Debate: Mandatory COVID-19 vaccination for healthcare workers – is it justifiable ethically?

YES – IT IS JUSTIFIABLE
Darren Dookeeram¹, Dave Dookeeram², Nilesh Persad^3
1Eastern Regional Health Authority. Sangre Grande, Trinidad and Tobago.
²DispatchHealth. Denver, Colorado USA.
³Trinidad Diabetic Eye Center. San Fernando, Trinidad and Tobago.

NO – IT IS NOT JUSTIFIABLE

Kareema Ali¹, Steven De Jager², Sanjay Ramnanan^3
1Eastern Regional Health Authority. Sangre Grande, Trinidad and Tobago.
²Diospi Suyana Hospital. Curahuasi, Peru.
³Exquisite Dental. St. Augustine, Trinidad and Tobago.

Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.

©2021 The Authors. Caribbean Medical Journal published by Trinidad & Tobago Medical Association

YES – IT IS JUSTIFIABLE

We make reference to recent coverage of British Health Minister Matt Hancock’s suggestion that all healthcare workers should have mandatory COVID-19 vaccinations.¹ Given the profoundly devastating effect that the pandemic has had on healthcare and socio-economic systems across the globe, it would be a logical assumption that healthcare workers, who are at highest risk as the primary interface to disease, would have no objection to such a suggestion. However, unfortunately, this has not been the case. The situation has presented a huge ethical dilemma to healthcare employers whether to continue to employ a healthcare provider if they chose to object to receiving the vaccine based on religious or personal beliefs, and if dismissing them from the employment is justified.²

The institution of a legislation for mandatory vaccination has been construed as “permitted coercion” and on a superficial level, and has been interpreted as a violation of the individual’s autonomy.³ The enforcement of such a legislation is also subject to interpretation, but in fact it remains the most important step in combating the Covid-19 pandemic. A recent Lancet publication confirms that an accelerated rollout of vaccination is essential to curb the burden of existing and variant viral strains.⁴

There is enough evidence that frontline healthcare workers are at a higher risk of contracting Covid-19. Specific subgroups within healthcare providers are more vulnerable and by extension more likely to spread this infection to their families, friends and other patients.⁵ It would therefore, likely to betray the principle of non-maleficence, since healthcare workers who have higher risk of contracting the pandemic but choose not to vaccinate themselves, willfully endanger those in contact with them. This is especially applicable to the most vulnerable such as the elderly and immunocompromised who constantly seek assistance from healthcare workers.

Furthermore, it has been established that Covid-19 has burdened the healthcare workforce not only with its impact on the systems but also on a personal level with significant morbidity and mortality. This has resulted in a crisis that has been unparalleled in the history of modern healthcare settings.⁶ Given that vaccination is the potential solution to attain herd immunity and protect healthcare personnel, it would also be contrary to the tenet of justice should healthcare workers choose to put themselves at risk of contracting illness and weakening the system further.

Finally, the vaccines for the Covid-19 pandemic have clearly demonstrated benefits both for the recipient as well as the members of the community. As such, healthcare workers who are respected authorities where common public can depend upon as a source of information should conduct themselves to be an enlightening beacon upon which the vaccination rollout is pivoted. It behooves the point of beneficence for healthcare workers to embrace the mandatory distribution of vaccination to ensure that communities are protected.⁷

In conclusion, as the world faces an unprecedented challenge, healthcare workers are uniquely poised to be a voice of reason in combating vaccine hesitancy and should champion the process of rollout and standards of excellence in public health. Mandatory vaccinations for healthcare workers should be viewed as an opportunity rather than a threat for service providers.

References

1. MacAskill, A.. England to make COVID-19 vaccinations compulsory for health care workers: Reuters; 2021 June 16 [cited 2021 Jul 19]. Available from: https://www.reuters.com/world/uk/england-seeks-make-covid-19-vaccinations-compulsory-care-workers-2021-06-16/
2. Smith, A., & Nagele-Piazza, L. Employers React to Workers Who Refuse a COVID-19 Vaccination: SHRM; 2021 April 26 [cited 2021 Jul 19]. Available from: https://www.shrm.org/resourcesandtools/legal-and-compliance/employment-law/pages/if-workers-refuse-a-covid-19-vaccination.aspx
3. Grzybowski, A., Patryn, R., Sak, J., & Zagaja, A. Vaccination refusal. Autonomy and permitted coersion. Pathog Glob Health. 2017: 200-205.
4. Sah, P., Vilches, T., Moghadas, S., Fitzpatrick, M., Singer, B., & Hoetez, P. Accelerated vaccine rollout is imperative to mitigate highly transmissible COVID-19 variants. E CLinical Medicine Lancet. 2021.
5. Nguyen, L., Drew, D., Graham, M., Joshi, A., Guo, C., & Ma, W. Risk of COVID-19 among front-line health care workers and the general community: a prospective cohort study. The Lancet. 2021: 475-483.
6. Giannis, D., Geropoulus, G., Matenoglou, E., & Moris, D. Impact of coronavirus disease 2019 on healthcare workers: beyond the risk of exposure. BMJ. 2019.
7. Colgrove, J. Immunization and Ethics: Beneficence, Coersion, Public Health, and the State. Oxford: Oxford Handbooks; 2019.

NO – IT IS NOT JUSTIFIABLE

We write to share an opposing opinion on the proposition that Covid-19 vaccinations should be made mandatory for all healthcare workers. As a preface to this we would like to emphasize that we share the view that vaccinations are life-saving and play a pivotal role in the response to the ongoing pandemic. However, we believe that coercion of healthcare workers is an inappropriate approach that may foster dissent in a workforce that is already being stretched to an extreme level of providing service to level of sacrifice.

Firstly, the most inherent argument is that all persons, and especially healthcare workers have the autonomy to adopt informed positions based on evidence and clinical experience. In the case of the Covid-19 vaccinations which have released recently, a healthcare worker may adopt a position that they would await full information before accepting a particular type of vaccine.¹ Mandatory administration of a vaccine may deprive them the opportunity being able to make conscious decisions; hence we would argue that it contravenes the principle of autonomy. Whereas one may argue that the ends justify the means in the short term to control the pandemic, healthcare workers, like any other individuals have the autonomy and right to ask questions about safety and risk.² New data suggest that the protection from a Covid-19 infection is longer lived than previously thought³, and that, at least in the short term, for persons who have already been infected with Covid-19 and recovered, vaccination does not necessarily add any more protection.⁴ Healthcare workers should be given the freedom to choose based on their autonomy.

Secondly, the process of mandatory vaccination may imply that the right to vaccinate an employee is arrogated upon the employer. This leads to significant uncertainty with respect to not only ethical principles but also legalities. For instance, if only one vaccine type is available in a country, and if an employee is mandated to take that vaccine, this could potentially accentuate absenteeism in healthcare workers.⁵ This can result in twofold problems. Firstly, workers may perceive this to be violating their rights, and secondly, if many healthcare workers choose to absent themselves because of the mandate, then workplaces are required to make compromises for their absenteeism.⁶ This has the potential to unjustly hinder the capacity and responsiveness of the health system in delivering services in the middle of a surge when their expertise is most needed.

We need to clarify at this juncture that we are no way suggesting that vaccinations are not useful, in fact, quite the contrary. However, we disagree with the stance that decisions should be forced upon healthcare workers by administrators and policy makers. Rather, we would suggest that the root causes of vaccination hesitancy amongst healthcare workers be dealt with in an honest and open manner to ensure that there is moral suasion and influence through proper scientific channels rather than mandates. There is enough scientific evidence published to assist in this process of educating and making a persuasive case for vaccination. Healthcare workers should be engaged and their concerns alleviated through dialogue that acknowledges their fears. This will increase the likelihood that the decisions that are made are rational and informed.⁷ We also believe that this would allow for a motivated workforce that will be accepting vaccination in a well-informed, educated and volitional manner. In our view, healthcare workers after being at the forefront of a battle that has eroded the wellbeing at every level across the globe, at the least deserve this approach of understanding their concerns and educating them passionately about vaccination.

References

1. Elhadi, M., Alsoufi, A., & Msherghi, A. (2021). Knowledge, attitude, and acceptance of healthcare workers and the public regarding the COVID-19 vaccine: a cross-sectional study. BMC Public Health, 955.
2. Bowen, R. (2020). Ethical and organizational considerations for mandatory COVID-19 vaccination of health care workers: A clinical laboratorian’s perspective. Clin Chim Acta, 421-2.
3. Turner, J.S., Kim, W., Kalaidina, E., Goss, C.W., Rauseo, A.M., Scmitz, A.J., et al. (2021, May 24). SARS-Cov-2 infection induces long-lived bone marrow plasma cells in humans, Nature Available from: nature.com/articles/s41586-021-03647-4
4. Shrestha, N.K., Burke, P.C., Nowacki, A.S., Terpeluk, P. & Gordon, S.M.. Necessity of COVID-19 vaccination in previously infected individuals: medRxiv; 2021 Jun 05 [cited 2021 Jul 19]. Available from: https://www.morg/content/10.1101/2021.06.01.21258176v2
5. Rubinstein-Reiss, D., & Caplan, A. Workers With COVID-19 Vaccine Side Effects Deserve Time Off To Recover: Health Affairs Blog; 2021 Feb 05 [2021 Jul 19]. Available from: https://www.healthaffairs.org/do/10.1377/hblog20210204.959004/full/
6. Centers for Disease Control and Prevention. Post-vaccination Considerations for Workplaces: CDC; 2021 Apr 02 [cited 2021 Jul 19]. Available from:https://www.cdc.gov/coronavirus/2019-ncov/community/workplaces-businesses/vaccination-considerations-for-workplaces.html
7. Nagele-Piazza, L. Can an Employee Refuse to Get a COVID-19 Vaccine? : SHRM; 2021, Feb 25 [cited 2021 Jul 19]. Available from: https://www.shrm.org/resourcesandtools/legal-and-compliance/employment-law/pages/employees-refuse-to-get-a-covid-19-vaccine.aspx