Mandating flu jab, but not COVID-19 jab, ethically justified for healthcare staff

Press release

Few side effects; cuts infection risks; minimises staff shortages and presenteeism
And professional obligations to patients trump personal freedom, argue ethicists

Mandating the flu jab for healthcare staff is ethically justified, but the same can’t be said of the COVID-19 jab, argue leading ethicists in an extended essay published online in the Journal of Medical Ethics.

Unlike the COVID-19 jab, the pros outweigh the cons for all age groups: the flu jab is safe and has few side effects; it cuts the risk of infection; and it minimises staff shortages and ‘presenteeism’, they suggest. 

And healthcare workers have professional obligations to protect patients from a virus that is particularly deadly for older people who are overrepresented among hospital patients. Such obligations trump curbs on personal freedom, the authors contend.

In light of the infection control issues raised by the pandemic, and the steps taken by various countries to overcome vaccine hesitancy, the authors compare the ethical criteria for mandating vaccination of healthcare staff against COVID-19 and seasonal flu.

A vaccine mandate for healthcare workers would align with existing professional requirements, based on preventing harm to patients. But not every professional obligation is also a legal requirement. 

Further ethical criteria are therefore required to justify such a policy, the authors explain. 

These include the pros and cons of the vaccines and the availability of less restrictive alternatives to achieve comparable health benefits.

During the pandemic, several countries mandated COVID-19 vaccination for healthcare workers: France; Italy; many US states; several Canadian provinces; and Australia.

The UK government also planned to do the same, but stopped short amid fears of staff losses and perceived heavy-handedness in light of the emergence of the milder Omicron variant.

However, it did consult on mandating the seasonal flu jab for healthcare workers, around 1 in 4 of whom don’t get vaccinated against the virus. 

Flu kills more than 11,000 people every year in England alone, a toll that rose to more than 22,000 in 2017-18.

Data from London University College hospitals during the 2018–2019 flu season suggest that 15% of inpatients with flu caught the infection while in hospital (nosocomial infection).

In some flu seasons large numbers of unvaccinated staff fall ill, prompting shortages or ‘presenteeism’—where staff with the infection keep on working—so heightening the risk of spreading it to patients and colleagues.

“Vaccine mandates are typically controversial as they entail limitations of individual liberties for the sake of the collective good,” acknowledge the authors. 

“However, when it comes to [healthcare workers], liberty-based counter-arguments are more difficult to apply. Quite simply, [healthcare workers] have an ethical and professional obligation not to harm patients, or to minimise the risk of harm to patients, which other people do not have,” they point out.

“It is already commonly accepted that [healthcare workers] should take on at least some additional health risk for the sake of their patients…The issue at stake is not if this is justified, but how much extra risk is justifiable by contractual and professional obligations,” they add.

COVID-19 vaccines are associated with a small risk of blood clots and myocarditis (inflammation of the heart muscle), and given the relatively low risk of serious illness from COVID-19 among younger staff, the cons may very well outweigh the pros, they suggest.

Nor do the current crop of COVID-19 vaccines seem very effective at preventing spread, while the protection they afford against symptoms tails off within months.

What’s more, COVID-19 illness severity has reduced, due to changes in the circulating form of the virus, high vaccine uptake in those at highest risk, high rates of natural immunity and increasingly more treatments becoming available, point out the authors.

These issues don’t apply to the seasonal flu vaccine, which has been used for decades, has a well established safety profile, and few and mostly minor side effects, they highlight.

Higher flu jab uptake minimises risk of harm to patients, not just by reducing the risk of infection, but also by reducing the risk of staff shortages due to illness. And the evidence suggests that compulsory flu jabs increase uptake more than less severe measures, say the authors.

But the question remains as to what level of coercion is ethically acceptable. “One way to strike a balance between individual freedom and patients’ interests is to make vaccination a condition of entry into the profession rather than mandating those already employed, and adopt a conditional mandate if at all possible for those already in the profession,” they write. 

“Ultimately, there is an ethical balance to be drawn between protecting patients (including their own right to not acquire serious but preventable nosocomial infections) and coercing some healthcare professionals into having a vaccine that they would prefer not to receive.”

They conclude: “For reasons that we have given above, the balance of risks and benefits suggests that an influenza vaccine mandate, but not a COVID-19 mandate, would currently be ethically proportionate.”

But they caution: “Mandates should be introduced on a disease-specific and vaccine-specific basis. The problem must be a significant one; the vaccines must be safe and effective at preventing illness and/or transmission; mandatory measures must be superior to less coercive alternatives; and the costs in loss of liberty and risk to health professionals must be proportionate in professional terms to the benefits to patients.”

Authors: Alberto Giubilini 1,2 Julian Savulescu1,2,3 Jonathan Pugh1 Dominic Wilkinson1,3,4
Extended essay: Vaccine mandates for healthcare workers beyond COVID-19
Competing interests: None declared.

Funding: UK Research and Innovation; Department of Business and Innovation, Victoria State Government; Wellcome Trust; Australian Research Council

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