The strength of vaccination as a public health tool is that it both protects the individual and contributes to protection of the community by reducing the spread of disease. This is also its weakness: when individuals do not vaccinate, either because they cannot or choose not to, herd immunity – the state where enough individuals are immune to a disease to provide indirect protection by inhibiting community transmission – is weakened. Achieving very high rates of vaccination is therefore important to its success as a public health intervention. This blog post surveys the ethical and human rights considerations relevant in implementing vaccine mandates.
The Covid-19 pandemic has caused significant loss of life globally, in addition to ongoing pressures on health systems and the emerging evidence of longer-term effects of the disease. The near-miraculous development of multiple effective vaccines against Covid-19 within a year demonstrated the power of well-funded research and responsive regulatory action, building on decades of work in vaccine research. In combination with other public health measures, achieving high vaccination rates is a key part of the path out of the pandemic. As voluntary rates slow, and herd immunity remains elusive, it is tempting to look to vaccine mandates to get rates up and over the line.
What are vaccine mandates?
Vaccine mandates can encompass a range of sanction designs. Criminal penalties, such as fines and imprisonment, were a feature of nineteenth-century compulsory vaccination statutes requiring parents to have their children vaccinated against smallpox. Such laws were of variable efficacy, and fell into abeyance following the introduction of conscientious objection clauses in the late-nineteenth and early-twentieth centuries.
Modern mandates more commonly focus on specific groups through targeted incentives or penalties. Incentives, such as the now-repealed Maternity Immunisation Allowance, may not technically constitute a mandate, but can be significant enough, especially to those on lower incomes, that they operate in much the same way as a mandate. In recent years, incentive-based approaches have gradually been replaced by penalty-based approaches, such as the No Jab, No Pay and No Jab, No Play policies which restrict access to childcare and family assistance payments if children have not received the vaccinations required by the National Immunisation Program Schedule. While medical exemptions are available, these policies removed conscientious objection exemptions.
While the Australian government is always very careful to emphasise that vaccination in Australia is voluntary, the practical implications of these measures are such that childhood vaccinations are, except for the wealthy, essentially mandatory. Similarly, occupational vaccine mandates, such as certain childcare and aged care employers that require employees to be receive annual flu vaccines, are voluntary only in the sense that the choice is between vaccination and unemployment.
A return to population-wide vaccine mandates is extremely unlikely, but targeted Covid-19 mandates requiring evidence of vaccination for specific purposes, such as employment, travel or health insurance, are being seriously considered, if not already being implemented. Significantly, such mandates are going beyond previously accepted high-risk contexts, such as healthcare and aged care, and are being implemented in contexts such as a museum and a fruit processing plant on the basis of workplace health and safety considerations rather than under public health orders. This raises questions about the extent to which such mandates are ethical and lawful.