Should COVID-19 vaccines be mandatory?

A complex debate, with no simple answers.

By Maryanne Demasi, PhD

There are few medical issues more polarising than COVID-19 vaccines. 

Now, the debate has pivoted to whether they should become 'mandatory'.

In 2019, the World Health Organisation declared that vaccine hesitancy was one of the top ten global health threats. 

The constant flip-flopping of COVID-19 science policies over the last year has only deepened fears about getting vaccinated. But will making the COVID-19 jab compulsory solve the issue of lagging vaccination rates? 

No jab, no pay

Last week, Australian food manufacturer, SPC, broke ranks and became the first Aussie company to mandate COVID-19 vaccines for all its employees, without any official Government health directive. 

The move has dialled up outrage on social media, many vowing to boycott SPC products, but the company has the support of some political leaders.

At a recent press conference in Sydney, Premier Gladys Berejiklian pleaded with businesses. 

“If you’re a boss, if you’re an employer…please put pressure on your staff to get vaccinated. We’re doing that, we need you to help us,” Ms Berejiklian said.

The World Economic Forum encouraged employers to fire unvaccinated workers, tweeting that it supported employees being forced to choose between taking one of the COVID-19 vaccines, or face unemployment.

In the US, President Joe Biden, has now ordered that all civilian federal workers must have COVID-19 vaccinations or face weekly testing and other restrictions. Some have complained it doesn’t go far enough demanding that employment should be contingent on vaccination. 

SPC’s announcement is expected to encourage other Australian businesses to follow. Major airlines, Virgin Australia and Qantas have called for a government-led vaccine mandate for all airline employees doing operational work. 

And a slew of US businesses are already mandating COVID-19 vaccines for their employees, including Facebook, Google, Uber, Delta Air Lines, Cisco, Microsoft, and Ford. 

Earlier this year, the Indonesian government declared that COVID-19 vaccination would become mandatory for all its citizen. Anyone who refuses the jab will be punished with a fine, freezing of social aids or a suspension of access to public services.

While there is no official policy to mandate vaccines by the Australian government, Prime Minister Scott Morrison has handballed it to businesses to make their own decisions. 

The businesses will need to shoulder much of the legal risk if one of their employees is harmed by the vaccine, prompting the Australian Chamber of Commerce and Industry to call for indemnities, which have already been offered to doctors and the vaccine manufacturers.

Is mandatory vaccination a good move? Let’s explore.

Protecting the vulnerable

In Australia, mandatory vaccination already exists in areas of aged care, childcare and health, because the job requires contact with vulnerable members of the community. In June, the Federal government took it one step further.

Scott Morrison PM announced that "COVID-19 vaccinations" would be mandated for residential aged care workers as a condition of working in an aged care facility. Some states have also mandated vaccines for high-risk workers such as those in quarantine. 

Similar laws have been introduced in countries such as the US, UK, Italy, France, and Greece (with exemptions for religious beliefs, medical contraindications, or philosophical grounds). 

It has sparked fierce protests and left many healthcare workers feeling slighted (see photo).

It is argued that health care workers have a moral and ethical obligation to do everything possible to avoid exposing their vulnerable patients to the virus, especially in a setting where the virus disproportionately affects older people, and hospitalised patients who are more likely to suffer the serious sequelae of COVID-19 harms.

In the UK for example, it was reported that over 40,000 people in hospital caught COVID-19 while in hospital being treated for another illness. Some patients and nursing home residents died from infections they caught from their caregivers. 

Over 50 US medical organisations such as the American Medical Association, the American College of Physicians, and the American Nurses Association, have called for compulsory vaccination of healthcare staff. 

So, if it is supposedly a ‘no brainer’, why is there strong opposition to mandatory COVID-19 vaccination?

Objections to mandatory vaccination 

1.   It’s an “investigational” vaccine 

There are important differences between the COVID-19 vaccines and our existing, fully tested, fully approved, fully licensed vaccines. 

COVID-19 vaccines are still technically “investigational,” according to researchers in the BMJ. In the US for example, Pfizer, Moderna and J&J vaccines only have “emergency use authorisation” by the Food and Drug Administration (FDA).

That said, the FDA is expected to grant a full marketing license to the Pfizer vaccine by the end of the month, which is predicted to spur a wave of vaccine mandates in the private sector as well as schools and universities.  But there is vigorous objection already. 

A group of clinicians, scientists, and patient advocates have petitioned the FDA to refrain from fully approving any COVID-19 vaccine this year, asking it to “slow down and get the science right” before rushing to grant the vaccines a license. 

“We believe the existing evidence base—both pre- and post-authorization—is simply not mature enough at this point to adequately judge whether clinical benefits outweigh the risks in all populations,” they wrote in the BMJ.

Australia’s drug agency, the TGA has only granted “provisional approval” to the Pfizer, Moderna and AstraZeneca vaccines, which will last for two years and require the agency to continually monitor data as it becomes available. The phase 3 trials are ongoing and not scheduled to be completed until 2022/23. 

2.   Vaccinated people can still transmit the virus

We have been told by political leaders and health authorities that cities such as Sydney could be facing an “indefinite” lockdown — with only one clear pathway out – and that is to get everyone vaccinated to prevent transmission of the delta strain.

Last month, CDC Director Rochelle Walensky released research showing that fully vaccinated people infected with the delta variant, are carrying “high viral loads”, and that these vaccinated people had “measurable viral loads similar to those who are unvaccinated and infected with the delta variant.”

The authors of the pre-print study stated, “The study findings indicate that the delta variant of SARS-CoV-2 is capable of inducing infection even in fully vaccinated individuals and that a significant proportion of vaccinated individuals with breakthrough infections are capable of transmitting the virus to others”. [emphasis added]

In an interview with MSNBC, top White House advisor Dr Anthony Fauci stated: 

“Without a doubt, if people who are vaccinated get a breakthrough infection, they actually have enough virus in their nasopharynx , that they can actually transmit it to other people”.

Similarly, in the UK, Public Health England released a technical briefing (Page 35) which showed that the viral loads detected with the widely used PCR test, were similar in vaccinated and unvaccinated individuals. 

To be clear, COVID-19 vaccination does reduce the likelihood of acquiring an infection, but it does not completely prevent it (not 100% effective), therefore, vaccinated people can still transmit to others for which they care, especially if they are asymptomatic and complacent about continuing adherence to non-pharmacological control measures such as hand hygiene and social distancing.

3.   Why vaccinate those already immune?

Globally, it is estimated that over 200 million people have contracted COVID-19, over 182 million have recovered and as a result, have developed natural immunity. The CDC recently urged people to be vaccinated, despite having natural immunity.

But many argue that the ‘blanket recommendations’ to mandate vaccines for everyone, including people who already have “natural immunity”, is not only unnecessary, but wasteful, especially where there are shortages of vaccines to go around.

“Vaccine-acquired” immunity is mounted against the spike protein on the outside of the virus. But “naturally-acquired” immunity is mounted against the entire surface of the virus, some arguing that it is similar, if not superior, immunity especially against variant strains.

Israel is an interesting test case - it has very high vaccination rates but is now struggling with the new delta variant sweeping through its largely vaccinated population.

Data released by the Ministry of Health showed that in their latest delta wave, Israelis who were vaccinated were 6.7 times more likely to get infected by delta, compared to people who had existing natural immunity from a previous infection. 

Put another way, of the 835,792 previously infected Israelis who had recovered from Covid, 72 were re-infected with delta (0.009%) compared to 5,193,499 vaccinated Israelis of which over 3,000 were re-infected with delta (0.06%). 

For this reason, two high profile US senators have publicly declared that they would not be getting vaccinated since they had already acquired “natural immunity” from a previous COVID-19 infection. 

Further, a US study (pre-print) analysed 52,238 employees in an American healthcare system and found that vaccinating people who had already recovered from COVID-19 (that is, those with natural immunity), did not improve their immunity.

In no way is anyone encouraging people to deliberately contract COVID-19 to acquire natural immunity, but experts want a more selective approach to vaccination.

“The notion that we have to vaccinate every living [adult]– and eventually every newborn – in order to control the pandemic, is based on the false assumption that the risk of dying from COVID-19 is equally distributed in the population. It's not,” said Prof Martin Makary of Johns Hopkins Hospital.

A UK study showed a “substantially reduced risk of re-infection in the ensuing 6 months” after someone has recovered from SARS-CoV-2 infection.

A group of doctors are petitioning California Health to reconsider mandatory vaccination for healthcare workers, because it ignores the principle of medical necessity by imposing a medical treatment, with no added clinical benefit to the already immune vaccine recipient.

“To impose this draconian mandate on already immune members of the California medical community and the citizens of California is vastly unreasonable and unsafe,” they argue.

In a world where personalised medicine promises to focus on tailoring medical therapies for the individual, many argue that indiscriminately vaccinating everyone, is too heavy-handed.

4.   Does mandating vaccines persuade the vaccine hesitant? 

Policy makers justify the use of mandatory vaccines to increase vaccine uptake. However, it has been argued that forced vaccination can backfire, and fuel anti-vaccination views and breed mistrust. 

In 2020, researchers analysed the impact of Australia’s mandatory ‘No Jab, No Pay’ and ‘No Jab, No Play’ immunisation policies on parental attitudes to vaccination.

Notably, the researchers studied the behaviour of vaccine hesitant or refusing parents and found that despite potential loss of family assistance payments or access to childcare or kindergarten, the ‘No Jab’ policies did not change their behaviour. 

In his latest book, Vaccines: Truth, Lies, and Controversy, Prof Peter Gøtzsche writes, "mandates do not improve vaccine confidence, but make opposition to vaccination even stronger.”

Prof Gøtzsche writes about the impact of mandatory vaccination in Europe which was assessed by the EU-funded ASSET project – it found “no clear link to vaccine uptake”. In the end, better organisation of healthcare systems and strong communication strategies were proposed to be more effective than punishing people for not being vaccinated and depriving them of privileges.

Recently, seatbelt mandates have been cited as an example of where “mandating” an intervention has been successful. This is an unscientific comparison. Yes, seatbelt mandates have saved lives. 

However, it took many years to gain acceptance, time we do not have in a pandemic. Also, seatbelts are removable, they don’t have adverse harms associated with being injected in the body, and do not have unknown long-term harms. An excellent summary of the false equivalence between seatbelt and vaccine mandates is published by Dr Juan Gérvas here:

5.   The slippery ethical slope

Many are fearful of the dreaded “slippery slope” scenario, where something may seem reasonable at the time, but it opens the door to other laws that violate our right to choose and we may be forced to comply.

Many are questioning the ethics of the indiscriminate, widespread vaccination of everyone without considering the individual risk. Some have claimed that mandating an “experimental” vaccine, is a violation of the Nuremberg code which states:

“The voluntary consent of the human subject is absolutely essential. This means that the person involved should have legal capacity to give consent; should be so situated as to be able to exercise free power of choice, without the intervention of any element of force, fraud, deceit, duress, over-reaching, or other ulterior form of constraint or coercion;”

Fact-checkers have been busy labelling this as “misinformation,” refuting that the vaccines are “experimental”, however, the factsheets distributed to vaccinees in the US are clear:  

“There is no FDA approved vaccine to prevent Covid-19.”

“Compulsion strips healthcare providers of a basic right guaranteed to every other patient - the right to informed consent,” argues Prof Gøtzsche in his book.

“It is an intrusion in one person’s body in order to possibly (this hasn’t even been documented in reliable research) lower the risk of something untoward happening to another person”, he adds. 

“Some fundamentalists can only see positive consequences of vaccinations. When such people are in power, things can go badly wrong.”

Supporting mandatory COVID-19 vaccination for all, means supporting the disclosure of someone’s medical status. If we force people to disclose their medical status, regulate their behaviour, and infringe on their civil liberties, it is the definition of health fascism, and runs counter to a free and liberal society.

Creating a society of division has had, historically, dangerous consequences. What will our society look like once we deny people their freedom of choice?