More than 200 postsecondary institutions in the United States have announced they will require faculty, students and staff returning to campuses in the fall to be vaccinated against COVID-19. Few Canadian postsecondary institutions have announced similar intentions; the University of Saskatchewan, University of Regina, University of Alberta, University of British Columbia, and McGill University have publicly stated they intend to follow public health directives and will not be mandating vaccines at this time.
Universities and colleges have an obligation to protect and promote the health and safety of their students, faculty, staff and visitors. Given emerging evidence that COVID-19 vaccines are effective in preventing infection and transmission, requiring vaccination as a condition of returning to campus may be one way to resume in-person learning while discharging this obligation to protect campus health and safety.
However, postsecondary institutions must evaluate a number of scientific, ethical, legal and social considerations when considering whether to make vaccination a condition of returning to campus.
While some people object to campus vaccination requirements on the basis they constitute an unjustified infringement on individual liberty and autonomy, they are not entirely uncommon within university and college settings. For example, vaccination requirements may exist for students travelling internationally for learning exchanges or field placements, for those engaging in experiential learning in health care settings or other settings involving vulnerable populations, or for those working with animals.
The pandemic context presents novel considerations and challenges that ought to be specifically and explicitly accounted for when considering whether or not campus vaccination requirements for COVID-19 are justified and warranted.
There are eight considerations that universities and colleges should address when considering whether or not to make COVID-19 vaccination a condition of returning to campus. Addressing these considerations, no matter which decision is made, can help to enhance trust, legitimacy and accountability.
1. Necessity and proportionality
A vaccination requirement should be considered only if it is necessary and proportionate to protect and promote the health and safety of students, faculty, staff, visitors to campus and/or the broader community.
Where campus health and safety objectives can be achieved in the absence of a vaccination requirement (e.g., via other public health measures and the promotion of voluntary vaccination), a vaccination requirement should be considered unnecessary and unjustified, because achieving public health goals with less restriction of individual liberty and autonomy yields a more favorable risk-benefit ratio. It is therefore critical to understand whether vaccination uptake in the absence of a vaccination requirement and in the presence of other public health measures will be insufficient such that a lack of a vaccination requirement is likely to jeopardize campus health and safety and particularly the health of individuals on campus who cannot be vaccinated and those who are more vulnerable to infection and severe outcomes.
If a vaccination requirement is considered necessary and proportionate alongside other public health measures to achieve campus health and safety objectives, such a requirement should be regularly re-evaluated and removed when it no longer meets these conditions.
2. Vaccine accessibility
If proof of vaccination is to be a condition of returning to campus, vaccines must be accessible to all affected by this requirement. Lack of accessibility for those affected by a vaccination requirement would create an unfair demand for those who wish to return to campus but are unable to access a vaccine.
Domestic vaccine accessibility may limit some people’s ability to receive a full vaccine series prior to return to campus in the fall. Additionally, gross inequities in international vaccine distribution means that international students may be disproportionately negatively affected by a vaccination requirement if vaccines are not made accessible. Consequently, institutions should ensure vaccines are readily and freely accessible to all impacted by a vaccination requirement.
3. Intended campus populations
If a vaccination requirement is to be introduced, it should be applied consistently among and between campus populations who are at similar risk of exposure and transmission, or else inequities will be created or exacerbated.
University and college campuses are comprised of many distinct groups, including students, faculty, staff and visitors. Further distinctions can be made within these groups as well, such as undergraduate vs. graduate students; students living in residence vs. students not living in residence; students who frequently travel for collegiate sports vs. those who do not; students with placements in health care settings vs. students participating solely in classroom learning; and students who have research projects that involve interaction with human participants vs. students who do not.
A vaccination requirement should specify which groups are subject to it. If different requirements exist for different groups, an explicit justification for this differential treatment grounded in scientific, ethical and legal reasons should be provided. Explicit attention should be paid to power differentials when considering differential treatment for different groups, as well as the potential for the creation of stigma and inequities that are likely to be created or exacerbated among and between differentially treated groups.
4. Vaccine type
If proof of vaccination is to be a condition of returning to campus, institutions will need to consider which vaccines should be acceptable to meet this condition.
In Canada, four COVID-19 vaccines have been authorized for use. While these four vaccines are not all the same, it would be inadvisable to treat these vaccines differently in the context of a vaccine requirement as this would likely lead to inequities and threaten confidence in certain vaccines or vaccines more generally. With that said, several COVID-19 vaccines have been authorized in other countries but not in Canada, which may have been received by international students enrolled in Canadian postsecondary institutions. Institutions will therefore need to decide whether vaccines not authorized by Health Canada, but authorized by other countries, will be accepted within a vaccination requirement.
However, postsecondary institutions are not in a position to determine whether vaccines not approved by Health Canada should or should not be accepted within a vaccination requirement, nor will they necessarily have access to the requisite data that are submitted to national regulatory authorities to make such a determination. As a result, it may be attractive only to include vaccines authorized by Health Canada as acceptable vaccines within a vaccination requirement. However, decisions to not accept vaccines not authorized in Canada within a vaccination requirement could threaten public confidence in those vaccines or vaccines in general, stigmatize populations who have received those vaccines, and create inequities.
With that said, if it is the view of a university or college that vaccines not authorized in Canada should not be accepted within a vaccination requirement, then the second consideration outlined in this brief regarding vaccine accessibility would suggest that a vaccine to which the vaccination requirement applies should be made accessible to such individuals. Yet, the safety and effectiveness of receiving a Health Canada-authorized vaccine following the receipt of a non-Health Canada-authorized vaccine is uncertain at present.
5. Exemptions and accommodations
Even in the presence of a COVID-19 vaccination requirement, not everyone will be vaccinated.
COVID-19 vaccines are not advised medically for some populations, which means these populations might never be able to satisfy a vaccination requirement. This constraint should not render these individuals ineligible to attend university or college. Consideration must be given to whether students with recognized exemptions will be permitted to attend campus or if they will be provided alternative learning methods (e.g., virtual, online learning) of a similar quality to in-person learning. Alternatives to in-person learning should exist so as not to disadvantage those who cannot be vaccinated through no fault of their own. Those who can be vaccinated but choose not to can also avail themselves of these alternative modalities.
Special attention must be paid to the potential for stigmatization among populations who cannot or will not be vaccinated and the resulting social inequities that might be produced as a result.
6. Enforcement and noncompliance
Short of verifying vaccination status upon entry to all campus buildings and classrooms, which would almost certainly be unfeasible and inappropriate, enforcement of a vaccination requirement may prove challenging. Similarly, in common settings on campus, like libraries or lecture halls, it is likely unfeasible to readily identify unvaccinated individuals.
Postsecondary institutions must consider whether the sanctions for noncompliance are feasible, appropriate and carry the potential of disproportionately impacting particular population groups.
In the absence of a realistic enforcement mechanism or disincentive for noncompliance, a vaccination requirement may fail to achieve the goals justifying its establishment in the first place. In this case, a vaccination requirement may, in reality, function as an exhortative measure rather than a true requirement, which raises the question of whether exhortation, in conjunction with other public health and social measures, should simply be used to achieve campus health and safety objectives.
7. Ethical decision-making about vaccination requirements
Exercising authority and imposing requirements and sanctions in an area as personal as an individual’s health choices require strong justification. Part of this justification can be sourced from careful analysis of the scientific, ethical, legal, and social issues raised in the previous considerations, but it should also be sourced from meaningful engagement with key stakeholders and particularly those most likely to be impacted by decisions about whether or not to introduce a vaccination mandate.
Moreover, the process by which decision-making should occur ought to be inclusive, fair, and transparent, which can enhance the perceived legitimacy and trustworthiness of the ultimate decision. Irrespective of what direction is pursued, any decisions or policies about vaccination, including the processes by which those decisions were made, should be easily accessed by members of the institution and the public.
8. Legality
Many will be keen to see vaccination requirements implemented on university and college campuses in order to keep themselves and others safe. Others will oppose such requirements, and that this opposition is likely to be framed in terms of rights violations. Consequently, legal risks exist no matter the direction taken by universities and colleges. Decisions about whether or not to adopt a vaccination requirement should therefore be informed by legal counsels of universities and colleges and should be arrived at after engaging with the other scientific, ethical and social considerations raised in this column.
Many institutions will need to navigate collective agreements and employment contracts in determining the appropriateness of any requirement. Consideration should also be given to the liability universities and colleges may face if outbreaks and resulting harm are associated with programs or events, or that may arise if campuses are forced to close or move online due to vaccine-preventable outbreaks. Students that expect in-person learning may be less willing to accept changes to the delivery of education that were necessitated at the start of the pandemic when vaccines were not available.
If a vaccination requirement is deemed to be necessary to achieve campus health and safety objectives, it should be implemented in a timely manner to give students, faculty, staff and visitors ample opportunity to receive their vaccinations, submit documentation for exemptions, or prepare for alternative modes of learning or teaching. Irrespective of the introduction of a vaccination requirement, an ethical imperative remains to ensure that other public health and social measures are in place to prevent transmission and illness among students, faculty, staff and visitors. Among other things, this should include efforts to promote vaccination uptake through education, addressing vaccine hesitancy and where possible, making vaccines accessible to all students, faculty and staff.
Maxwell J. Smith is an assistant professor of bioethics and health policy and associate director of the Health Ethics, Law and Policy (HELP Lab). Jacob J. Shelley is an assistant professor of health law and director of the HELP Lab. Justine A. Dryburgh and Ivy Duong are graduates from the faculty of health sciences, incoming Western law students, and members of the HELP Lab. All are at Western University.