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Prime Minister Justin Trudeau speaks to Rana Kais as he greets health care workers and people receiving COVID-19 vaccines at a clinic in Ottawa, on July 2, 2021.

Justin Tang/The Canadian Press

With nearly a quarter of the eligible population in Canada still completely unvaccinated against COVID-19, the debate over whether to make vaccines mandatory has intensified.

Canada is among the most vaccinated countries in the world, with 78 per cent of those eligible having received a first dose of a COVID-19 vaccine, and 43 per cent fully vaccinated as of Tuesday. But that’s still short of the estimated 80 per cent to 90 per cent of eligible people needed to be fully immunized to keep infection under control.

To increase vaccination rates, various public-health authorities, institutions and employers have proposed mandatory vaccination policies. In June, B.C.’s Provincial Health Officer, Bonnie Henry, said the province was considering measures to require long-term care workers to be vaccinated against COVID-19. Some universities, including the University of Western Ontario, are requiring students to have at least a first dose to live in residence. In Quebec, health care workers in certain hospital units must be immunized or face consequences, including repeat testing, reassignment or unpaid leave.

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But the need to make COVID-19 vaccines compulsory is by no means clear-cut, and some experts warn the introduction of mandatory vaccine policies is not always justified or effective.

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On the surface, the debate tends to be seen as occurring between opposite ends of the spectrum: the “champions of vaccination” who are very motivated for people to get immunized, and those who are against vaccination, said Maxwell Smith, a bioethicist and assistant professor in the faculty of health sciences at the University of Western Ontario. But it’s much more nuanced, he said.

“Instead of people just saying ‘I’m pro-mandate or anti-mandate,’ it’s really about what settings, in which populations does this make sense? And, actually, where is it ethically justified?” said Dr. Smith, who led the writing of a World Health Organization policy brief on the ethical considerations and caveats of mandatory COVID-19 vaccination.

In the brief, he and his co-authors say mandatory vaccination should be considered only if it’s necessary for, and proportionate to, the achievement of an important public-health goal, whether that’s reaching herd immunity or protecting health care capacity. If that goal can be met with less coercive or intrusive measures, such as public education, a mandate would not be ethically justified, they wrote.

Blanket mandates for an entire population are rarely implemented in part to avoid overstepping public health powers, but also because there isn’t a strong justification for them, Dr. Smith said.

For specific situations, such as in long-term care homes, where the risk of COVID-19 poses an undue burden on others, a mandate may be ethically justified, he said. Similarly, requiring vaccines for students in university residences may be justified, given that the health risks of COVID-19 are much higher in congregate living settings.

However, other factors also have to be taken under consideration, such as the level of community transmission, he added. In schools, for example, high rates of transmission may provide stronger justification for vaccine mandates for eligible teachers and students, but that could change over time as the rate declines.

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Moving too quickly to make vaccines compulsory, without determining whether there is sufficient uptake without a mandate, could contribute to resentment or mistrust of the government or health authorities, he said.

In an opinion piece in The BMJ on Wednesday, authors Lydia Hayes and Allyson Pollock raised some of these issues, calling the move to make COVID-19 vaccines compulsory for care home staff in England “unnecessary, disproportionate and misguided.”

Even though vaccines protect against COVID-19 and reduce the risk of transmission, they wrote, “Vaccination is not a panacea for safety.”

Safety is achieved through other measures including adequate staffing, training and personal protective equipment, they said, noting COVID-19 deaths among residents in the first and second wave were, in part, a result of long-standing problems, such as staffing shortages.

At the University of Saskatchewan, epidemiologist and professor of community health and epidemiology Nazeem Muhajarine also cautioned that mandating vaccines could amount to putting “all our faith” into immunizations. The issue detracts from other important measures, such as rapid testing, ventilation, testing and tracing and wearing masks indoors, he said.

Dr. Muhajarine suggested instead to incentivize people by pointing out the kinds of day-to-day activities they can do safely if they get vaccinated, such as going to the movies, attending sporting events or gathering with others.

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“It’s not so much coercion,” he said. “It’s a possibility you’re presenting.”

Dr. Smith considers these kinds of requirements for social and entertainment activities, which could involve vaccine passports or passes, as distinct from mandatory policies imposed by employers or other authorities. But they, too, require careful consideration of the consequences, he said. For instance, there are equity implications since certain populations cannot be vaccinated because of medical contraindications, some groups experience barriers to vaccination and yet others are hesitant for various reasons, including a historical mistrust of government or the pharmaceutical industry, he said.

“One would need to think through how to address all of those [issues] just to make sure that we’re not just making the already disadvantaged even more disadvantaged by putting a policy like that in place,” he said.

With files from Chen Wang

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