When much of the world is still desperate for Covid-19 vaccinations, a handful of wealthy places are beginning to have the opposite problem. Hong Kong is one. Despite a free and easily accessible program open to all adults since April, only just over 10% of the population of 7.5 million has had both injections, with low rates even among the oldest. Hesitancy is so high that only half of residents say they intend to get vaccinated.
The combination of political upheaval, distrust in government and success in keeping caseloads low makes Hong Kong an unusual, even extreme, example of reluctance, as seen in studies of attitudes to other control measures, compared to Singapore and Malaysia. But the territory is far from alone as the rich world shifts from shortages to indifference, well before enough people have been inoculated to allow a safe reopening. The question arises of how governments push populations if — or probably when — hints, cash, free burgers and even the prospect of international travel prove insufficient to reach herd immunity, the vaccination rate of roughly 70% or more that’s necessary to protect everyone.
It’s uncomfortable to argue for obligatory jabs, even in a pandemic that has devastated families globally. Yet if we don’t get to better levels once vaccines are fully and freely available, some degree of compulsion may well be necessary. The benefit is too great, and the risk and sacrifice asked of citizens too small, to ignore. Authorities in England estimate that by the end of April, vaccines had averted at least 11,700 deaths among those aged 60 or over. Globally, of course, it’s many times that.
Public health usually operates on a sliding scale of state involvement. The Nuffield Council on Bioethics in the U.K. calls it an intervention ladder, ranging from “do nothing” (the sort of minimal intervention many people prefer) to “eliminate choice.” We remain somewhere around the lower rungs when it comes to Covid-19 vaccines, which are still rolling out. Information is being provided, citizens persuaded, access facilitated. But we’re already rapidly moving up toward the point where officials are beginning to guide choices with incentives in cash and kind.
In recent days alone, Hong Kong has talked about offering vaccinations at workplaces to make it easier for employees. In the U.S., the state of Ohio announced a lottery with $1 million cash prizes. New Jersey has offered free beer for getting a shot and West Virginia is targeting young people with $100 savings bonds. Elsewhere, Serbia promised 3,000 dinars ($31) to vaccinated citizens, one of the first countries to offer cash.
The good news is that there’s still plenty of room for such options to nudge people along. Hong Kong could certainly afford to dip into its fiscal reserves. A generous incentive of HK$5,000 ($640), the same amount offered under a plan to stimulate consumption, would cost a little more than $4 billion if all eligible over-16s are counted — a bit over 1% of gross domestic product and a worthy investment, considering the damage dealt by Covid-19 closures and restrictions. And payments do have an impact.
Unfortunately, encouragement isn’t likely to get us all the way to herd immunity, or not in enough places. So what happens then? Leaving aside employers, where arguments are different, is it acceptable for a government to consider disincentives, mandating vaccines for activities like eating out or even going to school, as already happens for childhood shots in many places? Vaccines are the greatest gift to public health after clean water. Should we consider an even tougher line?
Full compulsion — which implies fines or even prison, as opposed to simply not getting a benefit or public service — isn’t easily embraced. For me, that’s less because of arguments around personal liberty than because of the deep polarization in many societies, including the U.S., that would only worsen with such an approach. More importantly, some reasons deterring people from vaccinations — distrust of health or political authorities, or more pressing medical or shelter problems — deserve to be tackled, not papered over.
But the harm principle also suggests that intervention is necessary when there is real or potential injury to others, and the harm here is great — 3.4 million lives lost to date. The vaccines that could have avoided the vast majority of deaths are now becoming available to many more people, and time is of the essence.
Take University of Richmond philosopher Jessica Flanigan’s comparison between vaccine refuseniks and a person firing a weapon into the air. We’d want to stop the shooter because bystanders could get hurt or killed. The same, she argues, applies to vaccinations. It’s less about the right to refuse than the right not to get infected — especially for those who can’t be vaccinated, like tiny babies, the immunocompromised or those with severe allergies.
That doesn’t have to mean compulsion, but it can. Over a century ago, the U.S. Supreme Court supported a Massachusetts law that allowed cities to require residents be vaccinated against smallpox. The community, at least at a local if not necessarily federal level, can defend itself.
Another persuasive argument for moving up the public health ladder is made by Alberto Giubilini, at Oxford University, who says vaccines are like taxes. Protection from a disease like Covid-19 is a collective benefit that creates obligations the state can extract from us. None of us have the right to be free riders. Like taxes, vaccines entail a relatively small cost, prevent harm, and are, roughly, a fair way of distributing the burden of a communal responsibility. It’s not a perfect analogy — vaccines involve our bodies, not simply cash — but the equity aspect is compelling.
This of course means obligations for the state. For shots to be mandatory, they must be free and easily accessible. People may have to be given a choice of vaccine, and even most wealthy countries would take a while to get there. Crucially, governments would need adequate compensation programs to cover unforeseen adverse reactions, and many don’t have them.
We’re not at the point of compulsion yet, and hopefully won’t get there. Implementation would be messy and pushback likely. But if we accept that Covid-19 is something we should aim to control before more new and dangerous variants emerge, these are ethical debates that need to be had. Especially as we watch the stomach-churning spectacle of some countries desperately asking for shots while others allow them to go to waste.
Twisting the arms of citizens works; we know this globally from childhood vaccination campaigns. But there’s another compelling reason: fairness. Selective mandates for some workplaces, or to access some state services, would disproportionately affect specific groups, often at the lower end of the income scale — as with foreign domestic workers in Hong Kong. It’s easier for the wealthy to avoid small hurdles. One California study published in 2016 found that school vaccine exemptions in the U.S. are more frequent in White, wealthy districts.- Bloomberg