I recently came across a peer-reviewed article called ‘The Ethics of Vaccine Refusal’ in BMJ Medical Ethics written by Michael Kowalik. The work is aimed at determining whether one has a moral obligation to be vaccinated, and with that comes the discussion of whether vaccinated coercion is justifiable. No direct mention of COVID is made in the paper but said situation is understood to be in the background as motivation. With the aim of better understanding the paper’s claims, and my own thoughts, this is my attempt at breaking down and commenting on the article. I will structure this somewhat like a question-answer conversation where possible, with the intention that someone reading this does not need to read the original work (although it is recommended) in order to get the big picture.

Disclaimer 1

I am not an expert in medicine or ethics.

Disclaimer 2

This post and the original paper are not intended to answer the question of whether one should or should not be vaccinated, rather whether there is a moral obligation to be vaccinated. With that, it should be noted that this does not constitute medical advice.

Problem setup

  • We assume that an infectious pathogen is present in the population which poses some level of risk on the general population (this is a stronger assumption that data implies for COVID where risk is heavily stratified by age and specific factors)
  • We assume that a vaccination exists against the pathogen,and is widely available, effective, and safe.
    • effective: the vaccine reduces risk posed by symptomatic infection of the pathogen in the recipient of the vaccine. We do not make assumptions about the source of this protection (it could come from reducing the probability of transmission, infection, or harmful symptoms).
    • safe: the vaccine poses a minor (but non-zero) risk to the recipient.

Under which conditions can an obligation to be vaccinaded (OTV) exist?

There are two situations under which OTV is examined:

  1. The protection of those who cannot be vaccinated
  2. The protection of public health at large (overcrowding hospitals, vulnerable populations, etc.)

If neither of these conditions are the case, OTV does not stand on solid ground. Take two fictional characters, Alice, and Bob. Alice wishes to not be vaccinated (we choose to respect her wishes and do not inspect her personal reasons for this desire), and Bob is willing to be vaccinated. If we assume that the vaccine is safe and effective, we can satisfy both Alice and Bob without the need for coercion since Bob will take the vaccine, and Alice’s wishes will be respected. Therefore, in this context the use of coercion will be strictly gratuitous and discriminatory to Alice’s individual autonomy. As will be seen later, this is also a desirable state of affairs for Bob since in this situation he will also live in a world where he is safe from the disease and free from coercion (an intrinsically desirable condition).

Kowalik examines the two conditions (termed disasters) in the context of vaccine coercion in the following section.

Does the prevention of potential disasters caused by non-vaccination justify the use of force to compel vaccination?

A previous work provides a logical ‘proof’ that the answer to the question is ‘yes’.

  1. The vaccine is widely available, has a low probability of harming the taker, and prevents serious illness from the pathogen.
  2. If a majority of people refuse the vaccine, a disaster ensues (general public health suffers, or many individuals are put at risk)
  3. Individual freedoms can be overridden to avoid disasters. Therefore,
  4. ‘It is permissible to force individuals to receive the vaccine’ (OTV)

Kowalik’s answer to this question is no. He notes that the proof above relies on two unfounded assumptions:

  • That non-vaccination will necessarily cause the disaster, and vaccination is the only way to avoid the disaster (no evidence to support this claim is known).
  • No larger disaster will be caused by forcing vaccination.

What could these ‘worse disasters’ look like? Here, the author introduces the notion of ‘a life worth living’. As discussed in one of my previous blog posts we can easily imagine situations where for the ‘sake of living (being alive)’ we create a world not worth being alive in. We can easily imagine that taking safety as the sole guiding principle would require the stripping of so many natural rights that life begins to resemble imprisonment, and furthermore no longer resembles life. For this reason, Kowalik employs the same language as many arguments for vaccinations which rely on principles of harm reduction to say that vaccine coercion constitutes a real harm to life. To avoid these ‘prisons’, we generally adopt the principle that the quality or desirability of any policy should pay a penalty proportional to the degree to which it strips people of their natural rights.

The natural rights in question here are described in the paper as ‘body autonomy’ (my body my choice). Similarly to freedom of speech, this right is self-evident (a.k.a axiomatic; their existence does not require justification, only their removal). We do not force people to walk around with helmets 24/7 even though it will certainly reduce head injuries because it pays a hefty penalty for limiting bodily autonomy. We also do not ask people to justify their right to not wear a helmet when walking down the street, it is self evident. Nevertheless, we can certainly debate whether limitations to this freedom ought to be imposed albeit while always considering this ‘penalty’. Therefore it is possible that these penalties can be large enough or accumulate fast enough so that a disaster is inevitable.

So in the case where we prevent harm to Bob by forcing Alice to be vaccinated, we have to consider that we have also harmed Alice in the process. Moreover the harm of coercing Alice to be vaccinated is concrete and immediate, giving it a larger weight than the potential harm to Bob of an unvaccinated Alice which only exists probabilistically. On the subject of a probabilistic harm (aka a risk), we have to also note that the protection conferred by a vaccine is never absolute. Rather, all we can say about an individual that is vaccinated is that there is some (hopefully low but never zero) probability that they will harm someone. Vaccinated Alice is only a strictly greater risk to Bob than vaccinated Eve if Alice and Eve have exactly identical lifestyles and immune systems. This is to say that if Eve is exposed to many more people than unvaccinated Alice, or innately has a lower chance of responding to the vaccination, or has sufficiently prolonged and proximal contact with Bob, it is very possible that Eve is a greater danger than Alice. These details are raised so that a fair ‘balancing of harms’ can be developed and to show that it is not at all a straightforward exercise. With all of that in mind we can ask, is the risk to Bob (who may or may not be vaccinated) so great that the harm to Alice is justified, and is this the only way that the risk can be averted? Unless the risk imposed by the pathogen is so large, the effect of the vaccine is unambiguous, and there is a severe shortage of less coercive alternative measures for protection, there is no de facto reason to override bodily autonomy.

Side note

Here, I believe there is an assumption that the existence of a moral obligation to be vaccinated is equivalent (or implies) a justification for the use of force to have people vaccinated. However, there are cases where moral obligations may exist but not a justification for the use of coercion to enforce that moral obligation. Freedom of speech comes to mind. The moral obligation against gratuitously insulting people certainly exists, but the use of legal action to enforce this moral obligation will likely tread of protections of freedom of speech. This is only to note that the paper quickly jumps from moral obligation to focusing on the justifiability of vaccine coercion.

Does one have an obligation to be vaccinated for the sake of those who cannot be vaccinated (herd immunity)?

This question is aimed at the first condition of OTV (protecting those who cannot be vaccinated). Kowalik here takes herd immunity as an overall good, with the condition that it be achieved without coercion. Generally, when coercion comes into play an unjust situation inevitably arises from the fact that the benefits and risks of herd immunity are not distributed evenly. Some group of people compelled to be vaccinated will inevitably pay a much higher price (averse reactions) for the same benefit (herd immunity) than others. It is important to note that the unfairness does not stem from the risk itself, but from the imposition of the risk by force. If that same group of people were to undergo the same risk voluntarily there would be no injustice.

Despite this fact, coercion for the sake of herd immunity is usually justified through two scenarios:

  • The existence of some group that cannot be immunized and thus requires everyone else to be immunized on their behalf.
  • Discouraging those who do simply not want to bear the risks of contributing to herd immunity yet reap the its benefits.

In both cases, we can call these ‘free riders’, i.e. those who for whatever reason do not contribute toward herd immunity but nonetheless accept its reward. Absent of coercion, the ‘problem’ of ‘free riders’ is not well-defined since herd immunity achieved by voluntary action means that those that benefit from it without contributing are given a benefit they had no choice to opt out of and so its very ‘unjustness’ is questionable.

If one still believes that ‘free riding’ is wrong and wishes to enstate vaccine coercion one has to realize that they are merely choosing among free riders and never eliminating them altogether. This is because there is no reason to provide a free pass to those who cannot medically be immunized by forcing otheres to be immunized versus giving the ‘free pass’ to those who do not wish to be vaccinated and foregoing coercion. Going further, if the medically ‘unimmunizable’ and those who do not wish to be vaccinated are equally not entitled to a ‘free ride’ then who is? We are left with those who are vaccinated and immunized. Those who are vaccinated and not immunized also constitute free riders. But if the only ones entiled to a free ride are those who are already immunized, by definition they are unable to benefit from herd immunity since they are directly immune, hence a contradiction. Hence ‘free riders’ cannot be a basis for the argument for mandated herd immunity.

Does OTV as a form of reducing the risk to someone else’s life find justification?

This is the uncontroversial principle of ‘do no harm’. Generally speaking we accept that one is expected to not deliberately put someone in harm’s way. If the vaccine makes it so that Alice is a lesser danger to Bob, she has the moral obligation to take the vaccine. We already saw that this princple can be applied directly in the case where coercing Alice into taking the vaccine actually harms her to a greater extent than the harm Bob was facing (by appeal to her bodily autonomy). Also by that token, if Bob expects Alice to take on a risk (adverse effects) for him, Alice is entitled to expect the same of him. Although some amount of evidence about vaccine safety and the dangers of the pathogen can be used to say something like ‘because the vaccine is generally safe, Alice has the lesser burden so she should take it’. Despite this, we also hold that individuals ought to be the ones to decide what level of risk they wish to expose themselves to; even if the vaccine is observed to carry a low risk, it is ultimately up to Alice to decide whether that risk is too large for her personally. This leads to the principle of self determination.

The ‘do no harm’ principle is not sufficient; following it exclusively leads to absurd situations and it certainly seems like we are headed in that direction. For this reason, an opposing principle has to come into play here, which is the principle of individual autonomy, whereby we hold that an individual’s ability to choose for themselves among possible actions according to their values is sacrosanct and a condition worth preserving (self determination). Earlier we established that this condition is at the core of human life, and degrading it is a damage to life itself. Because of the opposition between the safety and freedom principles, we will always find ourselves in a tradeoff between allowing for some degree of risk in exchange for some degree of freedom. Anyone that holds any regard for individual autonomy implicitly accepts some reduction in the safety principle and vice versa. In practice, if vaccinated people are broadly protected, the risk to daily life imposed by allowing a minority of people to also exercise their autonomy and refuse vaccination would not represent a significant enough risk to justify coercing them to be vaccinated. The only grounds for mandating vaccinations that remain would be to invoke a principle whereby one ought to minimize their risk to others however small it may already be. But again, this principle cannot stand on its own because Alice can just tell Bob that he should say home in order to minimize the risk that he poses her even though he is already vaccinated.

Does OTV promote discriminatory policies even though it is based on action and not immutable characteristics (e.g. age, sex, race)?

The crux of Kowalik’s argument lies in noting that indeed the obligation to vaccinate is fundamentally discriminatory. By this, we mean that it punishes natural and intrinsic qualities of human beings, on the same level as age, sex, gender, etc. Discrimination enters the equation when we realize that vaccinations are meant to augment our natural state (i.e. confer additional immunity to the one we were born with). Again, on its own, undertaking this action is not discriminatory. If one wishes to augment their natural constitution out of their own free will there is no conflict. However, by introducing an obligation to undergo this enhancement, the natural human state becomes unlawful (or at least immoral) and this is by definition discriminatory.

Does OTV find justification as a means of avoiding overburdened healthcare systems?

Until now we have generally studied the direct effects of vaccination on individuals (Alice, Bob, and Eve) or specific sets of individuals (herd immunity), but another potential disaster often comes to mind when considering that at a population level, lack of vaccination may cause indirect societal problems such as overburdened hospitals. The article does not deal with this case directly but implicitly as part of the possible ‘disasters’ that mandatory vaccination could circumvent. However, the argument for mandatory vaccination for the sake of the proper functioning of social healthcare systems is very common so I thought it could use a bit more reflection.

The first point is that we can recycle a lot of the above arguments (i.e. arguments from discrimination and individual autonomy). But we can also note that we have something of an inverted ‘free rider’ scenario. Here, an unvaccinated subset of the population creates a burden on the rest of society since in theory they would be occupying a disproportionate share of medical resources. (I am ignoring the argument for global vaccination in an effort to completely erradicate the virus as this is widely accepted to be unrealistic.) The first question is, why is the first attempt not to try to accomodate this increased demand for medical resources? Medical practitioners are generally trained to not withold treatment on the basis of behaviour (the doctor never asks why you need treatment or whehte you deserve it, he simply provides it). Hospitals routinely allocate resources to people that willingly follow lifestyles that require disproportionate shares of the system (e.g. smoking, driving, unhealthy eating, etc.). Why should we assume that the set of permissible risky behaviours should remain the same and always require the same amount of resources? On what basis should we choose between allocating resources for smokers and not those who wish to forego vaccination? Of course, one can say that the vaccine is known to be safe and thus not comparable to smoking. And again we say that we generally accept that risk calculations pertaining to one’s own body and property are to be carried out by individuals so deciding whether the vaccine is safe enough is not something we can impose externally. Before COVID, the assumption was that the healthcare systems exist as a means of support our freedom and thus allow for a healthy society. But now we are seeing an inversion of this principle where instead our freedom is spent for the sake of the healthcare system.

Moreover, to assume that certain risky behaviours ought not to be accomodated by healhcare systems is a premise that could have easily been defended pre-pandemic. Since healthcare systems have a finite amount of resources such that it is never possible to give everyone the best possible care, any reduction in demand for healthcare will always translate to the improvement of somoene else’s care. This creates a zero-sum game. If we were to outlaw basketball, the demand for knee surgeries would decrease which would directly translate to more resources becoming available to provide better care for cancer patients. If not for cancer treatments, these excess resources could be put to any other public good, such as charity, or investing in the prevention of terrorism, etc. This leads us to ask why we are willing to make such sacrifices for the sake of protecting the right to bungee jump, eat unhealthily, etc. but not to protect bodily autonomy. Of course, it could be the case that it is too difficult to make this sacrifice in the name of bodily autonomy (perhaps not enough doctors can be trained fast enough). This difficulty does not negate the moral harm of removing freedom for the sake of the functioning of the healthcare system but it can add some weight toward its necessity. Addressing this difficulty through coercive measures if ever should be done on a tempoarary manner, until the healthcare system adapts to the new conditions. However, after nearly two years of ‘emergency’ it is clear that vaccination and coercion have been accepted as the only ‘solution’ to the crisis and not a rebalancing of healthcare systems (even a slow and gradual rebalancing is unheard of).