Written by Dr David Owens
Answer: The arguments are nuanced. This article represents a personal analysis of the issues.
The single greatest threat to Hong Kong is the low vaccination rates in the most vulnerable members of our population. Currently only 18% of the over 80s are vaccinated. This population are 600 times more likely to die and 15 times more likely to require intensive care treatment than a young person. It is important to appreciate that this threat is not only to the elderly themselves. Covid has the potential to overwhelm the health system leading to significant mortality in the wider population. The increase in mortality in Covid waves results from a combination of increasing mortality attributable to both Covid and other medical conditions. (1)
The current strategy is not working, vaccination rates remain relatively flat with only 50% of the most vulnerable half of the eligible population vaccinated. Government advisors have talked about their reluctance to ‘coerce’ seniors into vaccination. At the same time Hong Kong enforces regulations which control the size of social groups and mandates masks and compulsory quarantine. Has the time come to introduce vaccine mandates? As so often the issues are nuanced. Below I attempt to summarize the arguments for and against.
1 The Utilitarian Argument:
Using this argument public health is ultimately about the greater good. We have very clear evidence that widespread vaccination is in the interests of the vast majority of the population, both on an individual level and in maintaining the integrity of the health system. We already have mask and quarantine mandates and much of the world has been subject to lockdowns. Under this narrative the rights of the majority cannot be held hostage to interests of the few.
2 The Effectiveness Argument:
We have overwhelming evidence that vaccines are both safe and effective. More importantly in the context of this argument we have very clear evidence that vaccine mandates work. They seem broadly to be able to push vaccination rates from less than 70% to 90% or greater. In the context of Covid, especially with more transmissible variants, we will require rates close to 90% to protect health systems.
3 The Loss of Face Argument
In this narrative all public health interventions invariably have a political component. The public health arguments for masks and vaccination have been polarised to an irrational degree. Some people may either change their minds about vaccination or differ in opinion to the group with whom they most closely identify. It may be easier for these individuals to accept vaccination which has been mandated rather than confront their prevailing belief system.
1 The Individual Rights and Autonomy Arguments
This narrative would argue that an individual is entitled to control the integrity of their own body. Traditional medical ethics would argue that compulsory treatment is only justifiable when there is clear benefit to the individual which exceeds a known risk. Furthermore, the individual must lack the capacity to balance the choices and make a reasoned and reasonable decision. Whilst there are examples of compulsory medical treatment, they are rare, such as arguments about competency to consent. Such cases are generally subject to legal challenge and review. An informed and competent individual generally has the right to decline potentially life-saving medical treatment just as they retain their right to dress up in a winged suit and throw themselves off a mountain.
A further extension of the individual rights argument is ‘this is my risk to take’. This argument sees the risk of Covid as being small and the risks to the unvaccinated being predominantly to the unvaccinated. ‘I respect your choice to be vaccinated now treat me as an adult and respect my choice not to be vaccinated’.
2 Mandates Damage Long term Trust By Increasing Polarization and Division
Forcing people to do things against their will may increase resistance. This has the potential to increase political division. Mandates have the potential to be a symbol around which greater resistance to public health policy may grow. Acceptance of public health measures is closely correlated with trust in government and public institutions. There is good evidence that low vaccination rates in indigenous and ethnic minority populations (not only Covid) have been negatively impacted by previous public policy.
3 We Have Not Exhausted All Other Options
This narrative would argue for education and further policy change short of mandates. How about coordinated public health communication around the temporary nature of zero covid, the inevitability of an exit wave and a clear plan for exit including a focus on boosting immunity with vaccination. We could also consider carrots both financial and non-financial nudges.
Mandates can be critiqued in philosophical and political terms. They should also be considered within the context of the increasing evidence of the science around decision making. The field of behavioural economics has changed our understanding of the way in which humans make decisions. One of the most important lessons is that human behaviour is irrational, but in a predictable way. We are all subject to cognitive or heuristic biases. In the pandemic such biases are widely visible. Herd behaviour, confirmation bias and numerous examples of status quo bias. How long will it now take to remove countries from the blacklist or change the length of quarantine despite evolving evidence? The active positive choice has now become to change back to normal and that carries risks to the decision makers. Much easier to just keep things the way they are.
Since the early work by Tversky and Kahneman this field has produced a number of Nobel prizes, including for Thaler who coined the concept of Nudge. Nudges are fundamentally different to mandates in that they drive choice by providing positive options in choice architecture. Nudges are not financial in classical terms. They are most effective when framed positively. We have very good evidence that nudging behavioural change can be effective. There is certainly more that we could do to drive vaccination rates in Hong Kong by following the science and framing the choice around vaccination in more positive terms.
Regardless of these strategies we will never convince everybody. Another concept of social psychology is that of naïve realism. This is a belief, widely held, that we as individuals see the world in the context of the only objective reality. This bias leads us to believe that given adequate objective education and information, everybody else would reach the same conclusions and hold the same views as we do. There is a tendency to see people who disagree with us as irrational and biased. Studies of vaccine hesitancy generally show 60-70% of the population as pro-vaccination, at least to some degree, 20% hesitant but prepared to take vaccinations in some circumstances and anything up to 10% who have firmly held anti-vaccine beliefs. This evidence from social psychology would suggest a need to reframe attitudes to those who disagree and be respectful of their position. There is certainly good evidence that positive engagement and respectful debate is more likely to influence the hesitant than ranting. Of course another way of looking at this is that simply waiting for some people to ‘see the light’ will not work regardless of how long or patiently we wait.
Ultimately in a pandemic public health policy must balance the rights, responsibilities, risks and benefits to individuals with those of the population in both human and economic terms. Regardless of the arguments above, it is clear that mandates are increasing worldwide. Personally, I have always had sympathy with arguments against mandatory vaccination. I am especially swayed by the argument for free will and choice of a medical treatment and I remain uncomfortable with a policy of forced vaccination. I also believe there is much more that can be done in terms of education and particularly using our increasing understanding of decision-making theory in addition to financial incentives and non-financial nudges.
The free will arguments are less powerful when mandates balance the rights of the vaccinated against the rights of the unvaccinated. Vaccine passports do not force vaccination but increase choice available to the vaccinated. Under the social contract, rights and responsibilities invariably exist in tension. I have the right to drive a car, but it is mandated that I wear a seatbelt. I have the right to not wear a seatbelt but this limits my choice of transport. There is certainly the perception that the burden of cost has so far fallen on the vaccinated. People who followed the government advice to be vaccinated, at least in part in order to protect the health system and the unvaccinated vulnerable, continue to be subject to mask and quarantine mandates with no obvious benefit for their social choice.
I discussed the issue of mandates in a recent podcast with Professor Cowling. We have both previously argued for evidence-based public health interventions as the best way to build trust in public health institutions. In a previous article I considered the question of vaccine mandates for children in schools, is it ethical to vaccinate a child predominantly to protect the elderly and vulnerable rather than the child? I would argue not and especially when the elderly and vulnerable are refusing to be vaccinated. We should only vaccinate children if there is clear evidence of risk-benefit in favour of the child. The relatively low (but not zero) risks to children from Covid, especially in the context of an ongoing Zero Covid strategy, cannot yet justify vaccine mandates. The single greatest risk to Hong Kong is the low vaccination rate in the most vulnerable members of the population. The current policy of Zero Covid is a brittle strategy which carries the risk of a more transmissible variant seeding into our city and potentially causing significant damage to the health system. Herd immunity by vaccination alone is impossible and the primary benefit of vaccination is to reduce disease severity in individuals. The single most important public health challenge is to increase vaccination rates especially in the most vulnerable. In the absence of a clearly defined plan for exit, vaccine mandates specifically targeting the elderly and most vulnerable are an ethically justifiable intervention in order to increase vaccination rates and to protect other members of the population vaccinated and non-vaccinated, both young and old.
1. Rossman, H., Meir, T., Somer, J., Shilo, S., Gutman, R., Ben Arie, A., Segal, E., Shalit, U., & Gorfine, M. (2021, March 26). Hospital load and increased COVID-19 related mortality in Israel. Nature News. Retrieved December 7, 2021, from https://www.nature.com/articles/s41467-021-22214-z.