Since the discovery of the first SARS-CoV-2 infected case causing COVID-19 was reported in China in late 2019, there have been more than 360 million cases of COVID-19, linked to over 5.6 million deaths (World Health Organization (WHO), 2022a). As of 27 January 2022, there were 16.2 million cases of confirmed COVID-19 and 174 000 deaths with COVID-19 on the death certificate in the UK (HM Government, 2022).
Vaccines have been advocated as our best defence against COVID-19, with four approved by the Medicines and Healthcare products Regulatory Agency since early 2021 (UK Health Security Agency, 2021a). Frontline health and social workers who provide care to vulnerable people (including paramedics and ambulance clinicians) were among the highest priority groups for the COVID-19 vaccination since the UK COVID-19 vaccination programme was rolled out (Tang and Morgan, 2021).
By 28 November 2021, more than 90% of NHS staff in England had received at least two doses of the COVID-19 vaccination. NHS Ambulance Service data showed vaccination rates between 87.9% and 94.1% (NHS Digital, 2021), and significant efforts have been continued to increase the uptake of COVID-19 vaccines among healthcare workers.
With an amendment to the Health and Social Care Act 2008 passed through Parliament in December 2021, all health and social care staff in the NHS and independent healthcare services (including paramedics and ambulance clinicians) were expected to be fully vaccinated against COVID-19 by 1 April 2022. Only staff who do not have direct patient contact, individuals who are medically exempted and those who are taking part or have previously taken part in a clinical trial for a COVID-19 vaccine were not required to be vaccinated (NHS England and Improvement, 2022). However, on 31 January 2022, the Secretary of State for Health and Social Care announced that there would be a parliamentary consultation on the COVID-19 vaccination mandate as it was deemed no longer proportionate (Javid, 2022).
This article explores some of the reasons behind vaccine hesitancy and reflects on the ethical dilemmas related to mandatory COVID-19 vaccination among health professionals in the UK.
Vaccine hesitancy
Vaccine hesitancy is defined by the WHO as a ‘refusal or delay in vaccine acceptance despite availability of vaccine services’ (Butler and MacDonald, 2015).
Several studies (Biswas et al, 2021; Xin et al, 2021) suggest that the causes of vaccine hesitancy among health professionals are similar to those found in the general population. These include the perceived risk of COVID-19 infection, concern regarding vaccine safety and side effects, as well as several sociodemographic characteristics, such as age, sex, socioeconomic status and ethnicity (Biswas et al, 2021; Veronese et al, 2021).
Vaccine hesitancy is an important factor that influences the prevalence of COVID-19 and its multiple complications in the community. Evidence clearly shows that COVID-19 vaccination reduces the number of cases as well as the severity of illness in infected individuals (UK Health Security Agency, 2021b). Additionally, Pacella-LaBarbara et al (2021) argue that vaccine hesitancy could increase the probability of mutation, which is a significant public health issue.
It is important to reduce vaccine hesitancy among healthcare workers as they often interact with vulnerable patients and have a strong role in vaccine advocacy (Woolf et al, 2021). In one study, around 80% of participants rated COVID-19 vaccination information provided by health professions as ‘trusted completely/a great deal’ (Stead et al, 2021).
According to MacDonald and the SAGE working group on Vaccine Hesitancy (2015), the 3C model of vaccine hesitancy could be used to address issues around this problem among health professionals (Table 1) by: reducing complacency (focusing on uncertainty about the severity and potential long-term effects from COVID-19 infection); increase confidence (promoting the safety and effectiveness of the COVID-19 vaccines and dispelling myths and misinformation); and improve convenience (removing barriers for staff accessing the COVID-19 vaccination clinics).
Table 1. 3C model of vaccine hesitancy for health professional COVID-19 vaccinations
Table 1. 3C model of vaccine hesitancy for health professional COVID-19 vaccinations
| Complacency |
|
| Confidence |
|
| Convenience |
|
There is a relatively higher vaccine hesitancy rate among women in the UK (Emerson et al, 2021) and this trend is seen among healthcare workers as well (Biswas et al, 2021). This could be related to early concerns about the COVID-19 vaccine and pregnancy (as the initial vaccine trial excluded pregnant women). However, the Royal College of Obstetricians and Gynaecologists (2021) and the Joint Committee on Vaccination and Immunisation (Public Health England, 2021) have advised that the vaccine should be offered in pregnancy, and there is no evidence to suggest that the COVID-19 vaccine will affect fertility.
Variants and vaccine effectiveness
Multiple variants of SARS-CoV-2 have been reported in the UK and globally. Some of the variants have been associated with increased transmission and have become established globally, replacing the original Wuhan strain. These include the Alpha, Delta and, more recently, Omicron variants (WHO, 2022b).
Omicron variant
The Omicron variant, also known as SARS-CoV-2 (B.1.1.529 lineage), was first reported in South Africa in November 2021. It was designated as a variant of concern because of the high number of mutations it has, including 26–32 in the spike protein, some of which could lead to vaccine escape and a higher transmissibility than other variants (WHO, 2022c).
Early UK data show that Omicron is more transmissible than the previously dominant (Delta) variant. However, the severity of the illness with Omicron (using the risk access to emergency care OR hospital admission as proxy) is about half of that for Delta (UK Health Security Agency, 2021b).
Additionally, early UK data show that effectiveness against infection from the three approved COVID-19 vaccines (AstraZeneca, Moderna and Pfizer) is lower against the Omicron variant (Andrew et al, 2021). Those who received two doses of AstraZeneca demonstrated no effect against Omicron from 20 weeks after the second dose while those who had received two doses of Pfizer or Moderna vaccine had the effectiveness drop from around 65–70% to around 10% by 20 weeks after the second dose (UK Health Security Agency, 2021c).
On the other hand, vaccine effectiveness against hospitalisation with Omicron was still significant, with an estimated 68% reduction in the risk of hospitalisation for a symptomatic case after three doses of vaccine, compared to similar individuals with Omicron who were not vaccinated. This demonstrated a vaccine effectiveness against hospitalisation of 78–93% for Omicron after three doses of vaccine (UK Health Security Agency, 2021c) and suggests that vaccination is still the best defence against serious illnesses of COVID-19.
Ethical argument against vaccine mandates
The authors are not unsympathetic to arguments made in support of mandatory vaccines; there will likely be a future pandemic where anything but mandatory vaccines for all individuals may seem both unethical and illogical. Yet, as will be argued in this section by the second author (JS), to get this right in the future, the drawbacks of mandating vaccination must be recognised where it is unnecessary and, on balance, perhaps even harmful.
‘First, do no harm’, the maxim of non-maleficence (Beauchamp and Childress, 2019), is often levied in support of mandating vaccination for health professionals. From this perspective, a single case of harm to a member of the public from an unvaccinated health professional is unacceptable—yet, for this principle to be consistent, should not health professionals be considered patients themselves? The moment a health professional receives any vaccine, they become a patient. Any form of harm resulting from a coerced vaccine would therefore violate the principle of non-maleficence.
COVID-19 vaccination may not only result in physical harm through short-term side effects; coercing a vaccine-hesitant practitioner to receive the vaccine may also cause moral injury (Murray, 2019) and the long-term side effects of the COVID-19 vaccinations are unknown.
For health professionals who refuse to be vaccinated, a policy of redeployment of non-vaccinated staff into non-patient facing roles will likely be instigated, and those who cannot be redeployed will have their employment terminated (Iacobucci, 2022). This is certainly not a benign option; it both limits career development and prevents highly trained workers from carrying out their skills to the benefit of patients. This policy would also strip an already thin and overburdened workforce of yet more vital staff. Either redeployment or termination will cause harm to the vaccine-hesitant practitioner or the general public through staff shortages (NHS Confederation, 2022).
Offering redeployment to vaccine-hesitant health professionals as an alternative to vaccination is a coercive act. For an individual's decision to be truly autonomous, it needs to be made either outside external factors or in accordance with one's own values (Pugh, 2020). If someone was vaccine-hesitant, and was told that they must be vaccinated or face redeployment/termination, their decision would ultimately not be their own.
According to the principlist approach to medical ethics, the four principles are of equal importance (Beauchamp and Childress, 2019); others, however, have argued that autonomy should be considered ‘first among equals’ (Gillon, 2003), acknowledging its primacy in a modern, liberal society. Individuals are often allowed to undertake activities that could result in direct harm to themselves or indirectly to others, with autonomy prioritised even where other principles appear to be violated.
For example, a father of three can choose to spend his weekends BASE jumping, even if any resulting harm would be detrimental to his family's wellbeing, and use precious NHS resources that could be used for others. Furthermore, should this patient then make it to hospital, he would be perfectly entitled to refuse treatment, despite the clear negative consequences for his loved ones and those caring for him. When seen through this lens, mandated vaccines appear to contradict this widely practised moral convention.
Proponents of justice may support mandatory vaccinations for health professionals, stating that it is unfair for vulnerable patients to be exposed to unvaccinated health professionals. Yet we know that many unvaccinated health professionals belong to vulnerable groups themselves, such as those with mental health problems or those with learning or physical disabilities.
Additionally, individuals from some ethnic minority backgrounds have been identified as having lower vaccine uptake, partly because of a lower trust in government and public health bodies (Razai et al, 2021). Given the widespread discrimination some of these groups have experienced, this is understandable (Ross et al, 2020). Because of this, it cannot be ignored that a policy to coerce these people to receive vaccinations could cause significant moral harm, exacerbate intergroup conflict and distrust, and discriminate against an already underrepresented group of individuals who continue to face significant systemic prejudice and bias. The second author (JS) would argue that, on balance, this is unjust.
Furthermore, since ethnic minorities are overrepresented among the vaccine-hesitant, a policy to redeploy or terminate the contracts of those who have not been vaccinated could be seen as a form of institutional discrimination.
As it currently stands, the vast majority of people vaccinated against COVID-19 are from high and upper-middle-income countries (WHO, 2022d). The failure to share vaccines globally not only means an increased burden on the most poor and vulnerable societies, who are the least likely to have the infrastructure to cope with large outbreaks of the virus, but also may cause an outbreak of further variants of concern (Gavi, 2021). Given this global vaccine inequality, vaccinating high-risk groups in other countries should be prioritised rather than the coercion of UK-based health professionals into receiving a vaccine against their will.
A recent survey by the College of Paramedics (CoP) (2021) of its members found that only 58% of respondents supported mandatory vaccinations for health professionals. The COP is clear that, while it supports and encourages the uptake of COVID-19 vaccination, this should remain voluntary. This view is shared by the Royal College of Nursing (2022), Unison (2022) and the Royal College of Physicians (2021).
In the face of this opposition, mandating vaccines for health professionals has further implications. The general public may view the requirement for mandates as evidence of health professionals being unconvinced about the safety of the vaccine or deadliness of COVID-19. If COVID-19 vaccines are made mandatory, what does this say of future vaccines that are not? Health professionals and the wider public may view these future vaccines as unnecessary, resulting in a significantly lower vaccine uptake. This could result in a slippery slope with standards that need to be met for vaccines to be made mandatory being lowered.
It is for these reasons, among others, that mandatory vaccines are supposed to be introduced only where less intrusive means have failed, when the disease is highly contagious and serious (e.g. smallpox) or for eradication of the disease if this is within reach (Nuffield Council on Bioethics, 2007). But does COVID-19 currently meet these criteria?
There is a risk that the decision to mandate vaccination in health professionals may be viewed as further evidence to support libertarian arguments against government overreach and authoritarian policy. This may further disenfranchise the vaccine hesitant and embolden the anti-vaccine movement, as we have seen in countries such as the United States (O'Connell, 2022).
The second author (JS) believe that these inadvertent consequences, in addition to those already discussed, may ultimately eradicate any benefits seen from a potential improvement in vaccination rates through mandated vaccines. This is particularly the case when these consequences result from mandating vaccination against the current, seemingly less virulent strains of COVID-19 such as the Omicron variant (Alizon and Sofonea, 2021).
If these negative consequences were to outweigh any benefits obtained through mandating COVID-19 vaccines, this policy would be a failure. This failure could then be cited in future arguments against vaccine mandates in an even more devastating pandemic, where mandatory vaccines for all would surely be the most ethical of actions.
A utilitarian may argue that ‘the ends justify the means’, in this instance, that mandating vaccines may be the uncomfortable but necessary option to obtain maximum vaccine uptake and protect the public.
Yet when should the ends be measured? If taken as a snapshot of the percentage of frontline healthcare staff vaccinated against COVID-19, mandating vaccination and removing vaccine-hesitant staff may seem to be the most ethical action.
However, when you consider the potentially significant harm resulting from moral injury against the vaccine-hesitant, further breakdown of organisational culture, loss of frontline healthcare staff, institutional discrimination and the potential for this to result in less successful vaccine mandates in a future, more significant pandemic, will this truly lead to less harm overall?
For the reasons stated, the second author (JS) believes that the decision to make the COVID-19 vaccines mandatory for health professionals at this stage of the pandemic will have an overall negative impact on the wellbeing of practitioners and the general public.
Ethical argument in support of vaccine mandates
In this section, however, the third author (IC) will argue that it should be reconsidered that a vaccine mandate is unethical on the grounds that it interferes with clinicians' rights to make autonomous choices about their own healthcare. The claim that vaccine mandates compromise individual autonomy presupposes an implausibly individualistic conception of autonomy (Stirrat and Gill, 2005).
To consider autonomy as the uninhibited expression of individual desire runs contrary to more robust understandings—whether Kantian or Millian—according to which the proper scope of autonomy is determined by reference either to the requirements of duty or to the effects of the agent's actions on others (O'Neill, 2002).
It must be recognised that we live in groups and that our moral rights and powers are limited by the rights of others. Therefore, any justifiable expression of autonomy must take reasonable consideration of third parties and cannot be simply an expression of individual wish (O'Neill, 2002).
Society has a legitimate interest in regulating behaviour that directly harms others—even if by doing so, we constrain people's choices (Mill, 1871). Even modern proponents of autonomy such as Beauchamp and Childress (2019: 65) propose that a person's claim to non-interference ought to be overridden when their choices ‘endanger public health’ or ‘potentially harm others’. Of course, exactly how and when these limits are placed is complex and, in any given case, respect for individual liberty must be balanced against the protection of the physical wellbeing of others.
Consider the BASE-jumping father from earlier. Were he to choose to jump from a skyscraper into a crowd of people, others would (rightly) try to stop him.
It is known that vaccination reduces both the likely severity of COVID-19 symptoms and, crucially, the chances of catching the disease and of transmitting it to others (de Gier et al, 2021). Therefore, allowing health professionals to refuse the COVID-19 vaccine potentially harms their patients and co-workers (who have no choice but to interact with them) by exposing them to avoidable risk. For this reason, the third author (IC) believes that mandating the COVID-19 vaccine as a prerequisite for work that brings one in contact with vulnerable people is both reasonable and proportionate.
Clinicians should all be aware of the principle ‘primum non nocere’ (first do no harm). Mandating vaccines for clinicians upholds this principle. Paramedics deal with a diverse, undifferentiated population, and commonly encounter both clinically vulnerable patients and COVID-19-positive patients. Paramedics are obliged to take all reasonable steps they can to limit the spread of COVID-19. The third author (IC) would argue that a patient's right to receive medical treatment in an environment safe from unnecessary risk clearly usurps any individual health professional's right to refuse vaccination.
During the pandemic, many healthcare workers were uncomfortable with the language used in the media about healthcare workers being ‘heroes’. It has been argued that this gives the government and employers an excuse not to provide adequate personal protective equipment (PPE), and that such a term comes with an unreasonable expectation of risk-taking (Cox, 2020).
When stepping back from this language, it can be seen that alongside other measures, requiring vaccines can be part of ensuring safety in the workplace. Vaccine mandates can also be justified in terms of the legal and moral obligations that employers have to provide safe working environments for their employees. Health professionals deserve to work in safe environments but often have to work in small, enclosed spaces, with inadequate PPE and in close physical proximity to others. Unvaccinated staff may raise the risks of their vaccinated colleagues contracting COVID-19.
It is often argued that this sort of mandate is a slippery slope. The authors agree that a decision to make medical treatment a condition of employment must never be taken lightly and each case must be considered and debated on its own merits. However, we are in the midst of the worst public health crisis in the UK in a generation. In the view of the third author, mandating a vaccine that is believed with a high degree of certainty to be safe, during such a crisis does not seem unreasonable. Even if a precedent is set with this, the bar for that precedent is set so high as to be unlikely to be reached again in the near future.
The COVID-19 pandemic has highlighted social and racial inequality in the UK, with significantly worse outcomes for socially deprived groups, people with disabilities and communities of colour (Public Health England, 2020). Reasons for this are complex (Yaya et al, 2020) and require nuanced solutions.
As disadvantaged groups are worse affected by the pandemic, it is urgent that practitioners do what they can to mitigate these effects, not only for reasons of their obligations as health professionals (which are to reduce death and disease wherever they occur) but also as social justice advocates. As such, mandating the vaccine will help to demonstrate that the NHS presents a united front, allied against the spread of COVID-19 and in favour of the tools of modern science, which are essential in combating this disease. Having all members of the NHS fully vaccinated will both ensure the institution's resilience as it operates during the pandemic and allow NHS staff, through their example, to provide living proof of the safety and effectiveness of the vaccine to vaccine-hesitant individuals with whom they come into contact.
There is serious global vaccine inequality. However, it is naive to think that vaccine rejection by healthcare workers in this country will have a genuine effect on this. The authors think it is best to turn to Médecins Sans Frontières (2021) for their impassioned pleas to end vaccine nationalism and demand the ‘removal of intellectual property (IP) policies that restrict others' abilities to develop vaccines or medical innovations that can help end the pandemic’. There will be no end to this pandemic until there is an end to the nationalism, hoarding of resources and greed being practised by the governments of richer countries and pharmaceutical companies. This is not a reason for our healthcare workers to go unvaccinated.
Finally, it is worth considering this issue from a broader utilitarian perspective. It is uncontroversial for paramedics to say their goal is to reduce pain and distress and increase both the length and quality of life for the communities they serve. Under a utilitarian conception of a moral society, individual flourishing is important but it cannot take precedence over an avoidance of greater harm to a larger part of society.
Therefore, the third author would argue that it must be predicted whether the harm caused by the mandate, with some staff quitting or standing down into non-patient-facing roles, is greater than that of allowing an unvaccinated workforce to work with an undifferentiated population. It has been argued that large numbers of staff will be lost because of this policy. However, in other countries that have brought in such mandates, the numbers lost are much lower than predicted (Dyer, 2021).
In addition, there are ways to ensure staffing numbers are restored that do not involve compromising the health of vulnerable members of society. It is known that vaccinating the entire NHS workforce will reduce the risk of practitioners becoming critically unwell and reduce days lost to sickness and isolation. It is also expected to limit transmission of the disease in healthcare. Therefore, from a utilitarian perspective, this mandate is morally justifiable.
The third author believes that health professionals have a moral obligation to receive this vaccination. They know with a high degree of certainty that the vaccine is both safer than a COVID-19 infection and effective in terms of reducing the severity of side effects. Health professionals working in a pandemic incur serious risks to their health. The vaccine reduces these risks and, as well as benefiting its recipient, directly benefits all those who come into contact with them. In these circumstances, the third author believes that a mandate can be justified, and that vaccine mandates are supported by arguments around justice, beneficence, non-maleficence and utilitarian concepts of fairness.
Vaccine hesitancy may stem from irrational or unfounded medical or scientific beliefs, or from religious or moral conviction. However, in none of these cases can the right of a person to risk their own wellbeing for their principles be allowed to trump the protection of the health of other practitioners and of the communities they serve. The third author suggests that the needs of vulnerable patients must be prioritised over the comfort of vaccine-hesitant health professionals.
Conclusion
The authors urge all paramedics and ambulance clinicians to receive the COVID-19 vaccine, as it is the most effective way to protect themselves and others against severe complications of COVID-19.
However, future decisions on any vaccine mandates must incorporate wide-ranging ethical arguments, both for and against, some of which the authors have outlined here.
Finally, additional efforts should be made to address the underlying issues related to vaccine hesitancy among health professionals to both improve uptake and ensure health professionals act as advocates for the COVID-19 and other vaccines.
Key points
- Although vaccination is widely regarded as the best defence against COVID-19, many health professionals are hesistant about receiving a vaccine
- Using the 3C model of vaccine hesitancy to address vaccine hesitancy could increase the voluntary uptake of COVID-19 vaccines among healthcare workers
- Omicron is more transmissible but the illness it causes is less severe than the previously dominant (Delta) variant
- There are ethical arguments both against and in favour of mandatory vaccination among healthcare workers
- Future decisions on any vaccine mandates must incorporate various ethical arguments and support with additional effort to address underlying issues related to vaccine hesitancy
CPD Reflection Questions
- What are the common reasons behind vaccine hesitancy among healthcare workers?
- What are the different ethical principles that should be considered in relation to mandatory vaccination among healthcare workers?
- How could further vaccine uptake among healthcare workers be improved in the future?