To speed COVID vaccine uptake and bring the pandemic to an end, some commentators are calling on the government to mandate immunization as a condition for participating in society. This may seem like a reasonable policy, but there's compelling evidence that it could backfire.
Never mind your liberties, there's a deadly virus on the loose, and that's justification enough for the government to mandate that you get a COVID shot. In so many words, that's the case some legal scholars and political commentators are making in support of a coercive vaccine policy. Erwin Chemerinsky, dean and professor of law at the UC Berkeley School of Law, summed up this argument in a recent opinion piece for the Sacramento Bee:
It is time to focus on the duty we all have to protect each other and to end this pandemic. The government should require vaccinations as soon as vaccine supplies allow, and we should remind everyone that freedom does not include a right to endanger others.
Chemerinsky is both well-meaning and on solid legal footing. Getting a COVID vaccine is the best thing we can do to protect ourselves and others from infection. And the US Supreme Court has ruled that governments can mandate vaccination if doing so is deemed necessary to protect public health.
But conspicuously missing from Chemerinsky's analysis is any awareness of how the public is likely to react to forced vaccination, and therein lies its fatal flaw. The success of any public health measure hinges on earning the public's trust. Nothing undermines trust like trying to force skeptical consumers to get a shot.
The importance of trust
The peer-reviewed literature on science communication is replete with strategies to help academics successfully engage the public and all of these center around building trust with the target audience. We all know from personal experience why it's essential to establish trust with others; a lack of it is the death knell to any relationship and the consequences can be severe. The same is true of the bond between scientist and citizen, as the authors of a 2019 study noted:
But why is trust so important? First, scientific knowledge is a critical resource that enables political actors to inform and legitimate political decisions, and it is also important for laypeople in terms of forming public opinion about important political issues. Therefore, distrust in science can be problematic for society as a whole.
Contradictions and double standards
Consider this information about trust in light of how science communication has proceeded during the pandemic. For more than a year, Americans have been bombarded with contradictory, sometimes hostile messages about how to respond to the virus.
Masks were unnecessary until they were essential, though the government later admitted its justification for the initial no-masking policy was misleading. The idea that SARS-CoV-2 originated in a lab was once a conspiracy theory; now, it's a valid hypothesis worth investigating. Let's also not forget that the press has consistently demanded that anyone who expresses a contrary opinion on social media be silenced.
Writing in BMJ's Journal of Medical Ethics in January, a pair of researchers explained (without referencing the examples above) how contradictory and inconsistent reporting impacts vaccine hesitancy:
Confused messaging and poor preparation from governments at the start of the pandemic may also have undermined social trust. In the absence of social trust, a coercive or incentive-based [vaccine] approach may backfire … It is already apparent that skepticism about the virulence of COVID-19 and strong suspicion of pharmaceutical companies, scientists, and policy-makers has become part of some people’s social and political identities.
In other words, mandating that Americans get vaccinated may be the very thing that ensures they won't. Indeed, only seven percent of the US population has said they will get a vaccine if required. This prompts a worthwhile question, posed in an email by Xavier Symons, a postdoctoral research fellow at Australian Catholic University and co-author of the Journal of Medical Ethics article:
The issue for me is that we should always explore less restrictive alternatives before introducing coercive public health measures. The assumption underpinning vaccine passports and vaccine mandates is that unvaccinated people will otherwise frequent public places and will put others at risk. But have we really tried to convince people to vaccinate yet?
I think the safety concerns have been blown out of proportion, particularly here in Australia. COVID-19 vaccines are probably safer than most routine medical interventions ... but the way I think we should win other people over is by convincing rather than coercing them.
Chemerinsky's assertions that Americans have a duty “to protect each other” and “freedom does not include a right to endanger others,” while true, assume that passing a law or pressuring employers to mandate vaccines will compel vaccine uptake. This is an unjustified assumption.
A better way
There are a few things that could be done to encourage more people to get immunized. First, the media should stop reporting about widespread vaccine hesitancy. As I wrote recently, this signals to skeptical Americans that their vaccine fears are widely shared and thus acceptable, when in fact 61% of the country has been vaccinated or plans to get a vaccine as soon as possible. "We also know that, over time, people have moved from the 'wait and see' group to the vaccine enthusiasm group, suggesting that the 61% may be a floor, not a ceiling," the Kaiser Family Foundation reported on April 20. Of course, demand could decrease in the coming weeks or months.
Next, regulators could stop pausing vaccine distribution because of extremely rare side effects, which lends legitimacy to safety concerns circulating on the internet. Instead, they should explain the risks and benefits of getting the shot and let people decide if they want to get it. The public appreciates it when scientists acknowledge uncertainty.
One important exception worth considering is a mandate for frontline medical personnel. Caring for sick people every day drastically increases their risk of exposure to coronavirus, and consequently the risk of their patients. Requiring health care professionals to get vaccinated makes scientific sense and carries few of the drawbacks associated with a population-wide mandate. Fortunately, it appears that vaccine uptake among health care workers is increasing as more safety and efficacy data about the shots come to light.
In general, however, treating people as responsible adults capable of making smart decisions appears to be the best approach to vaccine policy. Or, as the Journal of Medical Ethics article explained,
[P]eople may be more willing to undergo the small risk of vaccination against COVID-19 if they perceive that public health professionals and the government treating them with respect, as equal citizens to be persuaded, rather than inferiors to be coerced.
 The 1905 SCOTUS case, Jacobson v. Massachusetts, centered around smallpox vaccination, which already had a long history by that time (George Washington required vaccination for Continental Army soldiers during the Revolutionary War in 1777). The current vaccines, though safe and effective as far as the evidence shows have not yet received actual approval. They were granted emergency authorization by the FDA, which could make the courts less likely to side with a mandate today.