In January, the National Bioethics Committee issued an opinion on the mandatory vaccination of the entire population against Covid-19
By Marina Vassiliou
Τhe whole population is living with the Sars-CoV-2 virus, which in less than a year has created an unprecedent global health crisis as it spreads rapidly, causing significant morbidity and mortality. At the same time, it has adversely affected people, their families and society as a whole.
The introduction of vaccines is an essential element in fighting the pandemic. It introduces an important tool which is aimed at protecting the population against the transmission of the virus and infection, as well as the manifestation of Covid-19 in general.
It is generally accepted, and historically proven, that vaccines are a powerful tool in protecting against diseases, both individually and collectively. They provide protection against diseases that were once a major cause of morbidity and mortality and which adversely affected people’s life expectancy and quality of life.
According to the National Bioethics Committee, the purpose of its opinion is to examine, in the light of the ethical principles available so far, whether vaccination against Covid-19 can or should be made mandatory by the state.
For the purposes of its opinion, the National Bioethics Committee gave a definition to “obligatory vaccination”. According to the opinion “obligatory vaccination” means the imposition by the government through legislation or via other, indirect means, of vaccinating part, or all the population and the imposition of sanctions or other measures in the event of non-compliance with such legislation. The opinion, according to the committee, may also apply to the imposition of obligatory vaccination by other entities such as: private companies for clients or their staff, schools for students and teaching staff, as well as the staff of health units.
Based on the opinion, at this stage, in order to take any decision on compulsory vaccination, or to enact a special legislation or to take restrictive measures, the specific features of this pandemic against other pandemics should be weighed. These peculiarities include the rapid spread of Covid-19 disease worldwide, the adverse economic and social consequences, and the impact on health systems, but also social concerns about the possibility of vaccination. Current scientific knowledge on the safety and effectiveness of the available therapeutic interventions should also be taken into account. In particular, as regards current scientific knowledge, the limited knowledge of the effectiveness of the vaccines should be seriously considered. In other words, to what extent vaccines are able to prevent infection, transmission, the arrival of the disease and/or its seriousness.
Additionally, their long-term safety, the duration of the induced immunity and, in particular, the need for repeat vaccinations and their effectiveness in specific groups of the population, such as the elderly, the vulnerable, the disabled and children, should be clarified.
The findings of the committee were based on the principles of ethics as outlined below:
The principle of beneficence
This principle is based on the obligation of health professionals to act in the best interest of the patient, maximising the benefit and minimising the harm. Unknown, or less known parameters, give an uncertain picture of whether an optimal and beneficial outcome can be achieved through the introduction of obligatory vaccination. The potential effectiveness and safety issues can play a major role between the benefit and the risk. These are not fully known yet and so the introduction of mandatory vaccination cannot be regarded as supporting the intention to minimise the harm.
The principle of non-maleficence
The said principle is based on ensuring that health professionals take action that does not cause harm, either through negligence or omission. The harms that can be caused by vaccines range from treatment failure to the occurrence of side effects that reverse the benefit-risk relationship mentioned above, to an extended level that constitutes an unfortunate outcome for the protection of public health. Therefore, in order to comply with the principle of non-damage, it implies that the risk of harm is either minimal or that there is a possibility of minimising it, parameters that are expected and should be expected to be documented in the future.
The principle of respect for autonomy
This principle stipulates that it depends on each individual to choose freely and with awareness whether to be vaccinated if offered the option, without any direct or indirect coercion. An important factor contributing to vaccination skepticism and reluctance are the less known or unknown parameters regarding Covid-19 disease and vaccines, especially as regards safety. Additionally, factors influencing people’s decision whether or not to be vaccinated may include their broader philosophy/worldview, their level of trust in conventional medicine, their religion, whether they tend to believe fake or misleading information, or any combination of the above. In order for the principle of autonomy to be fully implemented, people must have access to objective, adequate and consistent information about scientific developments in relation to vaccines. Without this information and empowerment, the principle of autonomy cannot be adequately applied. Information about the benefits and side effects of the vaccine should be accessible both through the media and social media in an objective way, so that the individual’s decision whether or not to be vaccinated is taken as a result of conscious choice and not as a result of deception.
The principle of justice
According to the principle of justice all citizens are treated fairly. This includes the equitable distribution of health outcomes across all social classes. The imposition of compulsory vaccination against the disease Covid-19 may create injustice, such as discriminatory behaviour against people who will not be vaccinated, either by choice or due to other personal or social circumstances. It follows that, on the basis of the principle of justice, compulsory vaccination is not justified at this stage and any future imposition must be justified in a transparent and sufficient manner to constitute a reasonable legal act.
The principle of proportionality
This principle stipulates that coercive (and prohibitive) interventions should be weighed against personal freedoms in relation to the wider social good. In addition, any intervention should be done in stages, namely the least urgent in relation to the available alternatives. In the case of obligatory vaccination as a last resort, the social benefit should be sufficiently justified to outweigh the personal freedom, after all the less invasive actions have been exhausted. At this stage, the less invasive actions have not been exhausted.
Principle of effectiveness
According to the principle of effectiveness, vaccination programmes should be cost-effective, provided that the cost of provision of a vaccine (for prevention) is significantly less than the cost of treatment in case of disease. Until this trade-off is studied more closely, and until vaccination programmes begin to produce objectively measurable results, it is too early to consider the principle of effectiveness to be applied successfully at this stage.
Based on the opinion, the introduction of vaccination programmes is an important tool for disease prevention and therefore contributes to the implementation of the principle of health maximisation. The data available so far are encouraging. However, questions remain to be answered in order for Covid-19 vaccination to be evaluated on how sustainable it is, and the extent to which it achieves maximum public health protection in the long run.
Findings of the committee
At this stage, based on the available scientific data and the examination of the ethical principles as set out above, the imposition of mandatory vaccination of the entire population against Covid-19 is not, at this early stage, a justifiable measure for the government to take although this view may change over time as more evidence and supporting data becomes available. Currently, therefore, any measures that directly or indirectly force the public to be vaccinated must be avoided.
It is undoubtably important for the government and the scientific community to provide objective, and adequate information on scientific developments in relation to vaccines. This will ensure that people are empowered and make informed decisions (resulting from conscious choice and not deception) regarding vaccinations.
Citizens are encouraged to actively and responsibly seek scientifically substantiated information based on their effective participation in society and the state’s efforts to stem the pandemic and its effects.
Finally, the degree of success of the vaccination programmes should be constantly evaluated. Such evaluation should take into account scientific progress and the extent of vaccination of the population, in the light of social rights and the collective benefit over individual rights and choices.
Marina Vassiliou is a lawyer at Elias Neocleous & Co LLC