As commander in chief of the Continental Army, George Washington faced an enemy more lethal than the British: smallpox. With the highly contagious virus decimating American troops, he ordered all soldiers be inoculated with a small dose of the virus, a scientifically proven method of inducing protective immunity.
This week, more than 245 years after Washington’s controversial decision saved countless lives and helped win the American Revolution, a panel of experts in public health, infectious diseases, and medical ethics came together to help universities and colleges grapple with a similar dilemma: Should they mandate vaccines for COVID-19, and if so, for whom?
Convened by the University of Miami, the hour-long virtual conversation underscored just how controversial vaccine mandates remain. It also brought into sharp focus the many questions and complex issues institutions must consider before the U.S. Food and Drug Administration approves the COVID-19 vaccines now authorized only for emergency use.
Among the questions addressed: How can we ensure equitable distribution of vaccines? How do we address vaccine hesitancy, especially among historically mistreated populations? Should college professors be vaccinated along with K-12 teachers? Can we employ incentives, rather than mandates, to encourage vaccination? Are religious exemptions valid? And does every individual have a responsibility for getting a vaccine?
“One thing is very clear: Now is the time to be having these conversations,” University of Miami President Julio Frenk said, noting that the COVID-19 vaccines, which he called “one of the most impressive feats of science in the history of humanity,” will receive final regulatory authorization in the coming months.
“Now is the time to be deliberating about the ethical implications. So, when the time comes, we can make the best decisions,” Frenk added. “If we have learned nothing else in response to COVID-19, it is that disinformation, fear, and skepticism cost lives and all of those can feed off ethical missteps on vaccination.”
Dr. Roy E. Weiss, the University’s chief medical officer for COVID-19 who moderated the discussion attended by nearly 200 people across the nation, opened by recounting a brief history of the development and effectiveness of vaccines and the pioneering public health advocates, like George Washington, who advanced their acceptance. But, Weiss noted, the very success of vaccines in all but conquering such diseases as tetanus, measles, mumps, rubella, and smallpox, have had the ironic effect of undermining their acceptance today.
“Vaccines are among the most effective prevention tools that are available to clinicians today,” said Weiss, chair of the University’s Department of Medicine at the Miller School of Medicine. “The problem has been because of the success, memory sometimes fails us, in that these infectious diseases, for which vaccines in the past have been very useful, have sort of faded from the public consciousness,” he pointed out.
If nothing else, the rapid emergence, spread, and lethality of COVID-19, which in just over a year has killed more than 2.5 million people globally—a fifth of them in the United States—has served as a wake-up call for people who are scrambling to secure appointments or waiting in lines to get their shots. But should those who are not inclined to join the stampede be required to do so on college campuses and universities, like Miami, which already has a mandatory weekly testing program for students?
Dr. Carlos del Rio, executive associate dean and distinguished professor of medicine in the Division of Infectious Diseases at Emory University School of Medicine, said he preferred “a more carrot rather than stick approach.” He suggested students, and the public in general, could be enticed with special privileges or incentives, rather than mandates. For example, he said, students who don’t get vaccinated could be barred from taking certain large classes or attending special events. A university’s health insurance programs also could offer discounted rates to those who are vaccinated—much like they charge extra to cover smokers.
“There are ways to encourage rather than mandate,” del Rio said.
Dr. Lainie Friedman Ross, the Carolyn and Matthew Bucksbaum Professor of Clinical Ethics and associate director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, agreed. “Before we talk about mandatory (vaccinations) one question is: can we achieve our same goals in a voluntary way?’’ she said. “One concern with mandates is that they can undermine public support and actually create a backlash and even reduce vaccine uptake.”
A primary care pediatrician, Friedman Ross also expressed support for the federal vaccine eligibility guidelines that give K-12 teachers priority over college professors. Although children aren’t super-spreaders, nor widely infected with COVID, she said, they are disproportionately suffering the secondary impacts of the pandemic, namely increased mental health crises and hunger, brought on by school closures and stay-at-home orders.
“We need to get them back into school because they’ve lost a year of learning, and we know that year has actually exacerbated the disparities between those with more resources and those with less resources,” she said.
Addressing how schools and colleges should deal with individuals who object to vaccinations on religious grounds, Kenneth W. Goodman, founder and director of the Miller School’s Institute for Bioethics and Health Policy, noted that mainstream theologians agree that nothing in the New Testament, the Holy Koran, or the Torah says, “don’t wear a mask” or “don’t get vaccinated.”
“In fact, the messages are just the opposite—mainly that we have duties to each other, and you don’t get to pick and choose which ones they are,” said Goodman, who helped create COVID-19 crisis standards of care and drug and vaccine allocation policies. “I have duties to people I have never met simply because I live in the same community as they and they do to me. That’s how public health works. It’s our interlocking sense of obligation.”
Del Rio summed up that communal obligation by saying he preferred to think of reaching herd immunity, the goal of vaccinating enough people to halt the virus’ transmission, as “community immunity”—a message that Weiss and the panelists agreed universities and other employees would be wise to embrace and share.
“You want to protect your community. And every time somebody gets vaccinated, we are protecting our community,” del Rio said. “Getting that concept of community across is, I think, very important.”
In concluding, Dr. Henri Ford, dean of the Miller School, said in times of crisis the physician’s ethical commitment to do what’s best for the individual patient must shift to what’s best for the public health. “Our moral and ethical choice is to do what will maximize the chances of affecting the greatest good for the greatest number,” he said. “Therefore, unless the various inducements proposed by Dr. del Rio result in a high rate of vaccination sufficient to achieve community immunity or herd immunity, as suggested, vaccination should become mandatory.”
But, Frenk emphasized, that will not happen at the University without further discussion. “Tonight's discussion is meant to help inform the decisions we will make in the coming months,” he said. “Like our colleagues across the country, we ourselves are still deliberating this issue with the health and safety of our community always top of mind.”
