How we think about COVID-19 vaccine mandates

Only 8% of constituents responding to my recent survey^{* view note} were categorically opposed to vaccine mandates, but that is enough to make me want to further explain my support for vaccine mandates in appropriate circumstances and generally my thought process on public health issues.

Defining “Vaccine Mandate”

I define a vaccine mandate broadly as any rule under which people face exclusions from roles or venues for choosing not to be vaccinated. A “vaccine mandate” is therefore different from “forced vaccination,” a term that I would reserve for a system in which people are held down and bodily forced to submit to injections. Nobody is advocating forced vaccination.

Vaccine mandates include a broad range of possible arrangements, varying widely as to the severity of the consequences for people who choose not to be vaccinated. I would put Mayor Wu’s recent announcement at the lightest end of that range: preventing unvaccinated people from entering restaurants, gyms, and theaters imposes only a very minor limitation. Everyone has other ways of eating, staying in shape, and entertaining themselves that do not risk exposing crowds of others. Vaccine mandates for attending school or keeping a job are more serious. At the furthest end of the severity spectrum would be vaccine mandates for leaving the home — nobody in the United States is proposing mandates at that level of severity.

Factors to weigh in considering a vaccine mandate

For me, decisions about vaccine mandates are judgment calls based on a number of factors, none of which can be perfectly known. The factors include:

1. The infectiousness of disease.
2. The effectiveness of the vaccine in reducing transmission of the disease.
3. The effectiveness of the vaccine in reducing severe health consequences.
4. The personal health risks associated with receiving the vaccine.
5. The public health benefits of keeping unvaccinated people out of a particular venue — high in a crowded restaurant, low in a desolate forest.
6. The expectation that the mandate will actually change behavior — either by reducing high-transmission behaviors or by increasing vaccination.
7. The harm of the mandate itself for individuals who will not or cannot comply.
8. The economic consequences of the mandate — negative or positive.
9. The capacity of the health care system and the extent to which the system is overburdened or appears to be on a curve to being overburdened.
10. A sense of the politics of the mandate — we are a democracy, so if government overreaches, it will defeat its own goals.

The first five of these — the health cost-benefit metrics — lend themselves to scientific evaluation. Not that we can expect crisp answers. The answers will usually be probabilistic and subject to change as the virus and our reactions to it change.

The next three factors — about likely behavior change and consequences for the individual and the economy — inevitably involve more guesswork. People will tend to apply their biases to evaluating these factors. Especially as to likely compliance, people will be influenced heavily by the attitudes of people close to them.

The ninth factor — capacity of the health care system and the trajectory of the health care burden — may be the crispest of the factors, although the trajectory involves guesswork. In Massachusetts, we have good shared information and collaboration among the hospitals and public health leadership. Hospital utilization is the metric that many leaders watch most closely as they consider the development of new COVID programs and the imposition of new COVID rules.

The final factor — the politics — has to be part of the equation. We are not China where the government can get away with shutting down a whole region for months. Government has to continue a dialog with people about their views and maintain a sense of the political limits of governmental power.

Making decisions about vaccine mandates

Some would like to make decisions about vaccine mandates on a principled basis, suggesting that the answer should be ‘no mandates’ as a matter of principle. This is not a viable legal argument — the power of public health authorities has long been recognized as legally legitimate in this country. It is nonetheless a compelling philosophical position — most Americans support personal liberty, especially as to the physical body of a person. However, I think that most people who take a principled position would back away from it if the decision factors were strong enough — a perfect vaccine with no side-effects for an invariably fatal, highly infectious illness that needs to be extinguished before it can mutate. I believe that for most people the vaccine mandate decision is a judgment call, either explicit or implicit.

So the question is: how should we a society make the judgment calls about vaccine mandates? I basically think we have the right process for these decisions at most levels of government: By legislation, we have created boards that include experts and often lay people. Those boards seek input, deliberate, and make decisions. Those decisions may or may not be subject to the political approval of elected executives. For example, we have the CDC and the FDA, state boards of health and local boards of health. The multi-layered approach allows local authorities to take stronger action when national or state action feels inadequate to their local circumstances. The decisions cannot be left entirely to experts. Experts can offer privileged opinions on the more scientific factors, but some of the other factors may be judged equally well or better by lay people. Our system allows for dialog between experts and lay people in defining public health policy. And, of course, elected executives are ultimately accountable for all of the decisions. It is appropriate that elected executives — Mayors, Governors and the President — apply their political judgment as to the sustainability of burdensome mandates.

How one feels about our public health system depends on which parts of it one has touched in life. Some people have had bad health care experiences and perceive health authorities to be corrupt or incompetent. My own experiences have led me to have some faith in the process. I’ve been fortunate to get to know many physicians, many public health professionals, some pharmaceutical researchers and executives, and some elected executives. I’ve ended up having a generally high opinion of them. So, when, after some deliberation, they make a recommendation about a public vaccine policy or mask policy, I’m generally prepared to accept it.

The legislative role on vaccine mandates

Sometimes people who feel that the public health authorities are being too aggressive or not aggressive enough want me to pass legislation to force their hand. I am deeply hesitant to attempt legislation about specific vaccine mandates, mask mandates, or social distancing decisions. Legislation is simply too cumbersome a process for public health decision-making. It is feasible for a board of a few people to make a thoughtful public health decision in matter of days or weeks, but almost nothing happens that fast in the 200-person legislature. Pandemic conditions — and our scientific understandings of those conditions — are constantly evolving. The legislative process simply cannot keep up with realities that change daily. We have to leave these decisions to the executive branch and the authoritative public health boards that we have created and empowered by statute.

I am nonetheless occasionally willing to speak out on public health issues and offer my lay perspective — like other people commenting on this post. I spoke out very early in the pandemic when I felt the executive branch hadn’t stepped into gear strongly enough. At this point, I feel that we have an ever expanding body of knowledge about the virus and what works and what doesn’t and I respect the professionals whose job it is stay on top of that body of knowledge.

Summary View

As a lay person, I support Mayor Wu’s recent mandate decision for recreational venues. I similarly support the decisions of public agencies and various institutions to require vaccinations of their employees or students/customers. These decisions make sense to me as judgment calls. But, more importantly, my experience has given me some confidence in the public health consultation processes that led to those decisions. As a legislator, I have to respect the public health process that we have created to sort out the diversity of available opinion. That said, I always appreciate hearing from constituents who feel we are doing too much or not doing enough.

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For my summary responses to themes in the comments below, please see this post. Please notes that comments posted before noon on Januaary 1 were originally posted on the survey “thank you” page and transferred to this thread. Comments were closed on this post on January 31, 2022.