Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; COVID-19) has infected 375 million people and has killed 5.66 million worldwide as of January 31, 2022. In the United States, 74.3 million people have been infected, and 883,000 have died. Primary-prevention measures intended to limit the spread of SARS-CoV-2 include vaccination, social distancing, masking, quarantining, and requent hand washing. Of these, only vaccination confers immunological resistance to viral infection.
Meaningful reduction of the burden of COVID-19 requires that the population attain herd immunity, defined as resistance to the spread of disease due to a significant majority of the population having developed immunity to the disease, either by immunization or natural infection. With respect to COVID-19, reliance on natural infection for the establishment of herd immunity is inherently dangerous, as it would entail preventable morbidity and mortality, and impose a considerable strain on the healthcare system. Population sectors that are generally healthy and have received a complete vaccination series have seen a significant reduction in COVID-19 infection. Large segments of the population, however, remain unvaccinated and account for the vast majority of ospitalizations due to COVID-19. With thirty-six percent of the U.S. population still unvaccinated or incompletely vaccinated as of this writing, there persists a substantial risk of infection and, thereby, fertile ground for the emergence of clinically significant viral variants.
Since its introduction by Edward Jenner in 1796, vaccination has allowed much of the world’s population to acquire resistance to myriad lethal bacterial and viral diseases. Vaccination has emerged as the most effective bulwark against COVID-19. If herd immunity to COVID-19 entails the acquisition of active immunity to SARS-CoV-2 by eighty to ninety percent of the population, then the COVID-19 threat should decelerate from its present pandemic level toward control, elimination, and, plausibly, eradication. On this basis, I wish to affirm that public-health ethics arguments support mandatory COVID-19 vaccination (with limited medical exemptions).
An ethical vaccination mandate presupposes that compliance with vaccination has not reached a desirable level through less-coercive measures on the ladder of “least-restrictive alternatives” that include education, financial incentives, and disincentives. There is robust historico-legal precedent for the constitutionality of public-sector vaccination mandates in the United States. The landmark decision of Jacobson v. Massachusetts (1905) is an example par excellence of such case law, in which it was decided that states may enact compulsory smallpox vaccination laws to protect public health. Public-health ethical considerations central to a COVID-19 vaccination mandate rest on the following facts: (1) the public-health threat posed by COVID-19 is extant; (2) less-coercive efforts have not encouraged sufficient voluntary vaccination; (3) COVID-19 vaccines are accessible to the entire population; (4) evidence of vaccine safety and efficacy has been widely disseminated; and (5) penalties for vaccination refusal, such as restriction of entry into commercial establishments, are reasonably proportional to the health-related risk of remaining unvaccinated.
Despite the incontrovertible success of vaccination mandates in the United States, conscientious ethical opposition to mandatory COVID-19 vaccination remains formidable. Discussed below are three main points of contention held by those opposed on ethical grounds to a COVID-19 vaccination mandate.
At the forefront of arguments held by those opposed to vaccination mandates is that the obligation to vaccinate constitutes an assault on personal freedom of conscience and freedom of choice (Wynia, 2021). Judicial decisions such as William O’Douglas’ majority ruling in Griswold v. Connecticut (1965) are invoked to uphold bodily privacy as one of the inviolable “penumbras and emanations” of the Bill of Rights. Public-health ethics arguments maintain, however, that restrictions on individual liberty, such as vaccination mandates, are justified if they prevent direct harm to the individual and others in his or her midst, particularly if less-restrictive measures have failed, and if the scope of the mandate is proportional to the threat posed by the disease.
Opposers of vaccination mandates hold that - in contrast to seatbelt laws, which impose restrictions on freedoms external to one’s body - coercive vaccination entails involuntary and irreversible alteration of one’s innate biological characteristics (Kowalik, 2021). From the opposers’ perspective, a vaccination mandate aims to augment - at potentially significant vaccine-related risk - the recipient’s heretofore healthy immune system for the sake of others in society with suboptimal immune responsiveness to vaccination, or for whom vaccination is medically contraindicated. Regarding coercive vaccination as discriminatory against intrinsic biological properties and, thereby, as an assault on the supreme right to “agent autonomy with respect to self-constitution,” Kowalik argues that compulsory vaccination for the sake of herd immunity instantiates an immoral means of attaining a purported moral good - a contradiction that precludes predicating mandatory vaccination on ethical grounds.
Kowalik, however, sidesteps two critical points. First, while a healthy immune system does have the repertoire to generate specific antiviral defenses in response to vaccination or by virtue of natural infection, the latter is conditional on surviving infection and the often devastating immunoinflammatory injury, termed cytokine storm, that can be wrought by the anti-COVID-19 immune response. It is precisely the healthy immune system that can be augmented by vaccination that stands to thwart the establishment and transmission of COVID-19 infection. Second, given that COVID-19 vaccination has a high safety profile and is eminently sensible from the standpoint of establishing herd immunity, individuals in civil society have a moral obligation to accept at least some personal risk and to concede a modicum of bodily autonomy through vaccination, just as individuals take on diverse risks such as military service or blood donation for the benefit of others in the community or in the population at large (Giubilini, 2020).
Those opposed on religious grounds to vaccination argue that a vaccination mandate would violate their free exercise of religion guaranteed by the First Amendment (Capron, 2021). Fundamental to public-health ethics, however, is that one’s religious practices, where they conflict with the law in matters of health and safety, are subordinate to the law of the land (U.S. v. Ballard, 1944), and that religious freedom, while essential to American society, should not be the overarching value in legitimating a vaccination mandate.
An ethical COVID-19 vaccination mandate, as suggested by Reiss and Caplan (2021), should balance the values of liberty, as it concerns freedom of choice and bodily autonomy; beneficence, manifested by prevention of harm due to COVID-19 disease; utilitarianism, in terms of establishing herd immunity aimed at protecting the greatest number of people; justice, with respect to equal access to the vaccine; and non-malfeasance, with regard to ensuring a high degree of vaccine safety. Finally, an ethical COVID-19 vaccination mandate should uphold the lofty public-health ethic of fairness, by challenging the choice of some to “free-ride” on herd immunity, and by enjoining the contribution of individuals to the public good, irrespective of personal benefit.
Capron, Alexander Morgan. “Covid-19, Free Exercise, and the Changing Constitution.” Hastings Center Report, 16 Nov. 2021, https://onlinelibrary.wiley.com/doi/full/10.1002/hast.1295.
Giubilini, Alberto. “Vaccination Ethics.” OUP Academic, Oxford University Press, 26 Dec. 2020, https://academic.oup.com/bmb/article/137/1/4/6047735.
Kowalik, Michael. “Ethics of Vaccine Refusal.” J Med Ethics, 2 Mar. 2021, https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3793981.
Reiss, Dorit R, and Arthur L Caplan. “Considerations in Mandating a New Covid-19 Vaccine in the USA for Children and Adults.” OUP Academic, Oxford University Press, 8 May 2020, https://academic.oup.com/jlb/article/7/1/lsaa025/5834620.
Wynia, Matthew K., et al. “Why a Universal Covid-19 Vaccine Mandate Is Ethical Today: Health Affairs Forefront.” Health Affairs, 3 Nov. 2021, https://www.healthaffairs.org/do/10.1377/forefront.20211029.682797/full/.