**5. Is there a right to not be vaccinated?**

The principle of respect for the autonomy of the individual, enshrined in the Spanish Patient Autonomy Law [17], allows the individual to refuse a treatment and, therefore, also to refuse vaccination [18]. It is clear, therefore, that an individual has the right to choose not to be vaccinated. It is also true that some legislation in democratic countries contemplates the possibility of compulsory vaccination in exceptional circumstances. For example, in Spain, Organic Law 3/1986, of April 14, 1986, on *Special Public Health Measures*, allows the approval of exceptional measures, such as compulsory vaccination, when there is a specific risk to the health of the population, such as an epidemic outbreak [19]. Knowing all this, we cannot forget that vaccination is a treatment applied to healthy people who are not suffering from a disease. Moreover, in the case of Covid-19, a large part of the population, those under 20 years of age and without previous health complications, has a very low percentage of serious complications. Therefore, the medical justification for vaccination, in many cases, would not be based so much on the protection of the individual as on the protection of the community (herd immunity) [20].

Before promoting compulsory vaccination protocols against Covid-19, the question which should be asked is: why is the percentage of individuals vaccinated voluntarily so low even in pandemic situations, as demonstrated with the H1N1 virus? Or, in other words, why does a person refuse a vaccine that could save his or her life?

In August 2017, France's health minister reported a decision to mandate vaccination against 11 diseases for minors starting in 2018. This measure was taken due to alarming data on low vaccination rates for diseases such as measles among the population of France [21]. In Spain, where vaccination is not compulsory, vaccination rates are among the best in Europe in the child population (between 95 and 98% for childhood vaccines), dropping slightly with those administered during adolescence (especially in booster doses). The lowest data belong to seasonal influenza vaccination (54% in 2018).

The French case is not unique in Europe. Other European countries are seeing their vaccination rates decrease year after year [22]. Several factors have led to a change in the perception that part of the population has about vaccines [23]: a feeling that the economic and business motives of large pharmaceutical companies which put pressure on public institutions and governments are more important than healthcare [24]; the belief that user deaths are directly related to vaccines rather than mere coincidences [25]; the sometimes alarmist communication of risks and side effects in the media [26]; healthy individuals are, in general, more fearful of the risk caused by vaccines than of the use of the drugs that treat that disease, because the decline in the number of diseases against which vaccines are given has distorted the perception - through ignorance - of the seriousness of many of them (this was seen during the measles outbreak in European countries two years ago) [27]; there is a certain distrust in scientific knowledge, which seem to change and be surpassed with each new discovery [28].

In the specific case of Covid-19, the two scenarios given above will give us different situations in regard to public trust. On the one hand, the first vaccines to be put into circulation will not necessarily be the most effective or the safest. This may lead some people to doubt whether or not to administer the vaccine. On the other hand, at the second stage, that of mass vaccination, the efficacy data of previous vaccines will be available, and the vaccine with the best safety and efficacy data can be administered, thus increasing the population's trust in the vaccines. In the scenarios described above, we may find different vaccines in different countries or even in different regions within the same country. In addition, trust in vaccines will depend on the evolution of the *fake news* that promote conspiracy theories about Covid-19 and vaccines against the virus. All these factors will affect the levels of trust/distrust of the population towards institutions and towards vaccines against Covid-19.
