To be truly ethical, vaccine mandates must be about more than just lifting jab rates

As New Zealand’s race to lift vaccination rates continues, and with pressure to lift social and economic restrictions too, the role of vaccine mandates is coming into sharper focus.

Yesterday the government signalled stricter rules will apply in health and education. But while public sentiment appears to be on the side of mandatory vaccination for certain sectors, mandates are still a big stick for governments to wield.

In particular, the threat of losing a job for not being vaccinated comes close to compulsion. That’s why it’s controversial, and why it needs to clear a high threshold of justification.

Before imposing mandates, governments have an obligation to provide trustworthy information about the risks and benefits of vaccines, to encourage as many eligible people as possible to get vaccinated, and to ensure vaccines are easy to obtain and their distribution is equitable.

So far, New Zealand’s vaccine rollout has been far from equitable. The government has been accused of ignoring warnings from Māori and Pasifika health leaders, leaving those already higher-risk communities vulnerable.

Nevertheless, at this point in the pandemic, with Delta spreading, it’s clearly essential that vaccine uptake is a swift as possible. So, as well as urgently improving vaccine accessibility, is it be justified to use mandates to lift numbers?

Medical mandates are different

Everyone who can get vaccinated should get vaccinated. By doing so, you protect yourself and help protect others from a potentially life-threatening virus at low risk to yourself.

Self-interest and obligations to others align. For individuals, vaccination is a win-win. What’s more, being vaccinated significantly lowers your chances of requiring intensive medical care and thereby taking up costly medical resources that others might need.

Read more: Why a domestic NZ COVID ‘passport’ raises hard questions about discrimination, inequality and coercion

When some individuals in a community are reluctant to do what they should to secure the basic needs of that community, it is sometimes justifiable to enforce co-operation.

Governments routinely use the threat of sanctions to compel costly pro-social co-operation – for instance, by requiring taxes be paid and requiring employers to implement health and safety measures.

But being forced to have a medical procedure is a different matter. We value autonomy over our own bodies highly. We intuitively recognise it would be wrong, for example, to force someone to donate their kidney to someone else, even if it would save their life.

Preserving bodily autonomy

Overruling an individual’s bodily autonomy should be used as an absolute last resort. And this holds even if we think the decisions others are making are wrongheaded, based on misinformation or utterly selfish. This is reflected in the Human Rights Act, which grants the right to refuse any medical treatment.

However, this still leaves scope for mandates because it is not the same thing as a forced vaccination. Rather, a mandate is a legal requirement that to be in certain settings (such as bars and restaurants), or in certain roles (such as a quarantine facility worker), one must be vaccinated.

Read more: Half of unvaccinated workers say they'd rather quit than get a shot – but real-world data suggest few are following through

If you really don’t want to be vaccinated, you can skirt the requirement by avoiding the places and roles it’s required for. No one’s bodily autonomy is violated.

Of course, the difference between this and compulsory vaccination to retain one’s job can be technical, even semantic. If mandates are to be used, therefore, it must be in a cautious and ethical way.

Public health is paramount

It’s also important to remember the vast majority of people who have not yet been vaccinated will not be hardcore “anti-vaxxers”. As well as barriers to access, people will have a variety of reasons, including uncertainty about the vaccine, inertia, and an aversion to needles.

Mandates will nudge the uncertain to resolve their uncertainties. They will motivate the foot draggers to get to the vaccination centre. And this wouldn’t be a violation of anyone’s autonomy, since these groups don’t object to vaccination as such.

Beyond that, mandates must be based on three main principles:

• they must be justified by demonstrable public health needs and not merely by their usefulness in achieving high vaccination rates

• they should not discriminate against particular groups (such as treating religious meetings differently to other indoor gatherings) so everyone feels they are shouldering equitable burdens and the bonds of reciprocity don’t fray

• they should be clearly about protecting public health, not shaming or shunning people; at a minimum, as Prime Minister Jacinda Ardern has said, everyone should be able to access basic services such as supermarkets, hospitals and pharmacies without having to show a vaccine certificate.

Read more: Health workers are among the COVID vaccine hesitant. Here's how we can support them safely

The price of one’s convictions

We should aim to ensure those who refuse vaccination still have as full a range of opportunities for employment and inclusion in social life as possible.

At the same time, no principle of justice requires society to guarantee the quality of life of those who refuse medicines is the same or as good as others enjoy. If one’s convictions entail exclusion from certain activities in life, sometimes that’s just the price of sticking to one’s convictions.

Balanced judgments still need to be formed about the merits of mandates in specific settings such as schools, bars and aged-care facilities. That will require weighing the practical and legal considerations, as well as the ethical and moral.

But vaccine mandates can and should be considered as a tool. For the small number of genuine objectors who are adamant they do not want to be vaccinated, it is true mandates will make life more restrictive.

But narrowly targeted and ethically designed vaccine mandates have the potential to ensure all but diehard anti-vaxxers will get the jab sooner rather than later. No one’s basic rights of bodily autonomy need to be violated. And strong measures to ensure maximal vaccination where it matters most will benefit everyone, including the unvaccinated.