MORE THAN ONE year after the start of the Covid-19 pandemic it is becoming increasingly clear that vaccines will prove to be essential in combating this global pandemic. The demand for such vaccines is great, yet supplies are currently limited in many countries. In some places, vaccines are available, but there is great push back and hesitation in being vaccinated.

The big question is, how do we get our population to be sufficiently vaccinated so that we can achieve herd immunity and halt the spread of the virus?

There are two options.

Firstly, voluntary vaccination where sufficient people are vaccinated, or mandatory vaccination if vaccine uptake is extremely low. These two options however present a number of ethical challenges that must be considered.

The first option is to prioritise autonomy and to accept that people are free to choose and therefore also free to refuse. One can attempt to persuade those who refuse or create a system of nudging, for example, displaying vaccination as the default option and request that people opt-out if they so wish. Incentives can also be offered to persons to encourage them to be vaccinated and to contribute to the common good of helping to achieve herd immunity.

The drawback of such a strategy is that herd immunity might not be reached. Another drawback might be that people will attempt to free-ride by not getting vaccinated while hoping that a sufficient number of other people will get vaccinated. They can then refuse vaccination and still reap the benefits of herd immunity. The paradox is that if too many people follow such a strategy, herd immunity will not be reached and there is nothing to free ride on.

The second option is to prioritise public health and making vaccines mandatory for the entire population or a part of it (e.g. certain professions such as the health care profession, police force, teachers etc.). Such strategy would guarantee that the vaccination strategy reaches a critical uptake and herd immunity is reached.

The drawback here is evident, as this involves a breach of an important prima facie ethical principle, namely that people have the right to autonomous choice where their health is concerned.

However, at times, public health actions can override individual choice to protect the health of the majority. It is also unclear to what extent there is public support for such a measure.

Which of these two strategies is superior depends on many factors, most importantly perhaps on how many people are willing to be vaccinated. However, the difficulty seems to be that the choice between these strategies has to be made before it is clear how many people will choose to be vaccinated. Starting with autonomous choice and then switching to a mandatory vaccination once it is clear that uptake is insufficient might be hard to justify socially, legally, and ethically.