COVID-19 vaccine boosters for young adults: a risk benefit assessment and ethical analysis of mandate policies at universities

COVID-19 vaccine boosters for young adults: a risk benefit assessment and ethical analysis of mandate policies at universities Author: Kevin Bardosh,Allison Krug,Euzebiusz Jamrozik,Trudo Lemmens,Salmaan Keshavjee,Vinay Prasad,Marty A Makary,Stefan Baral,Tracy Beth Høeg for Journal of Medical Ethics

Introduction

COVID-19 vaccine booster mandates have been controversial, especially in younger age groups. Two main factors continue to drive scientific controversy: a lack of evidence that booster doses provide a meaningful reduction in hospitalisation risk among healthy adolescents and young adults, and mounting evidence that widespread prior infection confers significant protection against hospitalisation due to (re)infection. Further, mandates have deleterious societal consequences and are eroding trust in scientific and government institutions.1 In North America, as of May 2022 at least 1000 colleges and university campuses required COVID-19 vaccination, and over 300 required boosters.2 More than 50 petitions have been written opposing these vaccine mandates,3 raising specific legal and ethical complaints.4 To our knowledge, few have changed their vaccine guidance for the 2022–2023 academic year and several have mandated the new bivalent booster.

Policymakers, public health scholars and bioethicists have argued both for and against COVID-19 vaccine mandates. The strongest argument made by proponents of vaccine mandates is based on the harm principle: insofar as vaccines prevent transmission and thereby reduce harm to others, restrictions on individual freedom are viewed as more ethically justifiable.5 However, a reduction in risk to others (especially if this is a small or temporary effect) might not alone be sufficient to justify a booster mandate in young people. Savulescu6 and Giubilini and colleagues7 have argued that, to be ethical, vaccine mandates require four conditions: that the disease be a grave public health threat; that there is a safe and effective vaccine; that mandatory vaccination has a superior cost/benefit profile in comparison to other alternatives; and that the level of coercion is proportionate.

Proportionality is a key principle in public health ethics.1 To be proportionate, a policy must be expected to produce public health benefits that outweigh relevant harms, including harms related to coercion, undue pressure, loss of employment and education and other forms of liberty restriction. Williams8 has argued that COVID-19 vaccine mandates may be justified for older but not younger people, among whom such policies are not proportionate given a lack of clarity that benefits outweigh harms. Such ethical assessments should rely on empirical data: thorough risk-benefit assessment requires quantification (where possible) of relevant risks and benefits for the group affected by the policy. With respect to poor outcomes due to COVID-19, the most consistent predictors are age9 and comorbidities.10 Similarly, age and sex are prominent risk factors for vaccine-associated reactogenicity11 and serious adverse events (SAE) such as myocarditis, which is more common in young males.12 Vaccine requirements should therefore be predicated on an age-stratified and sex-stratified risk-benefit analysis and consider the protective effects of prior infection.13

In this paper, we integrate a risk-benefit assessment of SARS-CoV-2 boosters for adults under 30 years old with an ethical analysis of mandates at universities. Our estimate suggests an expected net harm from boosters in this young adult age group, whereby the negative outcomes of all SAEs and hospitalisations may on average outweigh the expected benefits in terms of COVID-19 hospitalisations averted. We also examine the specific harms to males from myo/pericarditis. We then outline a five-part ethical argument empirically assessing booster mandates for young people informed by the quantitative assessment. First, we argue that there has been a lack of transparent risk-benefit assessment; second, that vaccine mandates may result in a net expected harm to individual young adults; third, that vaccine mandates are not proportionate; fourth, that US mandates violate the reciprocity principle because of current gaps in vaccine injury compensation schemes; fifth, that mandates are even less proportionate than the foregoing analyses suggest because current high levels of coercion or pressure may create wider societal harms. We consider possible counterarguments including potential rationales for mandates based on a desire for social cohesion or safety and summarise why such arguments cannot justify current COVID-19 vaccine mandates. We suggest that general mandates for young people ignore key data, entail wider social harms and/or abuses of power and are arguably undermining rather than contributing to social trust and solidarity.

Continue Reading / JME.BMJ.com >>>