Weighing a COVID-19 Vaccine Mandate for Healthcare Workers

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“An Ethical Analysis of the Arguments Both For and Against COVID-19 Vaccine Mandates for Healthcare Workers” (Journal of Emergency Medicine, 2022) focuses on the development of U.S. Food and Drug Administration (FDA) approved vaccines that led to mandatory immunization requirements for many healthcare workers wishing to avoid state medical board censure and loss of job.

While a majority of those in the medical profession accepted vaccine mandates, a vocal few characterized them as unnecessary and intrusive, as it violated their civil liberties and right to pursue whatever health care mitigation steps they saw fit.

Vaccine mandates historically fall under the purview of nations worldwide, starting with the state of Bavaria in Germany, which required smallpox vaccines shortly after they were developed in 1807. The precedent-setting 1905 U.S. Supreme Court case Jacobson vs. Massachusetts established that vaccine mandates at state levels were enforceable and legal when necessary to protect public health.

Today such mandates meet the criterion of “acceptability,” or something generally accepted by the public at large. This is particularly true when vaccine requirements are consistently applied in a way that is just, or “fair, equitable, and appropriate” to all involved, whether healthcare workers or ordinary citizens. With the demonstrated benefits of immunity to COVID-19 substantially outweighing the risks, vaccines meet this criterion. Further they are administered through legal means without bias or discrimination, and constitute a “necessary treatment.”

Precedent favors this perspective as well: over the past half-century, those who work in health care have generally abided by requirements that obtaining hospital privileges goes hand in hand with mandatory vaccines, when circumstances dictate. Before March 2020, when COVID-19 restrictions took hold, mandatory vaccination proof, or proof of immunity, regarding rubella, mumps, measles, hepatitis B, and tetanus was standard when obtaining clinical work engagements in a majority of US healthcare settings.

Another aspect of this argument is the concept of nonmaleficence, which aligns physicians with the Hippocratic Oath and a promise to “act in a way which does no harm.” In remaining unvaccinated, healthcare workers are not simply exercising free will. Because they interact with coworkers and members of the public in physical settings, they are exposing highly vulnerable people to potential viral transmission.

Beyond this, healthcare workers’ decision not to get vaccinated depletes society of the very type of professionals necessary to assist patients during a pandemic. The physician–patient relationship, as well as the societal healthcare construct, suffer as a result. Refusal to get vaccinated counters the utilitarian principle that underlies the intersection between public health policy, law, and ethics, of accomplishing “the best for the most.”

With utilitarian arguments common during crisis, such formulations can infringe on the individual’s rights. Some healthcare workers argued that, while the seasonal flu vaccine is readily available and required in numerous healthcare settings, it is not mandated at a policy level. Indeed, there are workarounds as a professional, such as wearing a mask throughout the flu season.

However, a new type of easily transmissible virus that has severe effects is different. In such a situation, one must weigh the level of risk with the unknown effects of a new virus. COVID-19 poses a greater threat to more people than the common flu. In turn, higher risks make an overarching mandate more necessary and permissible.

The authors go on to tie the vaccine mandate to the philosopher Immanuel Kant’s categorical imperative, which holds that moral laws are applicable to every individual. In particular, universalizability dictates that one should, as a moral actor, consider what the consequences would be if all other individuals acted in the way one is acting. Moral self-governance requires actions that one may not agree with or prefer, but which one submits to when they serve the greater good and, by extension, the well-being of fellow humans.

Eugene Saltzberg MD

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