Imperfect, but now more defensible than not

By Maria McDonald and Kevin Reel

As practicing healthcare ethicists, we have been asked: “Is it ethical to mandate* Covid-19 vaccination?”  Our answer six months ago would have been ‘not yet’. But ethical decision-making is typically about balancing facts with principles – like personal autonomy (freedoms) and beneficence (doing good). The principles of solidarity (acting together), collective good, prevention, and proportionality (reasonable restrictions to liberty to protect the public from harm) become increasingly important in a pandemic. Scientific knowledge changes.  The virus has changed. Other variables have changed. Our opinion has changed.

Some basic facts are that Covid-19 vaccines are very safe and effective, as demonstrated by the data on 27 million+ vaccinated people around the world. Covid-19 vaccines are not as ‘near perfect’ in their effectiveness as, for example, childhood vaccines which provide over 90 per cent protection. They are, nonetheless, the best option available at present – always in combination with other preventative measures such as distancing, masks, etc. Complications and side effects are minimal and well monitored. Public health decisions have been made considering all the information being collected. If you still cannot accept these premises, we’ll not change your mind here. Perhaps hearing about the experience of others who have reconsidered might be a better starting point for you.

With millions still unvaccinated in Ontario, there is too much opportunity for yet more damaging and deadly next waves, and for an even more virulent variant. Every person who is infected could be the source of another new variant. More certainly, every newly infected person is now more likely to infect others. Current statistics support the evidence that the unvaccinated are increasingly the most vulnerable to infection, serious illness, and long-term consequences. Nobody is completely safe.

Legally, there is a framework for introducing such mandates. Directives from the Chief Medical Officer of Health (CMOH) are one part of it.  The power to issue such directives arises once the CMOH forms the opinion that there is an “immediate risk to the health of persons anywhere in Ontario from Covid-19”.

Labour agreements do not necessarily prevent implementation of these mandates. One employment and labour lawyer has argued “In a unionized workplace, if there is nothing in the collective agreement to prohibit mandatory vaccination, an employer may unilaterally institute such a policy under its management rights.”

And ethically? Successfully managing the many threats of Covid-19 is only possible with collective action – the principle of solidarity applies. Threats include delays in diagnosis and treatment of non-Covid-19 patients – that is, any one of us. Acting together is the best way to prevent harm to any one of us, and to preserving public goods (like the health and community care system and its ongoing capacity to care for ALL people with ALL health concerns).

Society needs to consider the long view. With that view in mind, mandating some short-term constraints on personal freedom can be defensible and justified by virtue ethics (with qualities like prudence, fortitude, and selflessness guiding us), the ethics of care (recognizing our interrelatedness with others), and the evident consequences (foreseeable morbidity and mortality). We would hope that every reasonable person among us could agree that vaccination is ‘the best option’ in this extraordinary time.

Some are not convinced by these reasons, so we also appeal to the idea of duties. Our highly interconnected lives and networks now have the added connectivity of a dangerous and very contagious virus in our midst.  With our cherished autonomy comes responsibility. Everyone is responsible for considering – honestly and calmly – how one’s own decision to get vaccinated or not may affect others in our families and communities. Everyone has a duty to seek out credible resources, including trusted health care providers, to answer concerns or fears.

To help encourage vaccination during a typical flu season, healthcare organizations have used ‘behavioural nudging strategies’. These have also worked to some extent for Covid-19 vaccination. However, the increasing array of risks of harm from Covid-19 requires action beyond these gentler strategies. ‘Mandates’ increase the nudges to varying levels, reflecting the risks of the ongoing pandemic.

This is a race against time and harm. Even while lamentable, we now consider vaccination mandates defensible given the changed circumstances.  We argue this considering the individual lives that will be lost and others that will be damaged, and the high toll of further harms to the collective good if the spread of the virus is not minimized. We recognize that any defensible limitations to individual liberties must have their own limits, and we watch with interest legal challenges to these mandates. In our society, nobody will be ‘forced’ to get a vaccine, though some will have to make very hard choices between their reasons for not being vaccinated and the impact of adhering to those reasons if their workplace mandate includes termination. In the end, some unvaccinated individuals may have only two choices left: vaccination or a search for new employment with an organization not requiring vaccinations. Imposing this decision on that small minority of staff is a difficult decision to take. Those who make that choice clearly do so with great reluctance and fully recognize that few moments in living history have presented such strong arguments for this sort of temporary limitation on certain liberties.

Ontario is necessarily preparing for a difficult fall and winter with the next wave of COVID patients – likely involving more children this time. Yes, these mandates are an unprecedented limit on some personal freedoms, but they are an arguably defensible approach to an unprecedented situation society can only face collectively. With the long view in focus, short term mandates will allow all to return – safely – to enjoying the individual freedoms to which we are accustomed.

*‘Mandates’ for vaccination take many forms – essentially introducing any of a range of measures to promote vaccination. These include regular Covid-19 tests at differing intervals, to unpaid leave of absence, and in some cases termination of employment. The specifics are outlined in individual policies; no system-wide prescribed policy exists – only Directive 6 and its required minimum of vaccination, medical exemption or completion of education session.

Maria McDonald is an adjunct member of the Joint Centre for Bioethics, Dalla Lana School of Public Health, University of Toronto and Kevin Reel is an Assistant Professor with the Department of Occupational Science & Occupational Therapy at the University of Toronto and the Dalla Lana School of Public Health.