Is It Ethical to Mandate SARS-CoV-2 Vaccinations among Incarcerated Persons?

Abstract

Incarcerated persons have suffered a disproportionate burden of SARS-CoV-2 infection compared to the general population (Saloner et al. 2020; Otugo and Wages 2020), with heightened risk for adverse outcomes due to higher proportion of comorbidities among that population (Dumont et al. 2012). A recent report from the Centers for Disease Control and Prevention (2021), however, estimated that only 45% of incarcerated persons would be willing to receive one of the three effective vaccines (Stern et al. 2021). I argue that, in this case, statemandated SARS-CoV-2 vaccination among incarcerated persons is ethically permissible. I will show that incarcerated persons may constitute a core group of individuals with the potential to sustain the transmission of SARSCoV-2 in the general population, that the imposition, by the state, of SARS-CoV-2 vaccination would reduce SARS-CoV-2 infection, and thus SARS-CoV-2 deaths, among incarcerated populations and the general population, and finally, that applying the theory of act utilitarianism, state-mandated SARS-CoV-2 vaccination is ethical and would maximize the overall utility of the population. Importantly, however, the uptake of SARS-CoV-2 vaccination has been heterogeneous, with some prisons reporting over 70% vaccination rates among incarcerated persons (California Department of Corrections and Rehabilitation 2021). For our purposes, the discussion of vaccine-mandates and the ethical considerations therein will be limited to the subset of institutions with vaccination below the 50th percentile and turnover of incarcerated persons above the 75th percentile (defined as the number of releases divided by the number of entries plus the average prison population of the previous year (Baggio et al. 2019), decided in relation to cutoffs for herd immunity (discussed below) and as a mechanism to define the most high-risk institutions. Institutions with higher vaccine coverage may still warrant the focus of educational campaigns and incentivization in order to continue to improve vaccine coverage. Further, in order to minimize infringement on individual rights, I consider it advisable that independent review boards be established to oversee any efforts made towards vaccine mandates, ensuring sufficient explanation and justification be provided to subjected individuals, as well as to iteratively evaluate the ethical and biological factors that constitute our original justification to facilitate termination of the campaign at the earliest possible date. To begin, four important factors of the dynamics of SARS-CoV-2 transmission within the prison system are important to highlight. First, there is a high prevalence of SARS-CoV-2 infection among incarcerated individuals (Saloner et al. 2020; Otugo and Wages 2020). Second, risk for SARS-CoV-2 acquisition is compounded by overcrowding (Baggio et al. 2019), contributing to viral transmission (Cerami et al. 2021). Third, the population of incarcerated individuals is not static, but rather highly dynamic with an estimated 73.2% of the population renewed on a yearly basis (Baggio et al. 2019). That fluidity of population is important as there will consequently persist within the population of incarcerated persons a pool of individuals potentially susceptible to infection. And finally, that incarcerated individuals maintain significant contact with the general population, either through interactions with prison staff, visitors, or upon release. Thus, by virtue of those four factors, the population of incarcerated individuals may behave similarly to what is known in epidemiology as a core group— a group of individuals at high risk for infection that sustain transmission within the general population. Next, I suggest that the evidence is sufficiently strong to conclude that the three vaccinations available provide a high-level of protection from SARS-CoV-2 infection (Frenck et al. 2021; Baden et al. 2021), with notable decreases viral transmission post vaccine implementation within a population (Moghadas et al. 2020). In addition, individuals within the prison system have been shown to refuse vaccination against SARS-CoV-2 (Stern et al. 2021). Based on those two facts, and given the above conclusion that the population of incarcerated individuals may function as a core group, we may thus reasonably conclude that mandating SARS-CoV-2 vaccination among incarcerated persons would reduce both the