Mandatory vaccinations? May not be justified right now, bioethicist says

A Western University expert on medical ethics says mandatory COVID-19 vaccinations for the general public are unlikely to be ethically justified right now, because it's not clear such a policy would reduce the number of infections or deaths. Also, the limits on vaccine supply also make mandatory vaccinations ethically problematic.  

In a policy brief published for the World Health Organization, bioethicist and assistant professor Maxwell Smith wrangles with the thorny issue of mandatory immunization, in an effort to give guidance to governments. Smith, a member of Ontario's vaccination task force, said mandatory vaccine orders are not uncommon, although they don't typically include criminal punishments for those who opt not to get a shot.

What's more common are rules that restrict access to things like schooling, health care or certain types of employment for those who choose to not get vaccinated. So far, governments in Canada have ruled out compelling all citizens to get a shot, though some employers have considered making shots mandatory for certain workplaces, such as long-term care homes. 

And while Smith argues such polices can be justified in certain situations, such as health-care settings, it's important to first consider the consequences "including if this could threaten public trust or lead to reductions in our already overwhelmed health workforce."

Smith lays out some guiding principles to consider when weighing whether to make vaccinations mandatory.

He said any mandatory vaccination order has to:

• Be directed to a specific and important health-care goal, and if that goal can be achieved through less coercive methods — such as education — then mandatory immunization isn't ethically justified.
• Come with strong evidence that the vaccine is safe and effective.
• Happen in an environment of sufficient supply (which is lacking right now).
• Weighed with consideration given to the overall effect on public trust. Without this, Smith says a mandate order could actually reduce participation. 
• Happen only after a transparent decision-making process with care taken to respect the rights and views of different groups so as to not "discriminate or disproportionately disadvantage vulnerable populations."

In laying out its vaccine plan, the Ontario government gave the first priority to seniors in long-term care, where the disease has caused the most deaths. From there, other groups have been prioritized, including those with underlying health conditions, Indigenous populations and front-line health-care workers. 

'No clear way' to do this

Smith said while these prioritizations can be ethically justified, it's never easy to place priority on one group over another. 

"There's no clear way to do any of this," he said in an interview with CBC News. "When you're dealing with a scarce resource, when you do prioritize one group, that means another group won't be prioritized so there's always going to be debate and controversy about these decisions. And I don't think anyone is doing their job if they're not struggling with that all of the time." 

Trying to achieve fairness means putting the focus on those most at-risk for "negative health outcomes" when establishing the priority, Smith said. 

"What 'fair' really means in this scenario is to look provincially at the populations that are at greatest risk of severe disease, hospitalization and death and among those groups make sure you have an equal chance at becoming vaccinated."