Should health care institutions require employees to be vaccinated?

Should health care institutions require employees to be vaccinated?
© Greg Nash

“The hospital where I work said we should all get COVID-19 shots,” a colleague in California recently told me. “They want to shove needles into our arms. They sent emails, posted signs in elevators and scheduled lectures on Zoom. But I want to wait and first make sure the vaccines really work. I think the government rushed them out too fast.”  

He is hardly alone. About 20 percent of hospital workers are refusing to get vaccinated.  Other colleagues I know also balk.

Understandably, hospitals, nursing homes and other health care facilities want all their employees to get these shots — which, data show, are safe and effective. Unvaccinated staff could potentially infect patients, who may have weakened immune systems. Some facilities have thus started to mandate — or are about to — that all employees comply, including those without direct patient contact. Other institutions are debating what to do. Yet, many employees remain wary, though varying in their reasons.

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recent study of staff at a children’s hospital found that African-American employees were more than three times as likely to be hesitant. Latino staff were almost twice as likely, individuals with high-risk medical conditions three times as likely — and non-clinical and hourly (as opposed to salaried) employees, and those who have had the virus or were less concerned about severe COVID-19, were around twice as likely to be hesitant. Thus, while some appear overly worried about COVID-19 risks, others dismiss the dangers altogether. 

Unfortunately, vocal “anti-vaxxers” have long opposed any vaccines, and social media have been disseminating burgeoning amounts of misinformation about these shots.  The U.S. Conference of Catholic Bishops recently stated that Catholics should avoid the Johnson & Johnson vaccine, if given a choice, because scientists developed the product using cell lines derived from fetal tissue. The bishops’ pronouncement will likely further fuel public wariness and confusion.

Nearly 40 percent of the U.S. population as a whole, including one-third of African Americans and one-fifth of Latinos, remain hesitant. Unfortunately, countless people, especially those of color, face barriers even trying to get shots, but health care facilities commonly now have them available for employees. 

To be sure, additional data about the vaccines would be beneficial. Given the pandemic’s vast scope, the Food and Drug Administration (FDA) approved these products through Emergency Use Authorizations, not the usual rigorous vetting process; preliminary results have just started to become available about the vaccines’ potential effects on pregnant women, and are not yet available about children. Since the FDA approved the first vaccine in December, no data have been able to look for longer-term effects that may occur only after several months — since no one has had these products for very long. Thus far, no evidence suggests that any longer-term effects occur, but definitive data would be good.

So, what should these institutions do? Legally, since the vaccines were approved by the FDA without full vetting, forcing all employees to take them might be difficult, and some courts may oppose such efforts. 

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Importantly, employers need to be sensitive to the rigid hierarchies and immense power differentials that exist within their walls. In hospitals, physicians frequently rule, with senior doctors on top, followed by junior attending physicians, then fellows, then residents, then interns, then senior and junior medical students. On these ladders, nurses tend to occupy lower rungs than doctors. Nonclinical hospital workers, many who are people of color, including security, environmental services, food preparation and clerical personnel, sit at the bottom, and financially are the most vulnerable.

Unfortunately, even before the pandemic, our country’s economic and medical disparities have been expanding, not contracting.  American medicine has, alas, also long discriminated against people of color, many of whom are very aware of unethical experiments conducted on African Americans, most notoriously the Tuskegee Syphilis Study. Countless people of color may resist COVID-19 vaccines because of deep emotional distrust, not lack of cognitive information. 

Institutions that are starting to mandate vaccines (and to fire employees who refuse) argue that they have long required influenza vaccines, setting a precedent for such requirements.  But flu shots have existed for decades, and vast amounts of data document overwhelming safety. In contrast, COVID-19 vaccines are wholly new. With mandates, reluctant employees may feel unfairly coerced to get shots in order to keep their jobs, fostering anger, resentment and further mistrust that they may communicate within the communities in which they live, where increased vaccination is also needed. 

Instead, health care institutions should first seek as much as possible to diagnose and treat the underlying problem of employee emotional distrust, by carefully listening and trying to understand and address workers’ wariness as sensitively as possible. Townhall-style meetings, African American and Latino physicians and experts talking with small groups of hesitant employees, and dissemination of reliable, easily understandable information in both English and Spanish can help reduce misconceptions and suspicion. Hospitals should explain that employees with serious diseases can potentially get medical exemptions. Health care associations and others should engage with respected community leaders, including clergy, who might be able to help disseminate accurate information about vaccines to the communities where employees live.  

Before mandating shots and firing employees who decline, medical facilities should at least try to pursue these steps, and do so well. Other types of employers, including hotels, restaurants, school, cruise ships and varied offices, are wrestling with these same concerns and will look to see how medical centers are proceeding. Health care facilities differ from other workplaces in serving patients who may be more vulnerable to serious disease, but these institutions’ decisions likely will affect other employers’ approaches. 

Eventually, my colleague in California saw his family doctor, who had known him for decades and convinced him to get vaccinated. Hopefully, my colleague can now help persuade his co-workers, who will thus be more comfortable agreeing to be vaccinated as well — and avoid either feeling coerced or losing their jobs. 

Dr. Robert Klitzman is a psychiatry professor, director of the online and in-person Masters of Bioethics Program and a co-founder and former co-director of the Center for Bioethics in the Vagelos College of Physicians & Surgeons and the Mailman School of Public Health at Columbia University. He is the author of nine books, including “Designing Babies: How Technology is Changing the Ways We Create Children” (2020), and “The Ethics Police?  The Struggle to Make Human Research Safe” (2015). Follow him on Twitter: @RobertKlitzman.