Vaccinations by obligation?

The debate on the mandatory nature of vaccines has always been in favor of voluntariness in Spain.

The result has not been bad.

The obvious benefits of immunization and a proactive health system have led to very high rates of follow-up, even higher than in some of the eleven European countries where they are mandatory.

This has made it possible to achieve collective immunity without impositions.

But the covid-19 now opens a new scenario in which it is debated whether vaccination should be mandatory, something that raises important ethical dilemmas.

Until now, it was estimated that 70% of the vaccinated population would reach a level of collective immunity sufficient to stop the virus. That objective was feasible without resorting to the obligation. It was unlikely that, at least in our culture, 30% of the population stopped being vaccinated due to neglect or rejection. But with the delta variant, that 70% is no longer enough. Now it is necessary to vaccinate more than 90% of the population to achieve group immunity, and that is already more complicated. In many European countries, vaccination has slowed down, not because of a lack of vials, but because young people go less to get vaccinated.

WHO has always been more in favor of encouraging than compelling.

But several countries are already regulating different forms of enforcement.

In some countries, such as France, Italy or Greece, the vaccine is intended to be mandatory, under threat of sanction or dismissal, for health workers or personnel who care for frail people.

These and other countries also contemplate progressively coercive strategies for the general population, such as the implementation of a green certificate to access certain services or public spaces.

This certificate would be obtained with the complete vaccination schedule or a recent PCR test, to be paid for by each citizen, which in practice is a way of making vaccination inevitable.

More information

• The Constitutional Court prolongs the suspension of the Galician law that imposes compulsory vaccination

• The importance of vaccinating the laggards

• The mandatory vaccine: last option against the virus

Is that a good strategy? Is it justified from an ethical point of view? Bioethics has always had as a fundamental value the autonomy of the person, that is why it prefers persuasion to imposition. The obligation is only justified in serious and highly contagious diseases. And it must meet two requirements: that the purpose is legitimate and that it be proportional. It is about weighing the assets that the individual has to sacrifice, in this case their autonomy and freedom, against the collective benefits that can be achieved, in this case group immunity. The lower the weight of the first and the greater the second, the more justified the measure will be from the ethical point of view.

From an ethical point of view, there is not much difference between forcing confinement and forcing vaccination. Both limit autonomy and freedom. And both involve individual risks and sacrifices. What changes is proportionality. Precisely because we now have vaccines, the nature of the risk is different. At the beginning of the pandemic, the enormous sacrifice of confinement was justified because the death toll was staggering and the health system was at imminent risk of collapse. But in the case of covid-19, mortality is associated with age and certain health conditions. With most vulnerable people already vaccinated, mortality plummets. The risk among young people is very low, but it does not disappear: it is estimated that among those under 30 years of age,one in every 100 infected will have to go to hospital, one in 200 will need intensive care and one in 15,000 will die.

This raises a very difficult question to elucidate: How many lives do we consider acceptable to sacrifice for the sake of individual freedom?

We could answer that any avoidable death is already too much, but that does not lead us to prohibit traffic in cities despite the fact that pollution also kills.

Supporters of the obligation argue that the individual cost of vaccination continues to be much lower than the collective benefit.

Achieving group immunity not only protects individual individuals, it prevents the virus from circulating and has the opportunity to mutate into vaccine-resistant variants, which would be catastrophic.

They also argue that with mandatory vaccination, the burdens of herd immunity are spread evenly.

The main objection to the obligation is that the same ends can be achieved with persuasion and, furthermore, the fact of imposing something that affects the autonomy and freedom of the person, can be counterproductive and encourage, as has already been seen in France, anti-vaccine movements. Spanish law recognizes the right of the patient to refuse treatment, even when it is of clear personal benefit. Today no one disputes the obligation to wear a seat belt or wear a helmet if you go on a motorcycle. These are measures that have saved many lives. But the perception of vaccines is not the same. And above all, the risk is not the same for everyone. That is what complicates the debate.