As an emergency room physician, I was fortunate to receive my first dose of the Pfizer-BioNTech COVID-19 vaccine within days of its approval. And for this I am grateful. But as long as vaccines remain in short supply, I feel an obligation to continue to engage in measures to protect those who stand further down the immunization line: masking in public, social distancing, not hosting large indoor gatherings.

Health care worker Karen Crawford gives a thumbs up as nurse Yolanda Javier administers a Pfizer-BioNTech COVID-19 vaccine to her at St. John’s Well Child & Family Center in Los Angeles on Jan. 7. While the Pfizer and Moderna vaccines may reduce transmission, evidence suggests that even people who are vaccinated may be able to spread the lethal disease to those who are not. Irfan Khan/Los Angeles Times via TNS

But sooner or later – by the autumn, if we are fortunate – enough free vaccine will be available for any Americans willing to roll up their sleeves. That raises a question that many in the vaccine line are beginning to ask themselves: What ethical duties will we have, if any, to those who refuse to be vaccinated?

This dilemma stems from an increasingly likely scenario. Evidence suggests that both the Pfizer-BioNTech and Moderna vaccines will largely eliminate the risk of life-threatening illness among recipients and that those few who do become ill will suffer mild symptoms. At the same time, while the vaccines may reduce transmission – the verdict is still out – they will not lead to so-called “sterilizing immunity”; in other words, even those who are vaccinated may be able to spread lethal disease to those who are not.

If, as Dr. Anthony Fauci recently predicted, 70 percent to 90 percent of Americans will have to be immune for herd immunity to take effect, COVID-19 may remain a threat to the unvaccinated for years. Meanwhile, vaccinated Americans will want to get back to the business of congregating in groups, hosting long-delayed weddings and journeying gratuitously for leisure.

We will once again face a choice, individually and collectively, between saving lives and preserving freedoms. Only, for many, the tables will be turned. Individuals who reject public health measures, including vaccines, in the name of liberty will soon face an ongoing risk of fatal disease as those who are vaccinated assert their own rights to gather and travel. The only difference is that, unlike with masks or social distancing, the unvaccinated will be able to protect themselves fully with a shot that is both safe and free. In fact, the willfully unvaccinated may continue to threaten the health of the vaccinated by requiring hospital space for COVID-19 care, as well as health care resources that might be spent otherwise, such as upon developing cures for cancer.

Of course, some Americans may have more understandable reasons for doubting vaccination than others. African Americans, for instance, may be hesitant to trust a public health community that so recently treated them as guinea pigs. Fortunately, by the time the vaccine is fully available, tens of millions of Americans will likely have been vaccinated safely. Waiting for additional evidence of efficacy, as recently suggested by singer Dionne Warwick, may not be ideal, but doing so is far different from outright refusal.

A more complicated challenge are those rare individuals who, for underlying medical reasons, might not be able to tolerate vaccination through no fault of their own. Society has a duty to accommodate these individuals in some way – but not by imposing drastic restrictions on others until herd immunity is achieved. By analogy, airlines often ban peanuts on flights to protect passengers with severe peanut allergies, but nobody has suggested that peanuts be removed from store shelves. How to protect these “unvaccinatables,” to the degree they exist, will prove a quandary, and might justify widespread compulsory vaccination. Travel abroad may also raise concerns about our duties in nations where free vaccines are not fully available.

Some asks are easy – for example: Wear a mask. Even those who are vaccinated may be willing to do so indefinitely.

In contrast, once vaccines are fully available, those who accept them are likely going to refuse to postpone their family celebrations or curtail their business endeavors any further. The past 10 months have displayed how difficult it is to generate solidarity in a country divided not only by politics, but by values, science and facts. In another 10 months, many vaccinated Americans may have a clear answer to what they owe the unvaccinated: absolutely nothing at all.


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