Compass senior consultant and clinical ethicist Dr. Eric Mathison describes some of the factors that go into an ethical vaccination mandate, including making sure that a mandate is the right approach and looking beyond the mandate to ensure that employees have access to good information about the vaccines.
By Eric Mathison
Over the past few months, pressure on corporations has mounted as the battle over the ethics of vaccine mandates for organizations roars on. Leaders are increasingly being called upon to make a decision on the propriety of a vaccine mandate for their organization. A vaccination mandate places important values in tension.
Organizations have a responsibility to keep their employees and customers safe, but a mandate also restricts liberty and each organization has other obligations (e.g., public health), so there isn’t one straightforward ethics analysis that can determine the appropriateness of a vaccination mandate for all organizations. Still, there are some common factors to consider.
Proven Vaccine Safety
To start, there’s now ample evidence that the Covid-19 vaccines are safe and significantly reduce the likelihood of hospitalization or death, even when infections still occur. Getting vaccinated is the best way to protect oneself against acute harms and long-term effects of infection, and a lower transmission rate protects others. Further, we now know that vaccination mandates are the most effective way to increase vaccination rates. Other approaches, such as offering financial incentives to encourage vaccination, have either had no effect or have only made a mild difference.
Duty of Safety
The ethical argument for a vaccine mandate rests on the duty of employers to ensure that their employees and customers are safe. This duty is important for its own sake, but it’s also good business: employee infections will lead to lost productivity, while customer infections will negatively affect business. When a company has a fiduciary obligation to its clients, as is the case with healthcare organizations serving patients, the ethical justification for a mandate increases and might even become ethically obligatory. Justification similarly increases when a business is large and its employees frequently interact with the public. In these ways, a mandate can help mitigate social and economic harms in the broader community.
Signaling
Mandates also have a strong signaling effect. As interest in environmental, social, and governance criteria for business shows, a company’s values shape more than its daily operations. A vaccination mandate signals to employees and the broader community that the vaccines are safe and effective, and that the organization is committed to protecting the community.
Principle of Least Restrictive Means
While mandates are often ethically defensible, this doesn’t mean that they are always the best option. For example, leaders must consider the principle of least restrictive means (holding that public health measures should interfere with the autonomy of individuals to the least possible or necessary extent.) to determine if a mandate is necessary. It might be the case that the company’s vaccination rate is already sufficiently high or that other means, such as incentives or allowing employees to work from home, are sufficient to protect employees and customers.
In organizations where vaccination rates are too low, leaders must determine why this is the case to justify a mandate or develop an alternative response. In some cases, people have false beliefs about the vaccines or Covid-19 but have not had the chance to speak with an expert. Whether or not a mandate is ultimately implemented, leaders should provide education opportunities for employees to ask questions of healthcare providers and receive good information.
Social barriers
The social determinants of health are also relevant. Some people haven’t been vaccinated because they work multiple shifts and lack the time to go to an appointment, or they don’t drive and can’t easily get to a vaccination site, or there are language barriers that make it more difficult to navigate the health system. For these people, a vaccination mandate isn’t going to help them overcome these barriers. Instead, it will further exacerbate their vulnerability. The ethical implementation of a mandate requires that organizations find ways to reduce such barriers to vaccination when they are present among their workforces. Indeed, organizations have a basic duty of care to do this for their people whether or not they implement a mandate.
Accommodation issues
In addition to education opportunities and lowering barriers to access, leaders need to work out the details of the mandate to ensure that it meets the goals of the organization and is implemented ethically. A key part of this is determining the terms of the accommodation policy. Since many jurisdictions have anti-discrimination laws that might be relevant, legal consultation is an important step. However, legal compliance is only part of the picture; a policy that complies with the law might still fall short ethically.
The first main accommodation issue is determining the exemption criteria. Some places give legal protection only for religious reasons instead of other reasons of conscience, which an organization might deem appropriate or too narrow, depending on the circumstances. Relatedly, a process must be established for adjudicating exemption claims. Who will make the final decision? What level of proof must an employee provide? How can we know that a belief is sincerely held, and to what extent should the organization try to establish that? Should there be an appeals process, and what should that involve? The answer to each of these questions will determine how onerous implementing the mandate will be.
The second main issue is establishing what accommodation entails. A common misunderstanding I hear from both employees and leaders is a belief that accommodation means the employee can continue to perform their usual duties without any change of practice. To see why this is a mistake, it’s useful to think about what reasonable accommodation should include. If the goal of the mandate is to protect the safety of employees and customers, companies aren’t required to allow unvaccinated employees to impose risk on others. Instead, accommodation can include working from home, reassignment away from others, or changes in practice (e.g., increased use of personal protective equipment or being relocated to a private office). As always, the circumstances will dictate the range of acceptable options.
As this discussion shows, many conditions must be met for the ethical implementation of a mandatory vaccination policy. Meeting these high standards is possible, though. For example, Houston Methodist was an early leader in this area. In March 2021, they announced that Covid-19 vaccination would be a requirement for all employees and physicians in their hospitals by June. With the mandate, they increased the vaccination rate from 84 percent of staff to effectively 100 percent, with a few hundred being granted exemptions. As some of their leaders describe here, Houston Methodist thought carefully about the details of the mandate, including ensuring that their exemption policy was appropriate and complied with the law, and providing robust education opportunities for staff. Of course, what’s appropriate for a hospital system might not work for other organizations, but with careful deliberation, Houston Methodist was able to implement a successful and ethically robust policy.
The ethical case for vaccination mandates is principled, strong, and compelling. But, as with all policies, careful consideration is required to ensure that a mandate is appropriate and implemented correctly.