Article Critique Analysis

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Hello,

I need help with the following assignment. Attached is the article that needs to be analyzed and critiqued in the specific format below:

1. Identify the statement of the problem within the article and the main objective.

2. Evaluate the methodology used by the author (s).

3. Assess and offer perspective on the most significant outcomes of the study.

4. Describe the article’s recommendations and propose an alternative evaluation or research approach that might be utilized to investigate the situation; thow would you set up the research?.

5. Assess the article’s effectiveness from the perspective of a healthcare services leader and how they are delivered.

The other part of the assignment is conducting a 5-slide ppt (not including the cover and reference page) summarizing the outlined format above in regards to the attached journal/article. The ppt should be professional and brief, with some notes on the side to elaborate the slides.

To be clear: I need a word document with the criteria of 1-5 in APA format and a 5 slide PPT. Thank you for your help!

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The Double Democratic Bind:
Challenges to Enacting Mandates
and Combating Misinformation
Frida Boräng
University of Gothenburg
Ruth Carlitz
University of Amsterdam
Keywords COVID-19, vaccination, misinformation, social media, democracy
Following widespread availability of multiple effective vaccines against
COVID-19, countries have varied considerably in terms of how well they
have been able to inoculate their populations. While this reflects resource
constraints in some cases, politics have hindered the rollout of vaccination
Journal of Health Politics, Policy and Law, Vol. 49, No. 1, February 2024
DOI 10.1215/03616878-10910233 ! 2024 by Duke University Press
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Abstract
Context: Wealthy countries vary considerably in terms of how well they have been able to
inoculate their populations against COVID-19. In particular, democracies have been constrained
in their abilities to implement vaccine mandates, given enshrined protections of civil liberties and
individual freedom in such regimes. While scholars have begun addressing the democratic constraint on vaccine mandates, less attention has been paid to the additional challenges democracies face in constraining the spread of vaccine misinformation—particularly misinformation that
spreads online.
Methods: This study combines large-N cross-country analysis with a case study of Germany to
illustrate the “double bind” that democracies face when it comes to containing both the spread of
disease and the spread of misinformation through social media.
Findings: The cross-national analysis confirms that democracies have been less likely to enact
vaccine mandates, and they have also been relatively more hesitant to restrict what people can see
and share online. The case study of Germany highlights the normative and the procedural constraints underlying such decisions.
Conclusions: These findings show that resources are often not the binding constraint on effective disease control, raising questions regarding the ability of high-income democracies to respond
effectively to future public health emergencies.
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Journal of Health Politics, Policy and Law
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campaigns in many wealthy countries. In particular, democracies have
been constrained in their abilities to implement vaccine mandates, given
enshrined protections of civil liberties and individual freedom. Furthermore, democracies face challenges in constraining the spread of vaccine
misinformation—especially misinformation spread online. This is critical
given that engagement with social media has in turn been shown to increase
vaccine hesitancy and may thus erode voluntary compliance with vaccination policies (Wilson and Wisyonge 2020).
We are not the first to study the constraints democracies face in their
choice of COVID-19 policies. Focusing on social distancing, Cheibub,
Hong, and Przeworski (2020) found that democracies were more hesitant than autocracies to introduce measures that violate rights, such as school
closures, bans on public meetings, and lockdowns. They also found that
the most established democracies were the slowest to react to increasing numbers of death rates with such measures. Similarly, Frey, Chen, and
Presidente (2020) found that autocratic regimes imposed more stringent
lockdowns and relied more on contact tracing than democracies did.
Engler and colleagues (2021) focused on variation among democratic
countries and found that governments in countries with stronger protections of democratic principles in place before the pandemic were more
hesitant to introduce measures that would constrain individual freedoms
and lead to more power concentration. This resonates with Lührmann and
colleagues’ (2020) findings that in the European countries where pandemic
emergency responses conflicted with liberal-democratic standards, democracy was already on the decline before the pandemic. Leaders with autocratic ambitions may thus use a crisis as an opportunity to increase power
concentration and weaken democratic institutions.
The abovementioned studies do not deal with vaccination policies. Closest to the present study is a recent contribution by Munir and Munir (2022),
which asks what drives success in countries’ COVID-19 vaccine rollouts.
They argue that strong civil liberties constrain governments’ vaccine efforts
because more intrusive aspects of vaccine policies, such as mandates, face
resistance in light of such norms. However, they analyze actual vaccinations,
not vaccine policies. This makes it very difficult to conclude that (potential)
resistance to mandates matters, because the number of vaccinations is the
result of both voluntary and forced compliance.
Vaccine mandates deserve specific attention because they highlight core
ethical dilemmas in policy making. Although critical for public health,
vaccination policy “reaches into the most private sphere of citizens and
unavoidably conflicts with individual-based ethics” (Luyten et al. 2011:
Boräng and Carlitz – Double Democratic Bind
191
1. Despite this ethical dilemma, childhood immunization mandates have been in place for a
long time in several liberal democracies. However, it should be noted that such mandates are often
controversial and are contested by vocal groups. In this context it is also important to note that,
unlike the vaccines included in child immunization programs, COVID vaccines are based on
recently developed mRNA technologies, which may further complicate the ethical dilemma.
2. Political scientists such as Bennett and Livingston (2018) have instead tended to focus on
the challenges misinformation poses for democracy rather than turning the causal arrow in this
direction.
3. Misinformation is false or misleading information disseminated without an intent to deceive;
disinformation is purposefully false or misleading information disseminated with an intent to
deceive. Both are important from a health policy perspective, even though they can be difficult
to distinguish from each other, as we discuss in further detail below.
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280), and vaccine mandates contradict the doctrine of informed consent
for medical treatment (Somerville 2021).1
The challenges democracies face in constraining the spread of online
vaccine misinformation have received even less scholarly attention.2 This
is surprising, since misinformation has been such a central aspect of the
COVID-19 pandemic. While misinformation around health issues is
far from a new phenomenon, the COVID-19 pandemic is the first in which
online technologies have been used on a massive scale to provide people
with information — as well as mis- and disinformation.3 Indeed, already
on September 23, 2020, a coalition of UN agencies issued a joint statement in which they urged governments and other stakeholders to fight the
“infodemic” they argued threatened countries’ ability to fight the pandemic, particularly the rollout of effective vaccination campaigns (WHO
et al. 2020). This statement is in line with others suggesting that disinformation is a serious threat to COVID-19 vaccination efforts (van der
Linden 2022; Winter et al. 2021). Such mis- and disinformation has
demonstrable consequences. Using an experimental design, Betsch and
colleagues (2010) show that even short exposure (5 to 10 minutes) to
vaccine-critical websites increases the perception of the risk of vaccinating and decreases intentions to vaccinate. In the context of COVID-19
vaccination, Loomba and colleagues (2021) find that exposure to misinformation induced significant declines in people’s intention to vaccinate. However, these studies tend to focus at the micro level, rather than
illuminating the broader challenges democracies face in combating misinformation.
Indeed, the UN agencies stress that while governments should fight the
“infodemic,” this has to be done “while respecting freedom of expression,”
highlighting the inherent tension between the fight against misinformation
and democratic principles (WHO et al. 2020). Our study combines large-N
cross-country analysis with a case study to illustrate this tension—what we
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Journal of Health Politics, Policy and Law
call the “double bind” that democracies face in their choice of public health
policies as well as in containing the spread of misinformation through
social media. A case study of Germany illustrates the implications of misinformation for the effectiveness of voluntary health policy instruments,
and it highlights the normative and the procedural constraints underlying
vaccine policy decisions. Interestingly, electoral accountability constraints
do not seem to have worked against vaccine mandates in this case.
Democratic Constraints on Vaccine Mandates
Many factors likely make it more difficult for democracies to introduce
vaccine mandates than for autocracies to do so. First, legal constraints on
mandatory vaccination are likely to be more extensive in democracies
than in autocracies, given that civil liberties are often protected in constitutions for the very reason that they should be difficult for governments
to change. Although the scope of explicitly defined civil liberties varies
among countries, protections often have direct implications for vaccination policies, such as the right to privacy and the right to bodily integrity.
More general formulations about the protection of individual freedom
and dignity may also be activated against intrusive vaccine policies. More
generally, in democracies policy proposals are routinely assessed for
their compatibility with previous legislation, which tends to reflect such
protections. Indeed, in the context of COVID-19 policies, there are several examples of measures being delayed or stopped following judicial
review (Marzocchi 2021).
The perhaps most obvious constraint on democratic leaders’ ability to
introduce mandates is electoral accountability. Anticipating punishment
in future elections if they introduce unpopular public health measures,
politicians may refrain from intrusive policies. However, when this argument is used in the context of COVID-19 policies we often miss an explicit discussion about what the public wants. Governments can also be held
accountable for lack of action, so it is an open question whether the electoral
accountability mechanism will work for or against mandates. In situations
where a majority of the population is willing to get vaccinated voluntarily,
mandates would directly affect only a minority. But the majority may nevertheless be opposed to mandates if they perceive these as threats to individual freedom and bodily integrity, even if they themselves are not targeted.
Since it is difficult to make valid assumptions about what the public wants,
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Theory
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an evaluation of the electoral accountability mechanism requires information about public opinion on the matter.
This leads to the third mechanism constraining the enactment of mandates in democracies: vocal minorities. Citizens in democracies not only
have the right to vote but also have the right to protest. Even where a majority
of citizens support stringent public health policies, there may be a minority
that opposes them strongly and publicly. Democratic leaders could therefore
be hesitant to introduce policies that lead to major protests and civil unrest.
(Autocratic leaders may fear protests too, but revolts against vaccine mandates are less likely in settings where protests are deemed illegal and are
violently suppressed.)
Furthermore, the normative constraints on vaccine mandates should be
stronger in democracies. Normative constraints apply when an action is
less likely because it goes against shared norms and values. In democracies, these typically include the protection of civil liberties and individual freedoms. Thus, political actors likely perceive that they ought not take
actions that violate such principles even when they can do so. This means
that even in the absence of legal constraints, political leaders might be
hesitant to introduce vaccine mandates because these may violate the
norm that individual freedoms ought to be respected. To the extent that the
public values these freedoms and lets parties’ positions on them inform
their electoral choices, this factor also feeds into the electoral accountability mechanism. Moreover, such norms are also reflected in legislation, as noted above. But in democracies we can expect an elite-level
commitment to democratic principles regarding civil liberties and individual freedoms and rights that goes beyond legal constraints or calculations about electoral gains or losses.
Democracies are also distinct from autocracies in terms of respect for
procedures, even when these take time. In other words, the procedural
constraints should be stronger in democracies than autocracies. Although
the extent to which checks and balances are formally structured differs
considerably among democracies, intrinsic to such regimes are mechanisms that prevent too much power concentration and that allow many
actors to give input in the policy-making process. These mechanisms are
likely to be activated in particular when the issue at hand is controversial, since policy makers may feel especially urged to ensure procedural
legitimacy when the legitimacy of the output may be questioned. This
can have important implications for crisis policy in particular: crises
initially induce swift action, but procedural concerns slow policy making
down. Crisis policy proposals may lose momentum as reactions to the
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crisis change over time, and if they are not enacted quickly, they may not
be enacted at all.
In sum, we expect that democracies will be less likely than autocracies to
enact vaccine mandates, all else being equal.
Democratic Constraints on Limiting the Spread
of Online Mis- and Disinformation
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There are also good reasons to expect that democracies face more constraints than autocracies when it comes to effective regulation of online
mis- and disinformation. First and foremost, there are significant legal
constraints. In liberal democracies free speech and freedom of information have strong legal protection, often in constitutions, for the very
reason that they should be difficult for governments to change. This does
not mean that democracies protect all forms of expression, as laws against
hate speech illustrate. But in the context of online mis- and disinformation the distinction between lawful and unlawful content can be extremely difficult to pin down, given the potential ambiguity of these concepts. Disinformation implies an intent to deceive; however, establishing
that someone had such an intent can be very difficult. Furthermore, defining
misinformation purely in content-based terms (i.e., information that is
contrary to established facts) poses particular challenges in the context
of COVID-19, about which expert consensus has evolved rapidly and
been subject to uncertainty and change (van der Linden 2022). Since
any restriction on free speech would likely have to be very clearly defined
and delimited to be consistent with existing protections of freedom of
expression, efforts to regulate vaccine mis- and disinformation can be
expected to face significant legal obstacles in democracies.
Electoral accountability may also serve as a constraint on the regulation
of mis- and disinformation, given that the public is strongly opposed to
such regulations. Similarly, any attempts to regulate online communication in democracies may spur protests by vocal minorities for which the
issue of internet freedom is highly salient.
Normative constraints may also play a part, if political elites are hesitant
to restrict free speech even within the limits of what would be legally or
electorally possible.
Moreover, democracies face procedural constraints in combating online
mis- and disinformation. Indeed, Radu (2020) notes that among the 18
governments that have taken legal action to combat the “infodemic,”
democracies tend to enact measures that can be publicly deliberated, such
as task forces or media literacy courses.
Boräng and Carlitz – Double Democratic Bind
195
Methods
We present evidence of the double democratic bind first with cross-country
analysis. An illustrative case study of Germany then serves to unpack
mechanisms, and in particular to highlight which democratic constraints
may be driving the observed cross-national relationships. The case study
also illustrates the implications of mis- and disinformation for vaccine
hesitancy.
Cross-Country Analysis
We look across countries to understand the influence of regime type on both
the willingness of governments to enact vaccine mandates and on whether
and to what extent they restrict the free flow of information on social media.
We draw on a variety of data sources, described in further detail below.
Vaccine Mandates. We use the Oxford COVID-19 Government Response
Tracker for information on vaccine mandates. The tracker codes countries
on a daily basis on a number of policy responses. For COVID-19 vaccines,
a country is coded as “0” if there is no requirement to be vaccinated and “1”
if there is requirement to be vaccinated. This indicator is set to “missing” if
there is no available data. Given that a number of countries have enacted
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Taken together, this means that even when democratic governments perceive online misinformation as an important problem, any attempts to effectively regulate online communication are likely to face significant constraints. For autocracies, limiting what people see and share online is
more of a practical and technical problem than a legal or normative one,
and there are many examples of authoritarian regimes that steer online
communication tools, censor them, or use them to their own advantage
(Wilson 2017).
In sum, we expect that democracies will be less likely to censor social
media or engage in social media monitoring, all else being equal.
Notably, the two democratic binds that we have discussed differ in how
they relate to health policy. While democratic constraints on vaccine mandates are obviously and directly related to vaccine policies, the link between
online misinformation and vaccine policies is more indirect. By inducing vaccine hesitancy, misinformation can make voluntary vaccine policy instruments less effective, and in that way can hinder governments’
ability to implement vaccine policies.
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and then revoked COVID-19 vaccine mandates since the pandemic
began, we take the average daily value as of September 2022. We also
include an indicator of whether a country has ever had a mandate in place.
We restrict our analysis to countries that have achieved universal vaccine
access.
1. Average people’s use of social media to organize offline action.
Experts code how frequently this occurs, on a scale from 0 (never,
or almost never) to 4 (regularly).
2. Government social media monitoring. Experts code how comprehensive the surveillance of political content in social media is by the
government or its agents, on a scale from 0 (extremely comprehensive) to 4 (not at all, or almost not at all).
3. Government social media shut down in practice. Experts code how
often the government shuts down access to social media platforms,
on a scale from 0 (extremely often) to 4 (never, or almost never).
4. Government social media censorship in practice. Experts code the
degree to which the government censors political content on social
media in practice, on a scale from 0 (“The government simply blocks
all social media platforms”) to 4 (“The government does not censor
political social media content”).
For the latter three variables, we take the inverse, such that higher values
indicate more monitoring and censorship.
Democracy. We investigate the influence of democracy using the 2021
“regimes of the world” variable from the V-Dem dataset (Coppedge et al.
2022), which considers the competitiveness of access to power as well as
liberal principles. Experts place countries in one of four categories: closed
4. The V-Dem experts span a network of more than 3,200 scholars from more than 180 countries.
V-Dem typically gathers information from five experts to code each indicator. Their responses are
then aggregated with a measurement model that allows for uncertainty about estimates and potential biases. For more information see https://www.v-dem.net/about/v-dem-project/methodology/.
5. For more information about the Digital Society Project, including a codebook with more
details on the variables we examine, see http://digitalsocietyproject.org/.
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Social Media Usage and Restrictions. We draw on a new source of data
describing the intersection between politics and social media in countries
around the world, the Digital Society Project (DSP), which is based on a
survey of experts engaged by the Varieties of Democracy (V-Dem) initiative. The DSP consists of 35 questions and covers 179 countries from
2000 to 2021.4,5 We consider four variables:
Boräng and Carlitz – Double Democratic Bind
197
autocracy; electoral autocracy; electoral democracy; and liberal democracy. We code countries as being democratic if they belong to either of the
latter two categories.
Illustrative Case Study
We complement our cross-national analysis with a case study of Germany,
which, as we describe in further detail below, is a “typical case” that serves
to illustrate general trends and unpack the mechanisms (Van Evera 1997)
underlying the double democratic bind. Germany’s 2021 score on V-Dem’s
Liberal Democracy Index is 0.822, placing the country in the 95th percentile of all countries scored by the index in that year. Furthermore, Germany
is a very good case for unpacking the mechanisms and studying the implications of the democratic constraints on vaccine policies. A proposal for
a general vaccine mandate was on the table during the pandemic, as policy makers perceived that a voluntary approach was not sufficient to reach
the government’s vaccine policy goals. Moreover, for some time during the
process, the major political parties supported a general mandate at least
in principle. Still, in the end, a proposal for a general mandate for people
older than 60 was defeated in parliament. We draw on media accounts,
expert reports, and secondary sources to assess which of the mechanisms
described above were most consequential for this outcome, and how
they operated.
For mis- and disinformation, we cannot systematically evaluate which
mechanisms are at play because we do not observe a policy process, as
we do for vaccine mandates. The misinformation problem is very general and applies to many policy areas, and it therefore precedes specific
policy debates, whereas for mandates it is easier to observe the mechanisms in operation during the policy process. This represents a limitation
of our study. We therefore discuss the democratic constraints that hinder
6. Alternate models also consider GNI data from 2020, which is available for a slightly larger
set of countries.
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Control Variables. We control for country income by using data from the
World Bank’s World Development Indicators (WDI) on gross national
income (GNI) per capita, in current US dollars, adjusted for purchasing
power parity. We also control for country population as well as population
density (people per square kilometer of land area) and degree of urbanization, again using WDI data. We use data from 2021, except for population density, which is only available for 2020.6
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Journal of Health Politics, Policy and Law
effective regulation of online mis- and disinformation at a more general
level. Importantly, we also illustrate how mis- and disinformation have
implications for the vaccine policy context by inducing vaccine hesitancy.
Cross-National Analysis
Democracy Constrains Vaccine Mandates
Democracy Facilitates Open Social Media
Table 2 provides evidence suggesting that people living in democratic regimes enjoy more open access to social media. Democracies are consistently less likely to engage in social media monitoring and are moreover
less likely to censor social media or shut it down wholesale. These results
are robust to controlling for country income, which captures in part the
capacity that different governments have to control the online flow of
information. Interestingly, richer countries are less likely to shut down
social media, even when controlling for their democratic status.
The final two columns also show that people living in democracies take
advantage of such unfettered access to social media to organize offline as
well. This has important implications in our context, since, as noted above,
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Among the 154 countries that had achieved universal vaccine access in
our sample, 73 enacted some sort of mandate, although the breadth of such
mandates has varied considerably. As shown in figure 1, the most commonly implemented type of mandate was for people in “high-contact”
professions (e.g., airport staff, educators, and health care workers). The
next most common type of mandate was for state employees (government officials and military). Mandates targeting the general population
were relatively rare: only 12 countries enacted a mandate targeting some
subset of the general population, and just seven enacted a mandate covering all people older than 15.
If and when countries enact mandates, there is also considerable variation in how long they are able to keep them in place. Peru had a mandate in
place for just 15 days, whereas Iraq had a mandate in place for more than a
year (487 days). The average mandate length is 234 days.
Statistical analysis, shown in table 1, indicates that democracies were
significantly less likely to enact mandates of any kind, and that if they did
enact them, such regimes also did not tend to keep mandates in place for as
long. These results are robust to controlling for country income and population density.
Boräng and Carlitz – Double Democratic Bind
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Table 1
Democracy and COVID-19 Vaccine Mandates
Democracy
(1)
Ever
mandate?
(2)
Ever
mandate?
(3)
Average
mandate
(4)
Average
mandate
-0.78**
(0.35)
-0.90**
(0.44)
0.12
(0.21)
-0.00
(0.00)
-0.69
(1.88)
124
-0.18**
(0.07)
-0.20**
(0.09)
0.03
(0.04)
-0.00
(0.00)
0.21
(0.38)
124
GNI per capita (2021, log)
Population density
Constant
Observations
0.32
(0.27)
137
0.45***
(0.06)
137
Notes: Standard errors in parentheses. Models 1 and 2 present the results of logistic regressions;
the dependent variable is a dummy variable indicating whether the country has ever had a vaccine mandate. Models 3 and 4 present the results of OLS regressions. The dependent variable
indicates the average value of mandate presence. All models consider countries that have achieved
universal vaccine access only. * p < 0.10, ** p < 0.05, *** p < 0.01. Downloaded from http://read.dukeupress.edu/jhppl/article-pdf/49/1/189/2043090/189carlitz.pdf by guest on 18 January 2024 Figure 1 Types of vaccine mandates across countries. 2.32*** (0.08) 179 -1.02*** (0.13) -0.07 (0.05) 0.07* (0.03) 1.66** (0.72) 158 -1.28*** (0.11) 1.28*** (0.06) 179 -0.97*** (0.09) (3) Censorship -0.74*** (0.10) -0.03 (0.04) 0.06** (0.03) 0.43 (0.55) 158 (4) Censorship 1.08*** (0.07) 179 -0.90*** (0.11) (5) Shutdown 0.69*** (0.12) -0.63*** (0.11) -0.09** (0.05) 0.07** (0.03) 0.55 (0.63) 158 2.14*** (0.09) 179 (7) Organize (6) Shutdown 0.50*** (0.13) 0.21*** (0.05) 0.12*** (0.03) -1.62** (0.73) 158 (8) Organize Notes: Standard errors in parentheses. The dependent variable in columns 1–2 indicates the frequency of government social media monitoring. The dependent variable in columns 3–4 indicates how often the government shuts down social media in practice. The dependent variable in columns 5–6 indicates how often the government censors social media in practice. The dependent variable in columns 7–8 captures how frequently people use social media to organize offline action. * p < 0.10, ** p < 0.05, *** p < 0.01. Observations Constant Population (2021, log) (2) Monitoring (1) Monitoring Democracy and Social Media Restrictions and Usage GNI per capita (2021, log) Democracy Table 2 Downloaded from http://read.dukeupress.edu/jhppl/article-pdf/49/1/189/2043090/189carlitz.pdf by guest on 18 January 2024 Boräng and Carlitz - Double Democratic Bind 201 Wilson and Wisyonge (2020) have shown that the use of social media to organize offline action is highly predictive of the belief that vaccinations are unsafe, with such beliefs increasing as more organization occurs on social media. Mandates and Misinformation: The Case of Germany Mandates Background and Timeline. Early moves toward a vaccine mandate were made in December 2021, when outgoing chancellor Angela Merkel, in 7. https://datareportal.com/reports/digital-2021-germany Downloaded from http://read.dukeupress.edu/jhppl/article-pdf/49/1/189/2043090/189carlitz.pdf by guest on 18 January 2024 The preceding statistical analysis lends support to our hypotheses that democracies are less likely than autocracies to enact vaccine mandates, and to censor social media or engage in social media monitoring, and thus potentially to rein in misinformation spread online. To better understand the mechanisms underlying such patterns as well as the implications of the democratic constraints, we consider Germany’s experience with COVID-19 vaccination. The country did enact a limited mandate for health workers, although it was only in place for 47 days—well below the average among countries enacting such policies. Moreover, Germany’s behavior with respect to social media restrictions and usage is typical for liberal democracies, as reflected by its DSP scores for social media monitoring (1.04 on a scale of 0–4, where 4 indicates more monitoring), social media censorship (0.4), and social media shutdown (0.11). Reflecting the limited nature of government restrictions, German citizens make great use of their free access to social media: recent estimates suggest nearly 80% of German citizens regularly use some form of social media.7 The country scores a 3.6 (on a scale of 0–4) on the DSP indicator average people’s use of social media to organize offline action, placing Germany in the 90th percentile on this indicator for liberal democracies. In what follows, we trace the decisions and processes leading up to the decision not to introduce a general COVID-19 vaccine mandate, to identify which of the suggested mechanisms were at play and how. We also illustrate the legal constraints that the country faced in curtailing the online spread of mis- and disinformation. Finally, we discuss how the widespread vaccine mis- and disinformation in Germany had implications for vaccine policies by describing the connection between exposure to misinformation and vaccine hesitancy. 202 Journal of Health Politics, Policy and Law Democratic Constraints. We first consider the legal constraints in the German case. The German Basic Law states in article 2 (on personal freedoms), paragraph 2, that “every person shall have the right to life and physical integrity.” At the same time, the Law on Protection against Infection provides for restrictions on the right to physical integrity to prevent communicable diseases, including mandatory vaccinations. Vaccine mandates would thus have to strike a delicate balance and would have been sent to the Federal Constitutional Court for review (Tonti 2020). It seems unlikely, however, that legal constraints were the main reas