Vaccine Mandates and Public Health Paternalism: A Renewed Debate

Abstract

Vaccine mandates moved from a settled, largely uncontroversial feature of public health law into the center of sustained political and legal conflict during the COVID-19 pandemic, reviving older philosophical debates about when state or institutional paternalism toward individual medical decisions is justified. This perspective revisits that debate with the benefit of several years of post-pandemic case law, exemption-process experience, and survey data on trust and hesitancy that were not available when the original mandates were designed. We examine the legal architecture running from Jacobson v. Massachusetts through COVID-19-era litigation, the philosophical status of the harm principle and libertarian paternalism as applied to vaccination, and the equity implications of how mandate compliance burdens and exemption processes are actually administered. A growing body of post-pandemic research on institutional trust suggests that coercive mandates carry a second-order cost -- eroded credibility for future public health measures -- that earlier ethical analyses of mandates underweighted. We argue that a defensible approach to future mandates requires narrower risk-based targeting, procedurally fair exemption administration, and explicit attention to how compliance costs are distributed
across an unequal population.