Mandating vaccination can be ethical if it is both necessary and proportionate.
A mandate is not necessary if there are less intrusive means of effectively increasing uptake, such as persuasion and incentives. The problem is that less intrusive means may be much less effective. Persuasion has so far failed. There is strong evidence to suggest that vaccine mandates are the most effective way to increase uptake.
In the earlier phase of the pandemic, some of the most medically vulnerable members of our community ended up catching coronavirus from those caring for them. Forty-thousand patients in England are said to have caught COVID while hospital inpatients. Some patients and care home residents died from infections that they caught from their caregivers.
First, we should ensure that all those who are high risk have access to vaccination. There are still approximately 10% of older adult care home residents who have not had a 2nd dose of the vaccine.
Increasing vaccine uptake may only have a limited effect in preventing transmission. The very limited data available regarding the effect of vaccines on transmission (following one dose) suggests only a limited effect (as low as 35 % and up to 50%). There are also confirmed reports of breakthrough infections, and even outbreaks, amongst fully vaccinated staff and patients, with all available vaccines.
Yes (Prof Wilkinson)
It is true that autonomy is not always decisive in public health, and that care workers have professional responsibilities to those in their care. But to justifiably override autonomy and remove someone’s livelihood, we need to know that doing so will be an effective measure, and that it is necessary. Neither are true of the proposed policy.
The UK government is set to announce that COVID-19 vaccination will become mandatory for staff in older adult care homes. Staff will be given 16 weeks to undergo vaccination; if they do not, they will face redeployment from frontline services or the loss of their job. The government may also extend the scheme to other healthcare workers.
We should ensure the risks our vulnerable face are as low as they reasonably can be. We should educate, inform, encourage, and even incentivise. But this isn’t a vaccine with the safety track record of the flu or hepatitis vaccine.
This won’t be the case for everyone. But , it should be up to the individual who will suffer the outcome to make an informed choice. That is perhaps the most basic tenet of medical ethics: respect for autonomy.
I think the COVID-19 vaccines are in most people’s best interests. But that’s a decision people should make for themselves.
By Dominic Wilkinson and Julian Savulescu
An edited version of this was published in The Conversation
We have good data to show that vaccines have been extremely effective at preventing death and hospitalisation, even in the old.
Mandating vaccination would increase vaccine uptake in care home workers, but would be a significant intrusion into individual freedom. Is it ethically justifiable?
No (Prof Savulescu)
It will likely confer some protection. But even in the best case scenario a staff vaccine mandate will not prevent family and friends from continuing to transmit the virus whilst visiting care homes. Singling out one group for coercive measure will be divisive, and may lead many staff to leave the already-understaffed profession.
There are emerging rare but serious risks of vaccination: blood clots for AstraZeneca, and probable myocarditis in Pfizer. COVID-19 deaths are predominantly in the elderly, whilst rare side effects are mostly in the young. Indeed, the Joint Committee on Vaccination and Immunisation is advising the government to hold off vaccinating healthy under 18s while we get a better picture of the risks.
A ‘conditional’ vaccination policy would be ethical. Care home workers (and NHS staff) who have not had the COVID vaccine should be redeployed to areas other than frontline care. It would also be ethical (in the absence of a medical exemption) to make COVID vaccination a condition of employment in the same way that hepatitis B vaccination is currently for some health professionals.
Second, those who work in the frontline with vulnerable high risk patients have an ethical obligation to take all reasonable measures to prevent spread of the virus to those they are caring for. They must follow guidance about the use of measures like hand washing and PPE. They should take part in lateral flow testing schemes. And they should be vaccinated.
Mandatory vaccination policies can sometimes be ethical. But, the proposal to make vaccination mandatory for care home workers is muddle-headed.
It is crucial to achieve a high vaccine uptake amongst older adult care home staff due to the high mortality risk faced by residents. ONS Data suggest that there has been a 19.5% increase in excess deaths in care homes since the beginning of the pandemic, with COVID-19 accounting for 24.3% of all care home resident deaths.
She (and indeed those in her care) have little to gain from her undergoing vaccination to gain additional immunity. A Public Health England study compared vaccine and natural immunity and found “equal or higher protection from natural infection, both for symptomatic and asymptomatic infection”. But under this scheme, she would still be exposed to the additional risks of vaccination. Moreover, if she has to take time off sick with the common side effects, thanks to her zero hours contract, she won’t be eligible for sick pay for four days, and perhaps not then.
For our care worker, not being vaccinated is not an irrational or selfish choice. She risks losing up to a week’s pay, takes on a (small) risk of serious side effects, and there is no confirmed benefit either to her or her patients.
That is a tragic and distressing situation that we must do everything possible to avoid repeating.
For most, these small risks won’t change the risk-benefit ratio. But for some the risk-benefit ratio looks very different. Imagine a twenty-year-old care worker, on a zero hours contract like 24% of her colleagues, who worked through the pandemic, and gained natural immunity from becoming infected.
According to SAGE, 80% of staff working in care homes with older adult residents (and 90% of the residents themselves) need to be vaccinated in order to confer a minimum level of protection to this vulnerable population. In mid-April, only 53% of older adult care homes in England were meeting these thresholds, whilst, as of the 10th June, 17% of adult care home workers in England have not had a single dose of the COVID-19 vaccine.
The policy is also unnecessary. Half of care homes have hit the target level of staff vaccination through voluntary means. Unvaccinated patients (who cannot be vaccinated themselves) could be cared for by vaccinated staff. Staff could be offered incentives to be vaccinated. This may tip the balance for those who are on the fence, or—importantly— who like our care worker, cannot afford to take the unpaid sick leave if they get the common non-dangerous but flu-like side effects.
A mandate could be proportionate if the public health benefit of increasing uptake amongst staff would outweigh the harms. Given the considerable vulnerability of care home residents, a vaccine mandate is proportionate in the current circumstances. Care home residents can’t choose who cares for them. Some remain only partly protected after vaccination. The risks of vaccination for workers are exceptionally low.
However, if vaccines are made mandatory for care home workers (or healthcare workers), they should be able to choose from available vaccines. Every effort possible should be made to address any concerns that they have about the vaccines.