Infection preventionists and the hospital leadership teams need to communicate with all stakeholders to balance the health of the community and protect the current and future workforce.
Vaccine mandates have been issued previously to maintain the health of the public, such as those to eradicate polio and smallpox. More recently, in 2004, health care facilities began mandating the influenza vaccine for health care workers. Compulsory inoculations can be viewed as morally reasonable but may interfere with individual rights. Institutions in their decision-making processes should consider personal freedoms and essential actions to protect the public.
As of this writing, the Pfizer/BioNTech vaccine has been fully approved by the US Food and Drug Administration (FDA). The Centers for Disease Control and Prevention (CDC) has not changed their position regarding mandates and continues to allow for local ones: “Whether a state, local government, or employer may require or mandate COVID-19 vaccination is a matter of state or other applicable law.”1 Some health care facilities may consider exemptions to mandatory vaccinations for religious reasons or medical contraindications. The compulsory policies being considered by various entities are not, in one sense, obligatory, as one can choose not to receive the vaccine. There are no criminal consequences for those who do not receive the vaccine.
State- or industry-mandated vaccination without exemptions is an attempt to protect the public as guided by the ethical principle to do no harm. However, it may have long-term implications. A compulsory vaccination policy with no exemptions places constraints on the workforce. It also constrains colleges and universities that are educating the next generation of health care workers and seeking clinical placements for their students. In a no-exemption facility, students, unvaccinated employees, and others will not be permitted to have a clinical placement or continue to hold their positions. Colleges and universities must consider whether to support the science behind mandatory vaccination or support their constituents’ request or need not to be vaccinated.
Additionally, health care facilities with a no-exemption policy may indirectly reduce the next generation of workers who are not in compliance, further exacerbating the looming shortage of employees in health care occupations. The termination of employees for not receiving a mandatory vaccine has been upheld in the courts.Mandatory vaccination must also be examined from the perspective of health care workers having direct contact with populations at risk of infection or death in health care settings.
These workers have an ethical obligation to “do no harm” to their patients. Health care facilities are obliged to create a safe health care environment for the populations they serve.
The vaccine mandate would serve to offer community protection or encourage herd immunity. Unvaccinated employees increase the risk of transmitting the virus to the patients and residents living in long-term care or communal settings. Such employees also increase the risk of vaccinated employees being exposed to the surging variants. Mandatory vaccination should be balanced to achieve public safety and increase herd immunity. This would protect the most vulnerable populations and help maintain the capacity of the acute health care system. From an ethical perspective, mandatory vaccination policies support the principles of beneficence, nonmaleficence, and justice.2
But mandatory vaccination requirements in health care settings also may be viewed as denying an individual the right to refuse health care treatment. Additionally, they do not take into consideration the ethical principle of autonomy. However, one must remember that choosing to work in health care comes with an ethical and moral responsibility to do no harm and to place the patient’s interests above one’s own.
History has shown that the refusal of vaccines is linked with the outbreak of vaccine-preventable diseases. Protecting patients from SARS-CoV-2 follows the same ethical principles that require health care workers to be vaccinated against any other illness with outbreaks of highly infectious disease. In 1991, refusal to vaccinate led to over 1000 cases of measles in Philadelphia, Pennsylvania, and in 2015 over 100 cases in California. Currently, health care workers must be vaccinated against common childhood and bloodborne diseases as well as various infectious diseases.
From a deontological standpoint, prudent individuals should abide by their duties when making an ethical decision. Health care workers have a fiduciary responsibility to prevent harm to their patients when precautions are available to prevent the transmission of disease. From a utilitarian viewpoint, individuals should be vaccinated to prevent the spread of disease as that would bring about the greatest amount of good for the largest number of people.
Requiring all health care workers to be vaccinated reduces the transmission of COVID-19 to patients, decreasing disease spread as well as maintaining the capacity of the health care delivery system during the pandemic.
It is therefore essential that when there is a public threat of highly infectious disease, such as COVID-19, infection preventionists (IPs), administrators, ethicists, investigators, and academics bring their voices to weigh in on personal freedoms and ethical obligations versus public health risks. The risks to the population must be weighed against the directives that are issued to ensure that the current direct care workforce is protected. Collaborative efforts to retain experienced frontline workers and sustain a future workforce will enable those who work in the health care system and other industries to deliver care and critical services to populations compromised by disease. IPs and hospital leadership teams need to communicate with all stakeholders to balance the health of the community and with protecting the current and future workforce. Creating a shortage of health care workers would be a costly mistake.
Consultations with all stakeholders in conjunction with well-designed educational programs that speak to the efficacy and safety of the COVID-19 vaccine are essential to encourage voluntary vaccinations. It is important that we remain unassuming about the unknown. Understanding the possible outcomes of all ethical and practical decisions may keep the community safe in the present and the future while we work through the realities.
MARY JEAN RICCI, MSN, RN-BC, is director of clinical education and an assistant clinical professor at the College of Nursing and Health Professions at Drexel University in Philadelphia, Pennsylvania.
FRANCES AMORIM, MSN, RN, CCE, is director of clinical education and an assistant clinical professor of practice at M. Louise Fitzpatrick College of Nursing at Villanova University in Pennsylvania.