Should they be compulsory in healthcare?

Should they be compulsory in healthcare?


To shield vulnerable patients from COVID-19, few people who work in health and long-term care would disagree with the ambition to vaccinate as many of their colleagues as possible. But there remain deep divisions over whether vaccination should be compulsory for staff who are not medically exempt.

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Mandatory vaccination is a hot topic. In a recent special issue, the BMJ investigates. Boy_Anupong/Getty Images

In a special issue of the BMJ, academics and a transplant patient debate the pros and cons of mandatory vaccination.

“If hospital chefs refuse to comply with new safe food preparation guidance, they have no good reason to expect to continue to be employed,” argues Michael Parker, professor of bioethics at the University of Oxford, United Kingdom, in the BMJ.

“So too in frontline healthcare roles, staff are rightly required to modify their practice in the light of evidence about patient safety,” he writes.

Prof. Parker believes the same principle should apply to COVID-19 vaccination.

In the United States, more than 50 medical organizations — including the American Medical Association, the American College of Physicians, the American Nurses Association, and the American Public Health Association — have endorsed a statement that calls for compulsory vaccination of healthcare and long-term care facility staff against COVID-19.

The Department of Veterans Affairs, some university hospitals, and some health systems have already made COVID-19 vaccination compulsory, though many of them allow exemptions on religious or philosophical grounds.

U.S. President Joe Biden has announced that federal workers and contractors must be vaccinated or else comply with new rules on mandatory wearing of masks, weekly testing, and social distancing.

In the U.K., the House of Commons recently approved legislation that would make COVID-19 vaccination compulsory for staff working in care homes in England unless they have a medical exemption.

The U.K. government is consulting on whether to extend the requirement to healthcare workers and other social care staff.

Italy, France, and Greece have already made vaccination mandatory for healthcare workers.

Prof. Parker notes that health and social care providers have a duty to recruit staff whose presence does not put patients at unnecessary risk.

He concedes that the situation is less clear for existing staff because employers have obligations towards them, such as ensuring they have reasonable working conditions and do not face discrimination.

However, he argues that employers should move staff who are reluctant to be vaccinated, or who have a medical contraindication, to roles where the risk to patients is low.

On the other side of the debate, academics argue in the BMJ that while health and social care workers have a duty of care to be vaccinated, mandatory vaccination is a “blunt instrument” to tackle a complex issue.

According to Helen Bedford, a professor of children’s health at UCL Great Ormond Street Institute of Child Health, London; Michael Ussher, a professor of behavioral medicine at St George’s University of London and the University of Stirling; and Martine Stead, deputy director of the Institute for Social Marketing and Health at the University of Stirling.

“[I]t is not necessary, acceptable, or the most effective way to achieve high uptake, and it raises serious ethical issues about freedom of choice.”

They write that compulsory vaccination may seem a straightforward solution, but it has downsides.

“Notably, it may risk increasing resistance to vaccination by damaging trust in the government and other organizations,” they write.

“This is of particular concern among ethnic minorities, who are overrepresented among health and social care workers, have been disproportionately affected by COVID-19, are less likely to trust government sources of information, and are more likely to be vaccine hesitant,” they add.

They also point out that if individuals choose to leave rather than undergo vaccination, this will exacerbate existing staff shortages.

In an accompanying comment article, Michael Mittelman, who has a rare kidney condition and has had three kidney transplants, argues in favor of compulsory vaccination — not just for doctors and nurses, but for everyone who comes into contact with patients, such as cleaners and staff who serve food.

“People like me, at high risk from COVID-19, must be protected by and from the staff caring for us,” he writes.

Mittelman has been vaccinated, despite the risks for people such as him who need drugs to suppress their immune systems in order to prevent transplant rejection.

His blood now contains antibodies against SARS-CoV-2, the virus that causes COVID-19. However, he points out that other immunosuppressed patients test negative for the antibodies after vaccination, meaning they remain at high risk from the disease.

Mittelman concludes:

“As a patient who needs care in multiple settings, I hope that mandatory vaccination rules become universal, with only medical exemptions permitted. It would alleviate some of my anxiety in receiving care.”

In a second comment article, Nadra Ahmed, who chairs the National Care Association in the U.K., says her sector shares the government’s ambition to have a fully vaccinated workforce.

But she believes care workers are being targeted unfairly at a time when they remain under intense pressure.

She writes:

“We have an exhausted and anxious workforce who, through this new legislation, are being targeted as the root cause of the spread of infection, such that they must have their employment conditions amended. Where is the consideration for alleviating real anxieties about adverse effects from new vaccines?”

She notes that most care workers are female and may have concerns about COVID-19 vaccination and childbearing. In addition, many carers are from ethnic minority communities and may have reservations about vaccination embedded in their culture.

Care homes already face a staffing crisis, with more than 112,000 vacancies in England, writes Ahmed.

She warns:

“The most dangerous assumption is that staff who walk out will be easily replaced: if staff who have not yet had a vaccine were to leave — potentially an additional 13% — care services would be unsustainable.”

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