Ethical and Practical Considerations Surrounding Mandatory Vaccination


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.

As COVID-19 continues to mutate, institutions deliberate on infection mitigation strategies to help them reach herd immunity. Health care workers are at great risk when vaccination rates are low. The principle of mandating vaccination as a barrier to transmission can be useful, yet present both advantages and disadvantages to their respective industries and necessitate the consideration of ethical principles such as deontology and utilitarianism.

Vaccines, social distancing, and masks are effective tools for protecting the public against the SARS-CoV-2 virus. Nearly all coronavirus deaths and hospitalizations are being attributed to unvaccinated individuals. The rapid transmission of the Delta, Lambda and Zeta variant is placing communities, workplaces, schools, and medical facilities at risk. Even those who are fully vaccinated can contract and spread the disease.

To maintain the health of the public, historical mandates have been issued to eradicate polio and smallpox and, more recently, in 2004, health care facilities began mandating the influenza vaccine for health care workers. Mandatory 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/BioNTeck vaccine now has full approval by the US Food and Drug Administration (FDA). The Center for Disease Control and Prevention (CDC) has not changed their position related to mandates so they CDC continues to allow for local mandates: “whether a state, local government or employer may require, or mandate COVID-19 vaccination is a matter of state or other applicable law.” Some health care facilities may consider exemptions to mandatory vaccinations for religious or medical contraindications. The compulsory policies being considered in various entities are not obligatory as one has a choice not to receive the vaccine. There are no criminal consequences for those who do not receive the vaccine.

State or industry mandated vaccination without exemption is acting in public interest to protect the public as guided by the ethical principle to do no harm but may have long-term implications. A compulsory vaccination policy with no exemptions places constraints on the workforce, on colleges and universities educating the next generation of health care workers 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 the mandatory vaccination or support their constituents’ request or need not to be vaccinated.

Health care facilities, especially, with a no exemption policy may indirectly reduce the next generation of the health care workers who are not in compliance and further compromise the looming shortage of employees in these occupations. Termination of employees for not receiving a mandatory vaccine has been upheld in the courts.2 Mandatory vaccination must also be examined from the perspective of health workers having direct contact with populations at risk for infection or death in health care settings.

Health workers have an ethical obligation to “do no harm” to their patients. Health care facilities also have a moral obligation to create a safe health care environment for the populations they serve.

The vaccine mandate would serve to offer community protection or herd immunity. Unvaccinated employees increase the risk of transmitting the virus to the patients and residents living in long-term care or communal settings. The unvaccinated employee increases the risk of vaccinated employees being exposed to the surging Delta variant. Mandatory vaccination should be balanced to achieve public safety to increase herd immunity, protecting the most vulnerable as well as the capacity of the acute health care system. From an ethical perspective, mandatory vaccination policies support the principles of beneficence, non-maleficence, and justice.

But mandatory vaccination requirements in health care settings may be viewed as denying an individual the right to refuse health care treatment and do not consider the ethical principle of autonomy. However, one must remember that choosing to work in health care is a choice that comes with an ethical and moral responsibility to do no harm and place patient’s interests above one’s own interest.

History’s Lessons

History has shown that refusal of vaccines is linked with the outbreak of vaccine-preventable diseases throughout time. Protecting patients from SARS-CoV-2 follows the same ethical principles for requiring health care workers to be vaccinated against any other diseases where there are outbreaks of highly infectious disease. In 1991, refusal to vaccinate led to over 1000 cases of measles in Philadelphia and in 2015 over 100 cases in California. Currently, health care workers must be vaccinated against common childhood and blood-borne diseases as well as various infectious diseases.

Deontology affirms that prudent individuals should abide by one’s 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. Utilitarianism recommends that individuals should be vaccinated to prevent the spread of the disease as it is the result that will 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, therefore decreasing the spread of the disease 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 a highly infectious disease such as COVID-19 that infection preventionists (IPs), administrators, ethicists, researchers, and academicians bring their voices to weigh in on personal freedoms and ethical obligations versus public health risks. The risks to the population must heed the directives that are issued to ensure that the current direct care workforce is protected. The collaborative efforts to retain experienced frontline workers and sustain a future workforce will maintain the ability of the health care system and other industries to deliver care and critical services to the populations compromised by disease. IPs 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. Creating a shortage of health care workers may 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 what’s not known. Understanding the possible outcomes of all ethical and practical decisions may keep the community safe in the present and future while working through the realities.

Mary Jean Ricci, MSN, RN BC, is the 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 the is the director of clinical education and an assistant clinical professor of practice at the M. Louise Fitzpatrick College of Nursing at Villanova University in Villanova, Pennsylvania.