America's most pressing pandemic problem comprises the following trio of troubling facts: 1) only 60% of all eligible Americans have been fully vaccinated despite abundant supply of free, accessible vaccines; 2) three in ten Americans say they have no immediate plans to get vaccinated; and 3) the Delta variant is driving a fourth surge of deadly infections, especially in states with low vaccination rates.
How ought we solve this problem? One approach is to get tough on the unvaccinated. Examples include: vaccine passports (i.e., authentication for entry to private establishments); banning unvaccinated students from attending colleges and universities; vaccine mandates for private- and public-sector employees; and perhaps even a federal mandate for vaccination.
These tactics are necessary for protecting our communities and restoring our ways of life. This plague has gone on for more than 18 months and will continue without these steps. Not everyone agrees, however. There are two kinds of opponents: the pragmatic and the political. We will respond to both.
The Opponents
The political opponents oppose mandates and passports because they believe they restrict individual liberty. According to them, even if "getting tough" would assuredly rid us of the virus forever, the costs to freedom would be too great to bear.
On the other hand, the pragmatic opponents believe these strategies won't work. For example, Vinay Prasad, MD, MPH, recently argued in MedPage Today that "strong-arm tactics" won't solve our problem. Those in medicine, public health, and bioethics who, like Prasad, reject the "get tough" approach deny that "force" or "pressure" will sufficiently boost vaccine uptake. Some even suspect that clamping down will have worse consequences. They have other ideas, but there is no point calling for failed tactics like cash incentives, prizes, and advertising blitzes. Unfortunately, these are old ideas that don't work.
A Faulty View of Freedom
Freedom-based opposition rests on flawed view of freedom itself. Passports and mandates are hardly "strong-arm tactics." These strategies are better seen as liberty inducers. They bring about freedom rather than deplete it.
These strategies are commonly described as liberty restrictions. But with their power to ensure adequate vaccination rates, they actually preserve, nurture, and promote liberty. A successful COVID-19 vaccination campaign will liberate us -- as individuals and as a collective -- from the callous grip of a pandemic that just won't seem to end.
When we classify mandates as liberty restrictions, we do so under the spell of a certain image of freedom. This image is modern, with roots in the Enlightenment. It is refracted in our institutions, and it animates current thinking across the American political spectrum. Most of us tend to think of freedom as having two signature features. First, freedom is individualistic: The individual's freedom is protected or restricted by laws, policies, and actions. Second, to be free is to be unbound: being free means being unconstrained, unruled, and unrestricted. The unbound individual, then, is the epitome of freedom.
Even on this modern view of freedom, some limits are necessary. Our society restricts the actions of would-be murderers, thieves, and harassers. And these restrictions protect individual freedoms, even the freedoms of those whose actions they restrict.
Analogously, can we justify vaccine mandates and passports by appealing to the individual freedoms they protect? Unfortunately, this path is littered with obstacles. For example, this requires ranking liberties in terms of importance. Freedom from severe illness, hospitalization, and death rank highly. But it's hard to know how to compare freedom from asymptomatic infection against freedoms to work, to learn, and to move through civil society. If we must weigh the individual freedoms mandates secure against those mandates restrict, we will encounter cases where the scale is evenly balanced. How many individual freedoms would be preserved or destroyed through "strong-arm tactics?" How much weight would we assign those freedoms? These accountings and appraisals are complex and difficult, and they inevitably lead to the division and impasse we see today.
But there's another way. It involves moving away from the image of the unbound individual. It involves reimagining freedom. This other view is participatory: It is about the individual's participation in a community and the kind of community in which the individual lives. Here, freedom is communal rather than individualistic. And rather than being unbound, individuals in the free community are bound by and to each other. Communal freedom achieves much more than the unbound individual ever could. It creates new possibilities and expands our horizons. Life is enhanced when our community is free because we can participate in communal freedom and the goods it creates.
In many ways, this view of freedom is like that of Rousseau's: A society is made free by individuals cooperating, by binding themselves to each other and to the rational pursuit of common goals. From this perspective, vaccine mandates and other "strong-arm tactics" induce liberty rather than restrict it.
Liberty Inducers Are Effective and Ethical
So, the political opponents are making a philosophical mistake about the kind of liberty at stake here. What about the pragmatic opponents who are concerned that more stringent tactics won't work?
To them we say that liberty inducers 1) will work quickly enough, 2) will work broadly enough, and 3) will be ethically justified despite their having some negative consequences.
First, liberty inducers will work quickly enough. There is a solid evidence base supporting mandates, passports, and the like. That support is found in data about laws and policies related to seat belts, smoking, and school-mandated childhood vaccinations, all of which achieved significant public health outcomes. These data cannot be dismissed by noting that the efforts took years while COVID-19 vaccine uptake is much more urgently needed. These past successes reveal that we have already laid the groundwork to support passports and mandates.
Consider the recent history of influenza vaccine mandates in healthcare settings. Hospitals were able to issue them nearly instantaneously, and compliance -- like the consequences of noncompliance -- soon followed.
Just as vaccine platforms can be modified to protect against specific pathogens, legal and policy frameworks can be swiftly tailored to meet specific circumstances. We value visiting loved ones at nursing homes, dining out, attending concerts, and exercising at the gym. Vaccine mandates can be rapidly initiated at these venues, especially with a vaccine that is now FDA approved. And if vaccination is a prerequisite for these activities, the need to get vaccinated becomes urgent.
Second, liberty inducers will work broadly enough. Polling shows that about 14% of Americans say they will "definitely not" get the vaccine and 3% will get it "only if required." These poll findings are misleading. The numbers would shift with different incentives and disincentives attached to vaccination status. Those stubbornly opposed to vaccination are viewing possibilities in the world as it is now. Liberty inducers alter that world. Intentions change with possibilities.
Finally, liberty inducers are ethically justified. True, they will have some negative effects. They won't move everyone, and for those unmoved there will be consequences. But the unmoved will move on, and their private, temporary setbacks are justified by our liberation from COVID-19.
Rather than restricting liberty, these strategies are necessary to achieving it. COVID-19 vaccine passports and mandates are past due. They are not too coercive. They will produce quick results and save lives. Ethics falls on the side of creating liberty through freedom from plague. Dawdling around using failed strategies just means more misery and less freedom.
Kyle Ferguson, PhD, is a postdoctoral fellow in the Division of Medical Ethics at NYU Grossman School of Medicine. Arthur Caplan, PhD, is the Drs. William F. and Virginia Connolly Mitty Professor of Bioethics and founding head of the Division of Medical Ethics at NYU Grossman School of Medicine.
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