When Covid-19 first became pandemic, one of the immediate challenges was to develop a safe and effective vaccine to prevent if not infection then at least illness and especially severe illness. Such vaccines were developed in record time. The challenge then shifted to rolling out those vaccines to the world’s population. At a global level, meeting this challenge, far from breaking any records, has been a colossal failure. The vaccines have reached only a small proportion of the people who want and should have them.
Those countries that have had some success in vaccinating their populations now face a subsidiary rollout challenge — getting the vaccine into enough of those people who are resistant to or hesitant about being vaccinated (whether in general or against Covid-19 in particular).
Meeting this challenge is important, because having many unvaccinated people facilitates the spread of the virus as well as the emergence of new and more dangerous variants. In SA, so-called vaccine hesitancy is relatively low. However, nearly a quarter of South Africans are reluctant to be vaccinated. This raises the obvious questions: should vaccination remain voluntary? Should it be mandatory?
Many people balk at the suggestion that vaccination should be required. This, they say, would be a violation of a competent adult’s individual freedom. The problem with this argument is that a right to freedom, if it is to be consistent, must be bounded by the rights of others. This is why liberals, the staunchest advocates of individual rights, rightly claim that a right to freedom does not extend to (wrongfully) harming others. For example, I may have the right to cough, but I do not have the right to cough in your face, for that can (wrongfully) harm you.
In refusing to be vaccinated — or to wear a mask, or socially distance during the pandemic — one is exposing not only oneself but also others to harm. This is why those who claim a commitment to individual rights cannot dismiss mandatory vaccination by appealing to the principle of liberty. This does not mean the state would be justified in forcibly restraining people and vaccinating them. It would certainly be wrong for medical professionals, whether acting as agents of the state or not, to participate in forcible vaccinations of competent but nonconsenting adults.
Vaccine hesitancy — and even resistance — comes in degrees, and much of it can be counteracted with modest incentives
It may seem that we are now left with an inconsistency. If the state is justified in interfering with individual freedom to prevent harm, why is it not justified in forcibly restraining and vaccinating those who refuse the vaccine? Part of the answer is that the phrase “mandatory vaccination” covers a range of possible practices. At one extreme lies forcible vaccination. Not far along from that end of the spectrum are criminal sanctions, such as imprisonment, for those who refuse vaccination. Further away are fines for non-compliance.
However, there are other restrictions, including nonpunitive ones, that are much less extreme and could reasonably be imposed on those who refuse to be vaccinated. For example, it might be entirely reasonable to refuse the unvaccinated permission to enter restaurants, schools or universities, or to board an aircraft. Such restrictions have long been in place for other vaccinations. For example, one may not enter some countries without proof of vaccination against endemic infectious diseases, and there are jurisdictions in which children must be vaccinated to attend school.
Some may wonder whether the imposition of such restrictions would be sufficient to count as making vaccination mandatory. After all, if you can refuse vaccination, is it really required? However, there is an important sense in which the imposition of restrictions would render vaccination mandatory. Vaccination would be mandated, in the foregoing example, for anybody entering restaurants, schools or universities, or boarding planes. You are required to be vaccinated if you want to be admitted.
Least liberty-limiting
The reason we should prefer such less imposing versions of mandatory vaccination is that in seeking to prevent harm the state should interfere with freedom to the least degree necessary to prevent the harm. Because a right to decide what is done to one’s own body is an especially important freedom, alternative means of preventing harm should be employed. It is likely to attain high levels of vaccination via these alternatives. Vaccine hesitancy — and even resistance — comes in degrees, and much of it can be counteracted with modest incentives.
Because incentives need not only be negative but can also be positive — the proverbial “sticks” vs “carrots” — social policy should consider not only restrictions to encourage vaccination but positive incentives that involve lesser restrictions on freedom. Positive incentives such as financial ones sometimes have their own costs, and these should be weighed against the alternatives. The point is that the state has multiple possible strategies for encouraging vaccination, and it should choose the least liberty-limiting but nonetheless effective ones available.
While it would be ideal if everyone were vaccinated, the costs to public health of a small proportion of the population remaining unvaccinated are small — and sometimes smaller than the costs to those individuals who have special reasons not to be vaccinated. The benefits of requiring those people to be vaccinated could well be disproportionate to the gain. People in whom vaccination is medically contraindicated or people with deep religious or other objections can be accommodated in small numbers without significant cost to public health. In such cases, exemptions should, at least sometimes, be granted.
Determining who should be exempt is not a straightforward matter, but it is also not unique to Covid-19 vaccinations or even to vaccinations generally. There are nuanced ways of thinking about when and how to accommodate religious views and other matters of conscience, and these could be applied to exemptions from mandatory Covid-19 vaccination. Balancing ethical considerations is often not easy, but it is preferable to the alternative: answers that are straightforward, but that come at the cost of oversimplifying.
• Benatar, a professor in the department of philosophy at the University of Cape Town, is director of the Bioethics Centre.
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