Why making vaccinations compulsory should be a last resort

Millions of Australians are in lockdown. NSW has a Delta epidemic that is hard to beat down and we face a long painstaking process to get high COVID vaccination coverage as a nation. So it’s inevitable that vaccine mandates will increasingly pull focus.

A requirement to vaccinate is an intuitive solution. On Monday, Peter Singer made the ethical case for mandates. Yet before we start urging community-wide mandates, governments should do all they can to get vaccines to the people who want and need them. Even a good vaccine supply is not an automatic guarantee of vaccine accessibility. Motivated aged care workers are still reporting real barriers to vaccination.

Retail worker Dara Knowles receives his first AstraZeneca shot on Monday.Credit: Penny Stephens

While the situation is improving with on-site vaccination, new walk-in clinics and vaccination events targeting priority groups, actual access to the vaccine has been limited for many. Bookings have been primarily online, which is difficult for many, and hard to find. There has been little choice about time and location. People with caring responsibilities, people without paid leave or sick leave, people who cannot comfortably line up for long, people with limited options for transportation have all faced barriers to accessing vaccine.

Mandates to vaccinate can be justified in certain higher risk settings where a vaccinated worker protects a person they encounter, like a patient, or as exemptions from certain lockdown restrictions. On Saturday, NSW Deputy Premier John Barilaro announced a scheme for vaccinated workers from the hard lockdown LGAs to be allowed back on site next week if they meet certain vaccination requirements. This is a vaccine mandate, and it is reasonable given we need certain industries to continue to operate.

But as a strategy to get generally high community vaccination coverage, there will be harms from jumping to mandates without exhausting reasonable options. Poorly thought up “pop-up” mandates from any sector will lead to chaos and the kinds of harms that compete with the ultimate aim of vaccination – human wellbeing.

Community-based mandates have a slightly different aim to occupational ones – to get high vaccination coverage. Yet they suggest that people have to be forced, rather than accepting that for the most part people want to do the right thing.

Talk about mandates takes the focus of vaccination off its delivery and place it squarely on the shoulders of individuals. Mandates implemented too early and without just process will fail to account for the real concerns of some about AstraZeneca vaccine safety where a real but small risk lies, that have been augmented by inaccurate and mixed messaging. They risk unnecessarily politicising people who are on the margins of vaccine acceptance who just want to address their concerns well. We have seen adversarial responses overseas to mandating vaccination in order to fully participate in social life – and the “us v them” chasms that appear to be widening as a result.

The World Health Organisation sets out pre-requisites for vaccine mandates to be justifiable. The mandate must be necessary to achieve an important public health goal that can’t be achieved by using other reasonable means (e.g. mask wearing, distancing, testing). The vaccine must be safe, and it must be effective. As well as protecting the individual, it must also be able to prevent spread to some degree so that it protects the public. There must be enough vaccine for everyone who wants it, and mandating the vaccine must not undermine public trust. These last two points are where the problems of mandating vaccine lie in Australia.

All of this is not to say that mandates are always unjustifiable. If dramatically improving access and communications does not drive up vaccination where it is needed, and quickly, then they may be desirable. But there are other, less coercive, measures to try first. A graded approach might be reasonable – mandatory vaccination for high-risk settings and mandatory documentation of protection in moderate risk settings – all calibrated to the background rate of community transmission. Israel’s COVID green passport required vaccination, evidence of recent infection, or evidence or recent negative COVID test as sufficient. Now they have high enough coverage, the passport is no longer required.

If mandates are deemed necessary, then how they are carried out is at least as important as the goal of high vaccination uptake. Employees should not discover that they are subject to a mandate on the evening news. Employers who want to ensure high vaccine coverage in the workplace should provide vaccination at work, paid time off for all staff to receive it and, if necessary, recover from it. Instead of talking about why some groups are hard to reach, we could be focusing on what makes vaccination services hard to use. Meaningful and transparent consultation and planning now will benefit trust in public health and vaccination that will pay future dividends.

Jane Williams is a public health ethicist at Sydney Health Ethics at the University of Sydney. Julie Leask is professor at the Susan Wakil school of nursing and midwifery at the University of Sydney. She is an adviser to the World Health Organisation on improving vaccination uptake.

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