8.4 Mandating Vaccination Anthony Skelton and Lisa Forsberg The race to develop a vaccine for COVID-19 is on. Finding a vaccine is the most promising route to lifting the public health restrictions currently in place to prevent the spread of coronavirus, which has already killed hundreds of thousands of people and infected many more. It is possible that a viable vaccine candidate may emerge in the not-too-distant future. At the height of the pandemic, Canadian prime minister Justin Trudeau was asked whether he would mandate vaccination for COVID-19. He replied that "we still have a fair bit of time to reflect on ... [the best vaccination protocol] in order to get it right." But the time to reflect is now. The legislative changes needed to develop and implement a policy are complex. Reflecting on the policy options and their moral justification will put us in the best position to select the most effective one available. Here we reflect on some arguments for a mandatory scheme (for other arguments, see Brennan, 2018; Flanigan, 2014; Giubilini, forthcoming; and Giubilini et al., 2018). There is some enthusiasm in several jurisdictions (including in Italy, Canada, and the United States) for mandating that parents vaccinate their children. In these jurisdictions, parents are (with some exceptions) required to vaccinate their (young) children in order for them to attend school or daycare. Might the best arguments in favor of mandating the vaccination of children also lend support to mandating vaccination more generally? One of the most compelling arguments for mandating the vaccination of children rests on the claim that sending unvaccinated children to school involves imposing a very significant risk of death and suffering on other children, especially those who cannot be vaccinated for medical 2 reasons. The argument runs as follows. If, by vaccinating their children, parents can easily and safely avoid imposing a significant risk of death and suffering on other children, parents ought to vaccinate their children. Vaccinating one's children is an easy and safe way to avoid imposing the risk of death and suffering on other children; vaccination poses only a very small risk to those who are vaccinated. The state has an obligation to protect children from exposure to easily avoidable risk of death and suffering. Therefore, the state ought to mandate that parents vaccinate their children. The same reasoning might justify a mandatory vaccination scheme for adults. Anyone who is not vaccinated poses a risk to others, especially to the most vulnerable. Individuals can easily and without much cost to themselves avoid posing a significant risk to others. If assuming a small cost in order to avoid posing a great risk to others is sufficient to justify preventing parents from taking advantage of school and daycare, would it not also be sufficient to justify mandatory vaccination more generally? A second argument in favor of mandating the vaccination of children goes as follows. Parents or guardians are not permitted to expose their children to substantial risk of death and suffering when it is easy to avoid doing so. Parents who do not vaccinate their children against serious illnesses expose their children to such risks. It is impermissible, then, for parents not to vaccinate their children against serious illness (unless there are medical reasons against vaccination). The state has an obligation to protect children from exposure to easily avoidable risk of death and suffering. Therefore, the state ought to mandate the vaccination of children (Pierik, 2018). If the COVID-19 vaccine is as safe and effective as, say, the measles vaccine, then there is a low-risk way to avoid an infection that may cause death or serious suffering. The state ought to mandate that parents vaccinate their children against COVID-19. 3 This is a compelling argument for mandatory vaccination of children, but it may not easily translate to the case of adults, because it is generally accepted that there are important differences between children and adults that justify differences in treatment of each class. Children, at least when young, are not autonomous and do not have decision-making capacity. When an individual is not autonomous or does not have decision-making capacity, it is generally taken to be permissible to treat her in her best interests. If a vaccine is safe and effective in preventing an infectious disease that carries significant risks of death or serious suffering, there seems to be compelling reason to vaccinate individuals lacking decision-making capacity on grounds of their best interests-whether the individuals in question are children or adults. But when adults possess decision-making capacity, it is generally taken to be impermissible to treat them paternalistically. Such adults are generally taken to have a robust right to refuse medical interventions even when those interventions are clearly in their best interests and when not undergoing the interventions will lead to their death or serious suffering. While the vaccination of children might be justified on grounds of their best interests, vaccination of adults who possess decision-making capacity would be hard to justify on grounds of their best interests on many moral views. There is perhaps one way in which the second argument might, in fashion similar to the first argument above, generate a case in favour of mandating vaccination for all. The reason the state has for preventing parents from inflicting risk of death or serious illness on their children might be that the state has a more general duty to protect the vulnerable. If this is the reason for mandating the vaccination of children, it might provide justification for a general scheme for mandatory vaccination. A mandatory vaccination scheme for everyone protects very young children and those unable to be vaccinated for medical reasons. If the protection of the vulnerable is a reason to 4 mandate the vaccination of children, why is it not also a reason to mandate vaccination more generally (at least for serious conditions like COVID-19)? A third argument for mandating the vaccination of children turns on differences between adults and children in terms of the nature of their well-being. Children might fare well in a different way than adults (Skelton, 2018; Wendler, 2012). It is plausible that what matters most to the wellbeing of adults is their subjective attitudes (authentic happiness or the satisfaction of their rational desires). This may not be true of (especially young) children. While happiness and the satisfaction of desires matters to children's well-being, it might not be what matters most. Perhaps so-called "objective goods" (things that make one better off without satisfying a desire or making one happier) play a significant role in children's well-being, for example, valuable relationships and intellectual engagement. Suppose that one such objective good lies in making a contribution in some way to some socially worthwhile endeavor (like research with the potential to find a cure for a serious disease). A child might do this by being enrolled as a research subject (Wendler, 2012). Making a causal contribution to societal herd immunity that protects the vulnerable might be one such good. If being vaccinated causally contributes to the good of herd immunity and protection of the vulnerable, it might be good for children to vaccinated. This might justify mandating the vaccination of children but not adults, on the assumption that what is good for adults is determined by their subjective attitudes alone. For adults who find no happiness or desire satisfaction in being part of socially valuable practices, it might not be good for them to participate in socially worthwhile endeavors like the creation of herd immunity. But many adults do, and more might revise their subjective attitudes to desire or take happiness in being vaccinated when properly informed of how socially worthwhile the creation of herd 5 immunity is. And, of course, if it turns out that the well-being of adults is enhanced by objective goods, including the good of contributing to socially worthwhile endeavors or something similar, it will be good for adults and children to be vaccinated. It may be that making vaccination mandatory would increase resistance to it, either by making more people unwilling to undergo vaccination or by making some people more determined not to undergo it. This, some have suggested, could lead to lower vaccination rates under a scheme that mandates vaccination than under one in which vaccination is voluntary. If, empirically speaking, instituting a mandatory vaccination scheme led to a reduction in vaccination rates, we might have to concede that a scheme of this sort would not be, all things considered, best. If mandatory vaccination schemes face resistance, it may be better to use nudges or some other mechanism to encourage individuals to vaccinate themselves and their children. It is worth noting, though, that this type of "resistance effect"-if real-might apply to alternatives to vaccination, such as lockdown or physical distancing measures, too, if these involved some element of coercion. It is not obvious, then, that a mandatory vaccination scheme would fare worse on this score than other coercive measures. Governments should therefore at least consider making vaccination mandatory, based on a comparison of the costs and benefits of the full range of available pandemic control measures. <A>References Brennan, Jason (2018). "A Libertarian Case for Mandatory Vaccination." Journal of Medical Ethics 44, pp. 37-43. 6 Flanigan, Jessica (2014). "A Defense of Compulsory Vaccination." HEC Forum 26, pp. 5-25. Giubilini, Alberto (forthcoming). "An Argument for Compulsory Vaccination: The Taxation Analogy." Journal of Applied Philosophy. https://doi.org/10.1111/japp.12400. Giubilini, Alberto, et al. (2018). 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