Ethics of Healthcare Personnel Declining Covid Vaccine Is it Ethical for Healthcare Professionals to Decline the Covid19 Vaccine if it is Available?

Commentary

I recently had a student pose this question to me after class (virtually). It did not take me long to answer, my response was “only in very limited circumstances”. Allow me to explain why. When I think of healthcare ethics the frame of reference, I use is Beauchamp and Childress, Principles of Biomedical Ethics 8th (Edn.) [1]. This work offers us the frame of a balanced approach with four primary principles (with this author’s interpretation). These are:

• Autonomy- Respecting the individual and the informed choices they make regarding their own health.
• Beneficence- To aim for good, for outcomes that are positive for all those we serves.
• Non-Maleficence- “Do no harm”, to avoid harm or risk to self or others whenever possible.
• Justice- To work toward fairness in all aspects of care for individuals and populations.

Before expanding on just healthcare workers let us examine what we know save lives, encourages health, and over all contributes to reduced morbidity and mortality. Proper sewage disposal, access to clean water/hand washing, and vaccinations are the trinity combination that have reduced or eliminated disease and death due to contagious virus in modern society Luby SP, et al. [2]. In the time of the coronavirus pandemic, we have continued to practice sewage removal, accessing clean water and encouraging hand washing, with the final element of vaccination upon us. The importance of completing large scale vaccination to prevent disease is imperative to eradicate current and future Investigation Paper viruses, including the current coronavirus. Humans gain immunity to germs from two ways over the course of their life. The first being though their mother when in utero. When in the womb, a mother’s immune system and fetus’ immune system cross over so when born, a child has some form of immunity against germs in the outside world; this interaction is analogous to future vaccinations. As we age, this begins to phase out and we gain new immunity against viruses by becoming exposed to them. Through our school, work, play, and other interactions our body encounters virus’, makes immune cell memories of these interactions, and when we encounter them again, use those immune memory cells to prevent us from getting sick. This was first noted back in 1796 Dr. Edward Jenner noted for the very first time while treating patients during the smallpox pandemic in Europe the milkmaids did not contract smallpox while the rest of the community got sick or died. The maids had been inoculated by encountering cowpox previously in their work, and their immune systems had made an immune cell memory of the virus. This discovery led to the first vaccine. Science was able to harness enough of virus’ genetic material which caused smallpox to create immunity so that the population could protect themselves and one another from contracting smallpox. Had this not been discovered the population would have otherwise been very sick or died. Therefore, vaccination is simply the controlled introduction of some viral genetic material in order to create and maintain immunity against viral diseases that otherwise disrupt our individual and societal life.

To be clear, according to Johns Hopkins Covid19 website accessed April 11, 2021. “The vaccine for COVID-19 cannot and will not give you COVID-19. The two authorized mRNA vaccines instruct your cells to reproduce a protein that is part of the SARS-CoV-2 coronavirus, which helps your body recognize and fight the virus, if it comes along. The COVID-19 vaccine does not contain the SARS-Co-2 virus, so you cannot get COVID-19 from the vaccine. The protein that helps your immune system recognize and fight the virus does not cause infection of any sort.” As we know, preventing disease is ethical from both a personal perspective, as well as an economical one. Healthy people cost a fraction of what sick people cost in our healthcare systems and enjoy living healthy and productive lives. Therefore, vaccination for almost all individuals is an ethical choice for society.

Utilizing the framework of principles of bioethics requires that decisions be based on a balance of these four principles; in this case it requires an additional consideration. We are currently and for the past year have been in a pandemic. A worldwide contagious disease now complicated with several serious variants has incurred significant damage to health. Both morbidity and mortality have been off the charts in terms of both the world and the United States. At this writing, the Johns Hopkins University Coronavirus Resource Center (Home - Johns Hopkins Coronavirus Resource Center (jhu. edu) reports:

• 134,305,119 cases worldwide
• 31,052,741 in the US
• 2,907,871 deaths worldwide
• 560,825 deaths in the US This is clearly not a usual health issue that individuals and health systems are prepared for and have resources in place to mitigate. For this reason, we need to apply the principles mentioned above in a more global manner. This different application requires both understanding individual health implications and population health implications of the Coronavirus Pandemic.

The population implications and contagious nature of this virus have challenged every aspect of health systems in almost every corner of the earth. This has created budget crisis around the world that had not previously been anticipated and challenged health systems from primary care to hospital intensive care and every aspect in between. We will attempt to highlight these implications through a review and analysis of the four principles stated above.

When we look at autonomy, often we are discussing consent for a surgery or other procedure. In most of those cases the implications mostly or all fall on the patient who is making the decision. This is as it should be in these cases as the impact (positive or negative) and fallout (positive or negative) are experienced by the individual who decides. It is always understood that a critical element of exercising autonomy is that the “decider” is fully informed of all potential benefits and risks of the procedure. Once that level of understanding is reached the patient (or parent, or surrogate when is not able to decide) the patient is the appropriate person to anticipate risk and reward and decide accordingly. In this case these conditions apply, but in the context of a population health crisis where the benefits are shared by the recipient of the vaccine and across the population. Additionally, there is a greater challenge assessing whether individuals are fully informed as, there is a good deal of misinformation about risk and potential risk with these vaccines that the health system isn’t directly involved with, thus creating huge obstacles to correcting misinformation and reaching that condition of “fully informed” by individuals considering accessing the vaccine.

The principle of beneficence calls on all those involved in healthcare to focus of the wellbeing of the patient. This is true whether the patient is Ms or Mr Smith, or the population of the US. We are still called on to aim to do good for the “patient”. This can be significantly more challenging in population health during times like this pandemic, making focus on this principle even more important. There is some confusion in the lay media about public health, with some inferring a meaning of government supported or run health. From the perspective of a principled approach, it makes more sense to see public health in the sense I have already referred to, that of population health. With a severe viral disease, now predictably morphing into more contagious and serious variants, looking at the health of populations is essential to impact morbidity and mortality. The already significant morbidity and mortality mentioned above will likely continue without intervention, and one of the most effective interventions can be vaccines. When we consider this question for healthcare professionals the implications become even more serious. Healthcare professionals by definition come into close contact with other humans, so beneficence calls on them to do whatever they can to make those interactions result in good. Clearly the potential benefit of vaccine would fall into that category.

On a very much related premise, the next principle of non-maleficence carries the same responsibility more directly. The admonition to “do no harm” that all who work in and around healthcare are familiar with seems to emanate from the concept of vaccine. To inject a substance into a human that prevents transmission of a highly contagious, potentially fatal disease would be an appropriate image to illustrate non-maleficence. Considering the process for approval of vaccines, even the emergency approval used in the US in this case to date, the level of caution, the amount of data collected to assure safety, and the ongoing monitoring of use and effectiveness all combine to limit cause for individual concern in favor of the demonstrated individual and group benefit.

The final principle of bioethics I mention above, that of justice may provide the clearest reason to call for more extensive use of vaccines and use of vaccines to achieve the goal of “getting back to normal” that we all hear about regularly. This idea of justice, fairness, and equity has been discussed at length by others in regard to access to vaccine by populations traditionally lacking access to healthcare. I agree with those observations and further would point out that it is only when most of all populations are vaccinated that we begin to achieve those goals of normalcy. That means justice calls on us to assure that populations who typically lack access or have obstacles to access must have access to vaccines – just as well all must. In fact, for vaccines to truly work for the entire population this is a necessity. Reading the work of America’s Founding Fathers, it is clear that when they said “justice for all” the intent was a call to humans around the world. This pandemic causes us to echo that call for justice globally.

So, to revisit the question posed to me by a student, no, it is not ethical for anyone working in healthcare to choose to forego the Coronavirus vaccine when it is available to them with very limited exceptions for documented health issues or sincerely held religious beliefs to the contrary. In those exceptional cases these individuals should not be in a position of contact with patients unless and until steps are in place to assure safety for all concerned. I routinely counsel students considering careers in healthcare that they will need to receive many vaccines in order to do their job safely for themselves, their patients, and those in their lives. I suspect as we progress to discuss re-opening the many venues currently curtailed because of the pandemic these questions and issues will deserve much more scrutiny and dialogue. Healthcare is the one set of professions I’m aware of where the conversation has been ongoing for years and can be an example and learning experience for others.