We cannot make perfect the enemy of the good. This country is built on compromise. And in a liberal democracy, the price of our freedom means accepting, within reason, that others may make choices we find objectionable, writes Dr. Matthew Strauss.
By Matthew Strauss, February 8, 2022
Hundreds of trucks have made downtown Ottawa their parking lot, as truckers call for an end to vaccine mandates. The Trudeau government may be unreceptive to their message, but both Saskatchewan’s Premier Scott Moe and Alberta’s Premier Jason Kenney have indicated an imminent end to their mandates. Dr. Kieran Moore, Ontario’s Chief Medical Officer of Health, has also indicated the province will review its mandate. This is good news, as I believe all such mandates should be removed for reasons of ethics and practicality.
Simply put, vaccine mandates for the general public are a straightforward contravention of standard medical ethics. Specifically the coercive nature of vaccine mandates violates a central principle: freely given consent. We have clearly recognized this in other areas in recent years, by having necessary and long-overdue conversations about what constitutes valid sexual consent.
These same principles also apply to medical consent generally. The Canadian Medical Protective Association publishes legal advice to physicians, in which they say for consent to a medical act to be considered valid, it must be voluntary: “Consent obtained under any suggestion of compulsion either by the actions or words of the physician or others may be no consent at all.” Specifically, if a physician becomes aware that a patient is seeking consultation at the behest of a third party (such as an employer), the Association notes the physician must ensure that “there has been no coercion.”
The College of Physicians and Surgeons of Ontario imposes similar requirements on its members: “If physicians believe that consent is not being freely given, they must ensure that there has been no coercion.”
Save for those with specific conditions that make getting vaccinated risky, I want all of my patients to get vaccinated. A full series of COVID-19 vaccination reduces the risk of death from COVID by more than 90 percent. I am willing to discuss the risks and benefits of this amazing intervention just about endlessly with any patient in order to obtain their free and informed consent.
However, while informed consent is paramount in clinical medicine, it does not always take precedence in the same way with public health. Individual doctors have a duty to individual patients. Public health applies a different lens: it seeks the greatest good for the greatest number of people. Accordingly, trying to do good for all might justify harm to a few in the process, as long as the population is clearly better off overall and the harm is not significant.
This public approach can legitimize coercion in very limited situations, such as seatbelt legislation, indoor smoking bans, and a prohibition on lead paint. However, it leaves individual physicians in murky ethical waters with respect to individual vaccinations.
This is important because throughout the pandemic, the use of coercive measures to pressure people into getting vaccinated has been normalized. They should not be acceptable practise. Threatening an employee with termination is obvious coercion. Not allowing parents to see their sick children in hospital is obvious coercion. Prior to the pandemic, it would have been widely acknowledged as unethical for physicians to vaccinate individuals who only seek vaccination in response to such coercion. Insofar as these mandates are effective in increasing vaccination uptake, this increase is only achieved unethically.
Incidentally, it is by no means clear to me that these mandates have led to a material increase in vaccine uptake. I have had countless conversations with individuals who refuse to even consider vaccination “so long as the government is forcing it on me.” Studies of vaccine mandates prior to the COVID pandemic have shown mixed results.
Some proponents of vaccine mandates do not call for them in order to increase vaccine uptake, but rather to protect the broader public from the unvaccinated. Ethically, I concede that this is a murkier proposition. If it were conclusively established that those unvaccinated against COVID posed a grave threat to society, such an exceptional violation of ethical norms might be justified. Luckily, we need not entertain such a controversial move, because it happens to be untrue.
As summarized in a recent Public Health Agency of Canada report, six months after receiving two doses of mRNA vaccine, effectiveness at preventing symptomatic COVID-19 infection in Ontario was 0 percent. Another study found that 240 days after vaccination, two doses were actually negative 16 percent effective! Studies in England and Denmark also found negative effectiveness of two doses, with the latter study showing that two doses to be 0 percent effective at 2.5 months.
Now I will repeat myself: two doses of vaccine are incredibly effective at preventing hospitalization and death. But so long as they do not appear to be very effective at preventing transmission, those who do not get vaccinated are primarily putting themselves, and not others, at risk. We are allowed to put ourselves at risk. Adults in this country are allowed to ride a motorcycle, smoke cigarettes, drink alcohol, and get fries instead of salad. Many of them have wound up as my patients in the ICU on this basis. My job is to dissuade against such activities, not to impose a blanket prohibition on them.
It is true that three doses of mRNA COVID vaccine does a much better job at preventing transmission, to the tune of 60 percent prevention. However, it still seems to be the case that effectiveness wanes over time. One study found three-dose effectiveness dropped to 49.5 percent after 111 days, while another found that it dropped to 48 percent at 3 months.
It seems likely to me that vaccine effectiveness against transmission, for any number of boosters, will continue to decline as time passes. Conversely, the CDC has reported that those who have recovered from previous COVID infection from Delta are three to five times less likely to get COVID than those who are merely vaccinated. Importantly, the protection gained via natural immunity does not appear to wane over the study period.
If we truly did want to segregate society into those who are at risk for transmitting COVID to others and those who are not, it is perhaps the COVID-recovered who should be granted the most freedom of all. I am afraid that failure to recognize this straightforward, scientific point only encourages conspiracy-minded individuals who believe that the COVID vaccination drive is merely a pretext to enrich Big Pharma. (Many such individuals have called my office to advise me of this supposed plot.) It goes without saying that we should not want conspiratorial, anti-vaccine views to become further entrenched as an unintended consequence of a poorly considered policy choice.
Finally, as a matter of practicality, we really need to consider the endgame. However draconian we make our passport policies, some members of society will still refuse to comply. Canada already has one of the highest rates of vaccination in the world with 85 percent of us having at least one dose – something we should be proud of as a society.
Perhaps we might be able to increase this by a few more percentage points by disregarding any consideration for bodily autonomy, freedom of movement, and medical privacy. We should consider whether abandoning such liberal democratic values is worth the price, which will be to ostracize one-in-10 Canadians from mainstream society. The long-term public health consequences of excluding so many Canadians from educational opportunities and gainful employment cannot really be countenanced (to say nothing of the short-term disruptions of the border blockades that appear to be underway). We cannot make perfect the enemy of the good. This country is built on compromise. And in a liberal democracy, the price of our freedom means accepting, within reason, that others may make choices we find objectionable.
It has been a long two years. We have all sacrificed something. Nerves are frayed. However, I truly believe the worst is behind us. Omicron has ripped through our population so quickly as to overwhelm our ability to test for it. This is lamentable, but the silver lining is that it has left many millions of Canadians with robust natural immunity in its wake. As the current wave of hospitalizations declines, the end of the pandemic is in sight. There are many social wounds to heal and it is incumbent on our political leaders to lead the way to encourage all Canadians to come together and repair our badly frayed social fabric.
Dr. Matthew Strauss is an ICU physician practising in Ontario, previously an assistant professor of medicine at Queens University, and currently the acting Medical Officer of Health for Haldimand-Norfolk. His views are his own.