One of the most significant ethical issues to confront the community in the current phase of the COVID-19 pandemic concerns the extent to which people should be required to achieve full vaccination.

The debate mirrors earlier discussions about where to set the balance between public safety and personal liberty. In the wake of events such as the 9/11 terrorist attack or the Bali bombing, successive governments introduced legislation to curb civil liberties that, in some cases, had been fought for centuries ago – with the shedding of much blood in the name of liberty.

However, there was scarcely a whimper of protest from conservatives at that time, or since. Former Prime Minister, Tony Abbott, spoke for many government leaders when, in February of 2015, he said that, “There is no greater responsibility – on me – on the government – than keeping you safe”.

That formula has been invoked time and time again in response to criticism from those who have questioned the erosion of civil liberties. Once again, Tony Abbott outlined the rationale for preferring public safety over personal liberty, noting that one or two people could pose a threat to the community. In the same national security statement quoted above, Mr Abbott when on to say, “But frankly, I’d rather lose a case, than lose a life.”

For the most part, the community has accepted this set of prescriptions. It is against this background that one needs to understand the approach of government to the menace posed by COVID – where lives can be threatened by the actions of just one or two individuals – including those who are free from malicious intent.

As noted above, I cannot think of single conservative commentator who took Mr Abbott (or other leaders) to task for their preference of public safety over personal liberty. Yet, many of these same commentators are lining up to condemn politicians who take an identical stance in response to the proportionately greater risk to life posed by COVID-19. In doing so, some have decided to oppose a range of government measures that they think identify as violating individual liberties – ranging from ‘lockdowns’ to vaccination.

Unhelpfully, the debate has been skewed by the failure to make a clear distinction between different types of restriction.

As far as I know, there has been no serious proposal – from government or the private sector – for ‘compulsory vaccinations’. Yet, this ‘red herring’ is causing widespread debate and a fair measure of concern.

So, how should we think about the issue of vaccinations?

It seems to me that the greatest source of confusion (and concern) lies in the failure to distinguish between three types of requirement: compulsory, optional and conditional.

Compulsory requirements are enforced – and those that contravene are subject to punishment. There are very few compulsory requirements in liberal democracies. Examples in Australia include: the requirement for children to be educated (e.g. attend school); and the requirement that adult citizens attend voting places and receive a ballot paper (whether they cast a valid vote or not is up to them). Most recently, we have had genuinely compulsory ‘lockdowns’. If you fail to abide by the rules, then you are subject to formal punishment by the state.

Optional requirements leave each person to decide whether or not to engage in the specified activity – without consequence. As such, they are generally held to be uncontroversial.

Conditional requirements are far more common. Typically, they are in the form of: ‘if … then’. For example, ‘if you wish to drive a car … then you must be licensed to do so’. Or, ‘if you wish to enter this mine … then you must wear safety equipment’. As will be evident, no person is required to drive a car or enter a mine site. To do so is a matter of choice. In this lies the principal difference between ‘conditional’ and ‘compulsory’ requirements.

I have not really heard anyone make the case for ‘compulsory’ vaccination. Rather, there are arguments being made in favour of vaccination as a ‘conditional requirement’. So, how might such a requirement be justified?

First, it is easy to justify such a requirement in order to protect the health and safety of a community or a workplace. This was the line of argument that Peter Singer attributed to John Stuart Mill, in his recent opinion piece in The Sydney Morning Herald. Second, one can also justify a conditional requirement as a precondition for being able to perform a function. Third, one can set a condition that requires a person not to render themselves either unsafe or unable to perform their role. For example, a mining company might require an employee to wear protective clothing or sunscreen. This is not solely to keep the employee safe. It also ensures that the person remains fit (physically able) to perform their role, free from injury.

The same thinking can also be extended to the idea that an employee should remain fit (physically able) to perform their role free from disease. As noted above, this conditional requirement could be seen as being directed towards the welfare of the employee. Or it could be a requirement for the benefit of the employer.

In either case, no person is compelled to work under such conditions. If they are not prepared to accept the condition, then they may choose not to work for an employer imposing such a requirement. As noted above, this is common and uncontroversial in many, many cases.

A final note: nothing here has any implications for what a person should or should not believe. For example, a person may have a ‘magical belief’ that they are protected from the risk of injury or disease, yet still be required to wear safety equipment. A person may believe that COVID-19 is a ‘hoax’ yet still have to meet the conditional requirement that they be vaccinated.

Governments, companies, etc. should not be in the business of imposing beliefs on others. They can seek to persuade – but nothing more. However, they have every right to set conditions on behaviour and then leave it to people to choose whether or not to meet the conditional requirements that have been set.

Of course, this leaves open one final possibility – that a person may be unable to meet the condition through no fault of their own. For example, some people cannot operate the pedals on a car – yet may still wish to drive. The fact that they cannot operate an unmodified vehicle is not a matter of choice (or an absence of will) – it is a physical impossibility. In such cases, society might try to develop mechanisms (e.g. modified control systems) to offset the limitations. However, this will not always be possible.

Should an employer set vaccination as a condition of employment?

The decision to undertake any kind of medical procedure is a serious one.

Normally, this would be a private matter – especially when it relates to the health of an individual. However, there are multiple precedents for setting conditional requirements of a kind that involve medical procedures, including vaccination. For example, as things stand, one cannot travel to certain countries without vaccination (yellow fever). But to what extent, if any, might the context of employment render a different ethical outcome? For example, should employers apply a ‘test of relevance’ (e.g. different requirements for people working in aged care/disability sectors than, say, for construction workers)?

Some might argue that there is room for conscientious objection – but it has always been a mark of genuine cases, of conscientious objection, that people be prepared to accept the consequences of acting in conformance with their conscience. Also, the duty is to act on a well-informed conscience. That is, one cannot claim the protections or validations of conscience when based in proven error (e.g. in the belief that vaccines do not work, that they contain micro-chips, etc.).

Thus, when it comes to balancing safety vs freedom it should be recognised that both values are of importance. However, good health is an enabler of freedom. Therefore, freedom from the risk of infection (e.g. amongst employees) should be given priority. This would allow for the establishment of ‘conditional requirements’ (such as in the case of a vaccine passport). But these requirements should be structured as the minimum necessary to secure safety. For example, if the job can be done while working from home, then that should be allowed amongst those who choose not to be vaccinated. On the other hand, if the job requires contact with others (if this is strictly necessary), then a refusal to be vaccinated would be equivalent to refusing to take an anti-doping blood test (in elite sports) or to wear safety equipment in a mine.

What questions should employers consider about vaccination?

1. Does vaccination significantly reduce the risk of transmission to others? If so, does the employer have a duty to limit the risk of infection faced by its employees (as a whole), customers, etc.?
2. Does COVID present a risk that an infected employee will be unable to perform their duties? If so, is the risk sufficient to justify a conditional requirement that the employee protect themselves from this harm?
3. What exceptions (if any) can be made for people who are unable to meet the conditional requirement (e.g. medically unfit to be vaccinated)? To what extent can the person’s work practices be managed to take account of this limitation (e.g. special facilities, use of additional PPE, etc.) so as to balance the interests of the individual and the wider group?

Conditional requirements are an everyday occurrence. They range from clothing requirements (e.g. to enter certain places), to the possession of licences, to the need for vaccinations when travelling to certain countries overseas. Some of these requirements are established to reflect cultural preferences, or as indicators of respect for particular institutions or places or as being necessary to realise values like those of ‘safety’, ‘efficiency’, etc.

In the end, when values compete – as in the case of ‘public safety’ vs ‘personal liberty’ the best approach is to seek to make every effort to minimise the damage to one value to the greatest extent possible while realising the other. It’s an approach that I think we failed to heed when it came to our nation’s response to the threat posed by terrorism – sowing the seeds that we seem to be harvesting today.

Perhaps this time round, we can do better.

As a small beginning, I wonder if we can at least drop the reference to so-called ‘compulsory’ vaccinations and instead focus on what might count as a reasonable, conditional requirement.

What started out as a trip to get my flu shot turned into a quick, loaded political decision.

Fortunately, by stopping and reflecting, I left politics to the pollies and made my decision based on ethics.

When Prime Minister Scott Morrison announced that anyone under 40 could approach their GP to get the AstraZeneca vaccine, I decided to act. We were not long into Sydney’s second lockdown and already I was feeling the frustration of isolation. I called my GP and was told to book a consultation first before making any appointments for the jab. I decided to make a day of it and booked both my consultation and flu shot as one appointment. Any outing in Covid times is a highlight, am I right?

One week later I sat down in front of my GP. He said, “I know you’re here for your flu shot but given the situation we’re in, I strongly recommend you get the AstraZeneca. What do you want to do?” In the space of 30 seconds I had to decide whether to AZ now, or to Pfizer at some time in the future, date to be determined. The challenge? Putting aside the loaded politics and making an ethical choice.

I am aware I am privileged in being able to make this choice in the first place; I have the means to transport myself to and from the clinic, English is my first language so I can understand the information and make an informed consent. I am fit and healthy and being in a medical clinic, whilst not always comfortable, is not a traumatic experience for me. None the less given the bad rap the AZ vaccine has received, it was a little daunting.

So here are three questions this Millennial asked themself about getting the AZ vaccine now or waiting for Pfizer:

1. Who am I doing this for?

I am fully aware that the Pfizer vaccine is the preferred jab given there are some risks for young people when it comes to taking the AstraZeneca. A few friends have managed to somehow obtain a Pfizer vaccination through connections, either that or some back-alley vaccine deal (letting my imagination run wild). Black market fantasies aside, when it came to my decision making, I chose the non-preferred option as there was plenty of AZ supply to go around. This choice was my contribution to ensuring the small amounts of Pfizer are provided to those who need it most urgently.

Of course, I could wait until there is plenty of supply of Pfizer. But given that medical advice is that the vaccine reduces transmission, the decision to delay can impact the people around me, people who I love the most, such as my partner who is a teacher. I have friends who are immune-suppressed, and family members who are elderly. I feel, the more we all do to suppress transmission in the community, the safer they will be.

2. What does the best outcome look like? In the short term? In the long term?

Recently the government released an advertising campaign to encourage the public to get vaccinated. Most have seen the footage of a young woman, around my age, on a ventilator struggling to breathe and becoming increasingly distressed. There has been a lot of discussion concerning that this advert was aimed at young people, the very people who can’t get hold of the recommended vaccine for this age group. Like many, I find myself repeatedly frustrated about the vaccine roll out.

But there are actions I could do now to play my part in preventing this lockdown from lasting any longer. I have friends in the UK, many of whom have had the AZ vaccine. I want to do everything I can to help get life back to normal. I feel an overwhelming responsibility as a citizen to do what I can to prevent the spread, protect myself and fellow neighbour, and avoid the possibility of passing it on to someone I love. I channelled this frustration into an action that I as an individual can take. My decision to take the AstraZeneca was my way of contributing in some small way to increasing acceptance of a mass vaccination campaign that will improve the lives of the majority in the long term. Whilst it’s reported there are some small amounts of discomfort (fever, body aches and chills for the first 24 hours post vaccine) it’s a short-term pain for a long-term great gain.

3. What are the risks involved?

My anxiety does have its moments and I can catastrophise at the drop of a hat. The human brain likes to predict the future so it can be prepared. In moments where my anxiety flares up, I try and remember it’s just my body trying to protect itself. We tend to focus on the negatives – an easy thing to do during a global pandemic – particularly when combined with media reports of the risks and misinformation across social media.

Negativity bias is rife and it’s easy for us to be more motivated or affected by negative information than positive.

Faced with needing to make a quick decision I relied on the information given to me by my GP in the consultation.

The consultation involves your doctor thoroughly taking you through the potential risks of the AstraZeneca jab. The AZ vaccine has been associated with a rare side effect called thrombosis with thrombocytopenia syndrome (TTS). According to the Australian Government Department of Health website (www.health.gov.au), in every 1,000,000 cases there is a 3.1 chance of TTS for individuals under 50. Given the current situation in Sydney I felt the risks of COVID far outweighed the risks of adverse side effects from the vaccine. Sure, we do not know what the long-term vaccine effects could be, but it was a chance to consider the trade off between facts and knowledge and the assumptions that there might be some long-term effects from the vaccine. For now, I am sticking with my faith and trust in the medical industry. They have been working hard these past 18 months and have been right so far. Plus vaccines are not new, the first recorded use is from the 16th century in China for smallpox.

So what did I choose …

In the end, after weighing up these questions I was stoked to get poked. By the evening I was hit with the prewarned symptoms of fever and body aches but by the time 48 hours had passed, I was fit as a fiddle. I was surprised by how many work colleagues congratulated me saying how brave I was or how proud they were to know a young person playing their part to combat this disease.

One small disappointment.  I didn’t get one of those, “I’ve been vaccinated stickers.” I may be 30 but the six-year-old in me was severely disappointed. Not even a lollipop… so if you choose to get the AZ vaccine… at least bring your own post poke treat.