into account when we allocate either ventilators or vaccines.

In the UK, the vaccination policy is simply to provide the vaccines to people who are at the highest chance of dying. So a 90-year-old was the first person to be vaccinated, but you might be 35 with a comorbidity and stand to lose 50 years of life, so you're more vulnerable to COVID-19, but maybe not as much as a 90-year-old. Should you be a higher priority candidate? What about health care workers, should they be further up the list in terms of priority? And what about quality of life? Is that something that should be taken into account? Many of the people who are at highest risk also have dementia, in some cases, severe dementia, to the extent that they might not recognize their family or other people, is that a factor that should be taken into account in the allocation of resources. Those issues haven't really been confronted. We've just divided all of our energy to COVID and not looked at risks of other diseases and how to allocate our resources in the fairest and most just way.”




Andrea Brody