This article explores the ethical question of whether it should be mandatory for nurses and other health professionals and social care workers to receive the vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and why this is a nursing issue. The term healthcare worker is used throughout to mean anyone who has close contact with patients, be they nurses, doctors, other health professionals, staff such as porters, administrative and catering workers in hospital, health and care staff who work in the community, and all those who work in care homes. The ethical debate will be constructed using the framework provided by Beauchamp and Childress (2009). The article aims to reach a conclusion on whether mandatory vaccination is ethical, and should be implemented in all healthcare settings.
The COVID-19 pandemic
COVID-19 is now at the forefront of everyday life in the UK, and practices such as social distancing, support bubbles, shielding and wearing face masks have become the norm. The pandemic has severely impacted many aspects of society such as health care, social care, education, hospitality, retail, leisure and tourism, not just within the UK, but worldwide. UK Chancellor Rishi Sunak has stated that the country will face a significant recession as a result of COVID-19 (BBC News, 2020a) and UN Secretary General António Guterres has warned that SARS-CoV-2 is the biggest challenge for the world since the Second World War (BBC News, 2020b).
The transmission of SARS-CoV-2 is thought to mainly occur through respiratory droplets normally generated by coughing and sneezing, and through contact with surfaces contaminated with these droplets (World Health Organization (WHO), 2020). As a result, effective hand hygiene, social distancing, the use of face masks and personal protective equipment (PPE) have become imperative in reducing the spread of the disease.
As BJN went to press, there have been more than 3.5 million confirmed cases of infection with SARS-CoV-2 in the UK and more than 95 000 deaths with COVID-19 on the death certificate (Public Health England (PHE), 2021). Dong et al (2020) created an international dashboard that reports the cases and deaths of COVID-19 worldwide and, at the time of going to press, more than 96 million cases of novel coronavirus had been reported, with over 2 million COVID-19 deaths (Johns Hopkins University, 2021). It was reported in July 2020 that the UK had one of the highest numbers of healthcare worker deaths from COVID-19 (Amnesty International UK, 2020a). This suggests that PPE is not enough to protect frontline workers and provides evidence that developing a vaccine is the best hope for combating the virus (National Institute for Health and Care Excellence (NICE), 2020).
The Government's management of care/nursing homes and domiciliary care during the pandemic has been criticised by many experts. Discharging elderly patients from hospitals back to care homes without a negative SARS-CoV-2 test to free hospital beds resulted in the virus being spread among some of the most vulnerable people in society (BBC News, 2020c). This practice was condemned by a parliamentary cross-party committee. As a result, a high percentage of the people dying of COVID-19 came from this at-risk group. Care workers and domiciliary workers often receive limited training (Sarre et al, 2018), but many have worked hard to prevent the spread of the virus in their care homes.
The introduction of lockdown measures in March last year had some success in reducing the spread of SARS-CoV-2; however, the easing of restrictions resulted in a rise in infections, hospital admissions and deaths from COVID-19. Following this, localised restrictions to minimise person-to-person contact aimed to bring infection rates down and had some success, but lifting restrictions over Christmas has resulted in another surge in COVID-19-related infections and deaths. The Government has faced criticism for its handling of the pandemic. The UK has higher death rates when compared to countries with similar socioeconomic status, which critics say is due, in part, to the first lockdown, beginning in March, being implemented several weeks too late (Anderson et al, 2020).
Vaccine development
Fadda et al (2020) suggested that SARS-CoV-2 vaccines form the most promising strategy for fighting the pandemic through primary prevention. However, as Graham (2020) highlighted, vaccine development normally take decades to advance and having a SARS-CoV-2 vaccine approved for large-scale distribution within a year is unprecedented. More than 90 vaccines have been researched and developed by research teams in pharmaceutical companies and universities across the world (Callaway, 2020). Researchers are trialling different technologies, with eight different types of vaccines being researched as possible ways to provide immunity to SARS-CoV-2 (Callaway, 2020) and many governments are providing funding for these enormous trials.
The rapid production of vaccines has led to some doubts among the general public as to whether the trials are being conducted rigorously enough. There is also a significant amount of false information spread via social media in support of the anti-vaccination movement (Wadman, 2020). A YouGov (2020) poll reported that only 71% of the UK public is willing to be vaccinated for COVID-19, and reports in the USA have suggested that willingness is as low as 50% among US citizens (Cornwall, 2020).
Like governments across the wold, The UK Government has also had the dilemma of deciding whom to vaccinate first, with frontline healthcare workers and those most vulnerable to severe illness prioritised (Cowburn, 2020). There is also insufficient evidence to show how long antibodies will be present in the human body and most scientists agree that regular booster vaccinations, similar to flu, will be needed (Cullen, 2020).
The first research to be peer reviewed and published in early December was the Oxford-AstraZeneca vaccine, which reported efficacy of between 62% and 90%, depending on dosage (Gallagher and Triggle, 2020; Voysey et al, 2021). This was followed in late December by the Pfizer-BioNTech vaccine (Polack et al, 2020) and the Moderna vaccine (Baden et al, 2020), with an efficacy of 95% and 94% respectively. All three vaccines require two doses to achieve full immunity (Mahase, 2020). The Pfizer-BioNTech vaccine also needs to be stored at -70°C, which adds to the challenges of vaccinating populations, especially in developing countries (Mahase, 2020).
The vaccination debate
The availability of vaccines has raised the issue of whether vaccination should be made mandatory for healthcare workers. There is an increasing number of conspiracy theories around vaccinations and COVID-19 (Gilroy, 2019; Ahmed et al, 2020), which may influence the views/opinions of some healthcare workers, potentially resulting in a negative reaction and reducing the uptake of a vaccination programme. However, nurses need to ensure they follow the Nursing and Midwifery Council (NMC) Code (2018). Point 6.1 is especially relevant regarding vaccinations:
‘Make sure that any information or advice given is evidence-based including information relating to using any health and care products or services.’
Furthermore, vaccinations are not without risk. For example the British National Formulary (Joint Formulary Committee, 2020) reports common side effects of the influenza vaccines being: decreased appetite, arthralgia, diarrhoea, dizziness, fatigue, fever, headache, irritability, lymphadenopathy, malaise, myalgia, nausea, skin reactions and vomiting. Some healthcare workers may be unable to be vaccinated for medical reasons, such having an anaphylactic reaction to some of the ingredients in the vaccine (Joint Formulary Committee, 2020). As a result, it is essential that healthcare workers make an informed decision regarding having the vaccine. Staff must determine whether being immune to SARS-CoV-2, and thus helping to reduce the overall spread of the disease, outweighs the negatives of developing a side-effect associated with the vaccine.
In 2018, influenza was responsible for 758 UK hospital admissions, with 240 patients treated in ICU (Jones-Berry, 2018). Additionally, 384 540 nursing days were lost due to influenza or influenza-like symptoms (Jones-Berry, 2018). COVID-19-related cases have been much higher, with a high number of healthcare staff unable to work due to having to self-isolate or having symptoms of COVID-19 themselves (NHS website, 2021). Therefore, it could be argued that a mandatory vaccination programme could significantly help to prevent this problem and protect healthcare staff and their patients.
During 2018-2019, uptake of vaccination against influenza among healthcare workers was 70.3%, which compares with 74.3% in 2019-2020 (PHE, 2020).
The WHO (2013) has stated that, for immunisation to be effective for the whole community, a critical threshold of 95% of the population needs to be vaccinated. If one quarter of healthcare staff were not vaccinated against influenza through a voluntary programme in the majority of NHS trusts, it could be argued that achieving the 95% threshold for SARS-CoV-2 vaccination could be challenging without making it mandatory.
Ethical theory
Beauchamp and Childress's ethical theory (2009) splits ethical decisions into four principles that can be used as a starting point for exploring the underpinning of ethical issues. These are:
These principles are considered to be the standard theoretical framework from which to analyse ethical situations (Aldcroft, 2012). These four ethical theory principles will now be discussed in relation to mandatory vaccination for healthcare workers.
Beneficence
Beneficence can be defined as an act of charity, mercy and kindness (Kinsinger, 2009). It could be argued that a mandatory SARS-CoV-2 vaccination programme could benefit healthcare workers. For example, COVID-19 is associated with extensive economic burdens such as healthcare costs, lost days at work and general social disruption; vaccination could help prevent the spread of the disease. This highlights the burden of an avoidable illness and could provide a rationale for mandatory vaccinations as an act of beneficence. Additionally, nurses have a duty of care to their patients. Aziz (2014) argued that nurses who receive the influenza vaccine are ensuring a duty of care toward patients by preventing them from catching flu. Therefore, it could be suggested that a mandatory influenza vaccination programme could be beneficial in enhancing patient and staff safety in a healthcare setting (Aziz, 2014). However, Behrman and Offley (2013) argued that the effectiveness of the influenza vaccine as a preventive measure is not profound enough to override the right of healthcare workers to choose. Would this argument be the same for the coronavirus vaccine despite the severe effects that COVID-19 has had on society?
A Cochrane review carried out by Demicheli et al (2018) on vaccines for preventing influenza in healthy adults concluded that healthy adults who received the influenza vaccine rather than no vaccine probably experience less influenza, from just over 2% to just under 1%, highlighting that the impact of the vaccine was modest. It could be argued that the beneficence of a mandatory vaccination programme for healthcare workers is uncertain because the evidence provided is not significant enough to override the right to choose. The ethical implications for healthcare workers not having the vaccine—knowing that it could benefit patients and other staff members—are still debatable.
Non-maleficence
Non-maleficence is defined as an obligation to do no harm to others (Jahn, 2011). Although the SARS-CoV-2 vaccine is used to reduce the risk of disease and therefore of harm to patients and staff in healthcare settings, it could be argued that a mandatory vaccination programme has the potential to cause harm. The Royal Pharmaceutical Society and Royal College of Nursing (2019) have argued that it is the healthcare worker's role to ensure that all recipients of vaccinations have provided informed consent before the procedure. Thus, by introducing a mandatory vaccination programme, the right to consent is taken away from the individual, which arguably causes harm. Additionally, the NMC Code (2018) states that it is important to respect the individual's right to refuse treatment, and a mandatory vaccination programme contradicts this right to refuse, which causes maleficence for healthcare workers.
Mandatory vaccination may cause anxiety and stress for healthcare workers, which could affect vaccination uptake. For example, it has been argued that a mandatory programme could increase suspicion about vaccination in some groups in society, and that those advocating mandatory vaccination have not considered the possible psychological and cultural consequences (Jones-Berry, 2018). Therefore, it could be argued that a mandatory vaccination programme is not ethical and could be considered maleficence (Beauchamp and Childress, 2009).
Autonomy
Autonomy is defined as having the power to make decisions and act within one's scope of practice (Skår, 2010). This suggests that healthcare workers have the choice to make evidence-based decisions within their knowledge base, such as the decision to receive a SARS-CoV-2 vaccine. NICE (2018a; 2018b) does not support the use of mandatory vaccination because it could negatively affect staff morale, leaving them feeling disempowered, lacking autonomy and resentful. Jones-Berry (2018) also suggested that mandatory vaccination programmes are unnecessary and will have a negative impact on healthcare workers' autonomy. However, Blackmore (2018) provided a solution for this, suggesting that an opt-out system similar to that used for organ donation would be a useful approach: this would allow healthcare workers who do not want to receive a vaccine to exercise their autonomy, allowing them to feel empowered about their decision. The opt-out idea is supported in the case of COVID-19 by Bowen (2020).
Although the consensus is pro-vaccination in most western countries, various issues have led to conspiracy theories surrounding vaccines and ‘anti-vax’ movements. The WHO has stated that the annual influenza vaccine protects between 50% and 80% of clinical disease in ‘healthy individuals’, which provides a rationale for why vaccination is important (WHO, 2019). The term ‘healthy individual’ is a matter of contention for some because the influenza vaccine is primarily promoted to elderly people, who may not be considered healthy individuals (Sullivan et al, 2008). However, the influenza vaccine can reduce severe complications by 70%-85% in older adults (WHO, 2019).
Anti-vax movements have formed as a result of anxiety about vaccination. There have been recent measles outbreaks around the world and Isaacs (2019) suggested that the reasons for this are complex. Reasons vary from country to country and include pockets of low coverage, from vaccine refusal in close-knit religious communities (USA), the collapse of health systems (Venezuela), cross-border importation, inadequate services and vaccine scares (Ukraine), and conflict (Yemen) (Isaacs, 2019). They also include active rejection of vaccination (Isaacs, 2019). The most popular reason for so-called ‘vaccine hesitancy’ is linked with the MMR vaccination controversy, which began with the suggestion that the vaccine had been linked to autism in children. This so-called research was published in 1998, but was discredited a few years later, with the Lancet, which had published the paper, retracting the article. In addition, researcher Andrew Wakefield was struck from the General Medical Council register and cannot practise as a doctor in the UK (NHS website, 2010).
The anti-vax movement, particularly in the USA, sees vaccination programmes as government interference in people's lives. This has led to measles epidemics in some states (Benecke and DeYoung, 2019). Such views are often endorsed through online forums and by some celebrities (Gilroy, 2019). This controversy has had dramatic effects on measles outbreaks globally. The infection rate of measles across the globe went up by 300% in the first 3 months of 2019, highlighting the dangerous impact that anti-vax and conspiracy theories can have on a population's health (Gilroy, 2019). A UK nurse, Kate Shemirani, built up a following of tens of thousands on various social media platforms due to the sharing and promoting of anti-vax conspiracy theories (Spring, 2020). This highlights how influential nurses can be because of an assumed position of knowledge and reputation. As a result of spreading misinformation, the nurse was suspended from the NMC register (NMC, 2020).
Conspiracy theories add to ‘vaccine hesitancy’, which is considered a major threat to global health (MacDonald, 2015). It is consequently essential that healthcare workers are provided with appropriate, accurate, evidence-based research in order to make informed decisions.
Justice
Justice, from an ethical viewpoint, can be defined as ensuring fairness and as an equal distribution of benefits and burdens (Avery, 2017). Additionally, Avery (2017) suggested that justice should be at the forefront of every nurse and healthcare worker's mind when making an ethical decision. Furthermore, Nordhaug and Nortvedt (2011) argued that the principle of justice is consistent with inequalities in treatment, as long as inequalities are justified by morally applicable features.
This links to the ethics of mandatory vaccination for healthcare workers because, it could be argued, it is not morally justified. This is evidenced by article 10 of the Human Rights Act (1998), which states that an individual has the protected right to make their own decisions and express them freely without government interference. Consequently, the choice to have the COVID-19 vaccine should remain with the individual healthcare worker because mandatory vaccination, it could be argued, is unmoral and unjustified. However, article 10 of the Human Rights Act (1998) also provides restrictions on this right to choose. For example, if a government is concerned about public health, it has the power to amend this right. Therefore, although mandatory vaccination of the influenza vaccine is seen as morally unjustified, it is not unlawful.
However, as COVID-19 has had such a huge impact on society and with thousands of healthcare workers having died as a result of COVID-19, mandatory vaccination is an option for the government (Amnesty International UK, 2020b; Lintern, 2020). With the potential of some trusts refusing to allow staff to work if not vaccinated, there might be situations where healthcare workers want to take the vaccine but are unable to due to a medical reason or an allergy to an ingredient of the vaccine. Such problems could be overcome by occupational health risk assessments—some vulnerable staff may need to be transferred to work in areas with a lower risk of coming into contact with COVID-19 patients, for example.
Critiques of ethical theory
Although Beauchamp and Childress (2009) provide a fundamental insight into ethical theory, it could be argued that the theory is deontological in its nature. Deontology is defined as a person abiding by obligations when making ethical decisions (Bowen, 2020). This suggests that healthcare workers may agree to mandatory vaccination to uphold their professional values and obligations; for example the NMC Code (2018) states that it is the nurse's duty to uphold the standards set out within the Code, such as upholding the reputation of the profession at all times.
Walker (2009) criticised Beauchamp and Childress's (2009) ethical framework, suggesting that ethical dilemmas cannot be simply split into four principles due to the complexity of ethical decision-making and the implications that this can have on patients. Page (2012) argued that the theory has received some criticism but, despite its limitations, is still widely used in clinical practice and academic literature.
Lamb (1995) stated that theoretical analysis ignores the effect of wider social context within ethical decision-making, supporting the ideology that ethical theory can lead to oversimplification of ethical dilemmas. Additionally, some feminists have suggested that ethical theory is biased in terms of gender, despite healthcare occupations being predominantly female (Welsh, 2014). Feminist theory proposes that medical ethics can lead to female oppression by excluding moral equality (Welsh, 2014). This suggests that ethical theory is not representative of all healthcare workers. Furthermore, according to Noddings (1982), women approach moral decision-making differently to traditional theorists. In her theory of caring, Noddings (1982) provided a normative ethical approach, focusing on relationships and dependencies within human life. The theory identified two key characteristics ‘caring for’ and ‘caring about’. ‘Caring for’ refers to the application of hands-on care services, while ‘caring about’ refers to caring ideas and intentions (Sander-Staudt, 2012).
Although the credibility of the Beauchamp and Childress (2009) framework could be debated, it could be argued that the theory is still significant in the way that medical ethics is debated within the UK.
Utilitarianism may be useful to consider within the context of this discussion. This ideology, which centres on the ‘greatest good for the greatest number’ of people, is significant to the debate of mandatory vaccination (Bowen, 2020). For example, vaccinating all healthcare workers could reduce the significant risk of infection within the general population; thus the actions of one group of professionals could benefit the rest of the population. However, Bowen (2020) suggested that the vaccine is largely experimental and has the potential to put staff members in harm's way when they are needed the most. This highlights the issue of whether we can justify the potential benefits to society as a whole when we consider the potential risks to individuals and their autonomous rights. However, this point was made prior to any of the SARS-CoV-2 vaccines being approved for safety. Nevertheless, since the start of vaccination programmes, healthcare workers worldwide, including in the UK, have been keen to take up the offer of vaccination.
Page (2012) suggested that ethical theory may not be included in day-to-day decision-making within clinical practice, but is helpful in discussions such as this one. Thompson and Thompson's (1985) ethical decision-making model placed emphasis on the identification of the ethical dilemma. The theory is separated into a 10-step process of identifying the context of the problem, the possible conflicts with values or principles, and evaluating and reviewing the results of the decision taken. The use of this theory demonstrates the limitations of Beauchamp and Childress (2009) and highlights its oversimplification of ethical decision making. Despite many just criticisms, Beauchamp and Childress's (2009) ethical framework is still a useful tool to consider when debating ethical dilemmas such as mandatory vaccinations for healthcare workers.
Conclusion
A mandatory vaccination programme for all healthcare workers would likely be beneficial for patients and colleagues within the clinical setting. This is because COVID-19 is having a significant effect on the population at large, particularly the vulnerable such as elderly people and those with long-term conditions. It has also increased the number of sickness days in an already stretched workforce. However, mandatory vaccination for healthcare workers can be considered ultimately unethical. The right to choose and consent to medical interventions such as vaccination remains the protected right of the healthcare worker and cannot be influenced by the Government. Furthermore, mandatory vaccination could have dramatic effects on workforce morale because of the lack of autonomy they would have, which could, in turn, influence patient care.
This article has demonstrated an approach to this ethical debate using an ethical framework and discussed its relevance in terms of beneficence, non-maleficence, autonomy and justice. However, because it is important that as many healthcare workers are vaccinated as possible, an opt-out system could be recommended in which healthcare workers have the right to express their autonomy in a way that would not affect staff morale (Blackmore, 2018).
This pandemic has highlighted the role of the nurse and given a positive perception of nursing. As a result, nurses and healthcare workers are in a position to influence the uptake of the COVID-19 vaccination programme within the profession, the multidisciplinary team and the general public. For a national COVID-19 vaccination programme to be successful, it will be essential that there is a high uptake of the vaccine by healthcare workers and that they provide appropriate evidence-based health promotion to patients and the general public regarding the positives and negatives of being vaccinated against SARS-CoV-2 through shared decision-making. If carried out effectively, this should result in a high national uptake of the COVID-19 vaccine because the majority of individuals will see that the benefits of being vaccinated outweigh the risks.