Ethical concerns surrounding mandatory vaccination: Perspectives of healthcare practitioners

INTRODUCTION

Vaccines, although generally considered a safe and effective means of preventing communicable diseases, are neither perfectly safe nor perfectly effective. For instance, some individuals may experience adverse effects after the administration of vaccines, while occasionally some vaccine recipients may not be fully protected. Vaccines, however, rarely cause serious adverse events as most adverse events associated with vaccines are minor and usually involve local soreness or redness at the injection site or perhaps fever for a day or two.^[1]

During outbreaks of infectious diseases that result in epidemics or pandemics, millions of lives are at risk particularly when there are no effective vaccines against the pathogenic organism. Such outbreaks disrupt normal life and are associated with huge economic costs. For instance, in West Africa, between 2014 and 2016 the Ebola virus epidemic led to about 30,0000 deaths, while the recent Coronavirus Disease 2019 (COVID-19) pandemic led to the loss of millions of lives globally.^[2] In both situations, the narrative changed with the discovery of specific vaccines that were unavailable when the disease outbreaks started.

The availability of a specific vaccine against an infectious disease can only effectively reduce the threat of massive loss of lives if a sufficient proportion of the public is vaccinated. This can be achieved easily when the people are willing and given the opportunity to be vaccinated. The decision to get vaccinated does not only affect the individual who receives the vaccine but also people around the individual and the general public as well. The concept of “community protection” technically termed herd immunity is the situation where a sufficient proportion of the population becomes immune from a particular infectious disease through vaccination (or previous infection) and thus unvaccinated members of the same population become indirectly protected because the high immunization rate prevents further transmission of the infection.^[2,3]

Attaining herd immunity is particularly important as it provides coverage to the proportion of the population that cannot receive the vaccine because of their age, disease condition, immune-compromised state, or other medical reasons.^[2,3]

Poor vaccine uptake is often seen in countries without policies demanding the mandatory vaccination of citizens. Identified factors that promote poor vaccine uptake include religious beliefs opposing the use of vaccines, the fear of iatrogenic diseases, the belief that vaccines are unnecessary or ineffective in preventing diseases, concerns about immune system burden, and state vaccine exemption policies.^[4-7] The policy to compulsorily get people vaccinated for the common good of the general public can be considered an ethical decision. In this context, ethics may be described as principles and values that govern human behavior in line with societal expectations.

Decisions about the use of vaccines are based on the relative balance of risks and benefits, although this balance may change over time.^[8] Vaccination laws were first enacted to control epidemic diseases. Now, they are also used to increase coverage with vaccines that are deemed important to protect the public’s health even in the absence of epidemics. The introduction of new vaccines to protect individuals and communities from emerging infectious diseases usually leads to an expansion of the scope of vaccination laws by countries. However, this practice is increasingly becoming subject to challenge and public outcry.^[9]

Publicity about adverse events alleged to be caused by vaccines has enhanced the controversy surrounding the recommendation and use of vaccines.^[10] Controversies surrounding the use of vaccines are further fueled in situations where mandatory vaccine coverage is suggested when there are no visible threats from the disease in question.^[9] The occurrence of new adverse events linked to the use of vaccines further feeds the controversy. For instance, the occurrence of intestinal intussusception after administration of the rotavirus vaccine led to a withdrawal of the vaccine and lent some support to the arguments of those opposed to vaccination.^[11] Persons opposed to vaccination have extensively used the internet and social media to communicate their beliefs regarding vaccines resulting in an escalation of the apprehension and negative perception of the public toward the uptake of recommended vaccines.

The Nigerian government in October 2021 declared COVID-19 immunization mandatory for civil employees and set a deadline for anyone who was not fully vaccinated to be barred from working.^[12] Some persons have faulted this declaration and considered it a contravention of the ethics of clinical practice in which no human should be coerced into undertaking any clinical intervention. This study was thus aimed at evaluating the ethical concerns surrounding vaccination mandates from the perspective of Nigerian healthcare practitioners.

MATERIALS AND METHODS

It was a cross-sectional survey carried out among healthcare practitioners practicing within the Uyo metropolis in Akwa Ibom state, Nigeria. Healthcare practitioners who participated in the study included pharmacists, physicians, nurses, medical laboratory scientists, and community health extension workers. A purposive sampling technique was used in recruiting participants for the survey. The interview session focused on identifying ethical concerns surrounding vaccination mandates by the government from the perspective of healthcare practitioners.

RESULTS

DISCUSSION

The uptake of vaccines globally is less than optimal.^[14] Epidemic outbreaks in various parts of the globe in the past have shown the risks associated with poor vaccine coverage. Legislation on mandatory vaccination has been enacted in many countries to curb the threat of the outbreak of vaccine-preventable infectious diseases. Subtle, non-coercive measures to improve vaccine uptake such as public health enlightenment campaigns have reportedly not yielded the desired improvement in vaccine uptake. On the other hand, mandatory vaccination has been identified as the major component of the global polio eradication strategy that has recorded tremendous success.^[14,15]

The majority of the healthcare providers interviewed in our study agreed that it is common for governments and institutions to mandate certain measures to protect the well-being of individuals or communities. In their assertion, such mandates can be ethically justified, as they may be crucial to protecting the health and well-being of the public. The Australian government, in a bid to eliminate conscientious objections to vaccination and encourage families to present their children for vaccination as scheduled, enacted the “No jab, No Pay” legislation in 2016. Similar mandates on vaccination have also been reported in some parts of Europe and some states in the United States of America.^[16] Such mandates have reportedly been associated with increased vaccine uptake. For instance, legislation making the evidence of immunization a requirement for entry into schools, childcare access, and access to welfare benefits resulted in increased vaccination rates in Europe.^[16-19] Usually, there is an increase in the uptake of vaccines when vaccination is made a prerequisite for school entry or associated with certain financial benefits.^[16]

We found that the majority of the respondents agreed that mandatory vaccination is justifiable if sufficient evidence shows that it is efficacious in interrupting the transmission chain of infection and preventing harm to others. In Italy, a study exploring the attitude of pregnant women toward compulsory vaccination reported that about 80% of the women interviewed were favorably disposed toward compulsory vaccination.^[20] The opinion of members of the public regarding mandatory vaccination varies. Some people, usually referred to as “anti-vaxxers,” are out-rightly against vaccination, while others who may not be averse to it are against the involvement of the State and the enactment of laws making vaccination mandatory. Yet, there are some people who are only concerned about the safety of the vaccines.^[21-24]

More than two-thirds of our respondents agreed that in a pandemic situation, employers may be justified in demanding vaccination status from employees and applicants. According to Wicker and Marckmann, mandatory flu vaccination of employees in the healthcare sector is only ethically justified if the vaccine is effective in preventing influenza infections in the general population and specifically among healthcare workers; and there is sufficient evidence supporting the claim that vaccination of healthcare workers against flu would reduce morbidity and mortality in patients who receive care from the healthcare providers.^[25]

A vaccine mandate is often perceived as a form of coercion from a government that limits people’s autonomy and freedom of choice. The extent and degree of coercion may vary and include restricted access to social amenities, or threatening punishment such as payment of fines, or forced vaccination in extreme cases. An attempt to enforce vaccination mandates brings to bear the notion that vaccination is not a personal choice, but an obligation to society. Mandatory vaccination policies appear to be an effective strategy to optimize the uptake of vaccines, enhance immunization rates, attain herd immunity, and prevent further transmission of infectious diseases. Reports from different sites have shown increased uptake of vaccines following vaccine mandates.^[26-29]

In many countries, mandatory vaccination is used for vaccine-preventable diseases affecting children.^[30] For instance, in Australia, parents are required to show evidence of vaccination of their children before being eligible to receive some social welfare benefits. In Italy and the United States of America, evidence of vaccination is a requirement for enrolment into some public schools and childcare centers. In some cases, adult healthcare providers are required to show evidence of vaccination before they are allowed to offer care to patients.^[31]

A report on ethical issues surrounding public health interventions recommends that the seriousness of the threat of the disease to the general population and the risks associated with the disease and the vaccine be taken into consideration when assessing the acceptability of a policy on vaccination.^[32] According to Savulescu et al., mandatory vaccination may be ethically justified if the infectious disease poses a serious public health threat, the safety and efficacy of the recommended vaccine have been established, the use of mandatory vaccination is a more cost-effective approach compared to other measures, and the level of coercion is suitable and commensurable.^[33]

CONCLUSION

In the opinion of the majority of the healthcare professionals who participated in the study, vaccine mandates may be ethically justifiable, as they may be crucial to protecting the health and well-being of the public. It is important for the government to take ethical concerns into consideration before enforcing mandatory vaccination on its citizens.