An Overview of the Bioethical Implications of Employer-Mandated COVID-19 Vaccinations
We know where we’ve been. We know the devastating impacts that the COVID-19 pandemic has had (and still has) on the lives, health, and financial security of all Americans. We know COVID-19 vaccines hold the promise of a return to ‘normal.’ But the emergence of COVID-19’s Delta variant has threatened to throw us straight back into 2020.
Employers and other health care purchasers are now in a unique position. They play a significant role in the economy and economic recovery, creating jobs and sustained employment for employees. Given that about 50% of the U.S. population has employer-sponsored health insurance, they also play a pivotal role in shaping the health of the nation. This puts them at a crossroads for how they choose to answer a challenging question – is there more they can and should do in the fight against COVID-19? One of the potential answers comes as another question: “Should I require my employees to be vaccinated?”
The keyword here is “should” (“can” is a legal question that has already been largely answered and is not the subject of this blog). But “should vaccination be required” leaves room for debate. While bioethical analyses typically rely on multiple frameworks, this blog should be considered a primer on two of the ‘hallmark’ bioethical principles: autonomy and justice.
In the Name of Public Health
The most obvious argument in favor of mandatory vaccination is rooted in public health, a discipline derived from the social principles of utilitarianism and justice. In short, utilitarianism can be simplified to the concept of the greatest good for the greatest number, while justice concerns the fair allocation of good and resources (including “health” as a good). Therefore, public health leaders take a holistic look at a population and make decisions at the group level, instead of focusing on individuals.
Among the ways an epidemic or pandemic can be contained is herd immunity. Herd immunity is achieved when a critical mass of the population becomes immune to a disease, making it difficult or unlikely for the disease to spread between individuals. This results in protection that extends to the entire community, including those who are not immune. Herd immunity arises either through natural infection, vaccination, or a combination of the two. The benefits of vaccination are that immunity can be achieved faster and more safely, with less individuals suffering the effects of the disease or related complications. Mandating vaccinations is a utilitarian means to achieve herd immunity and help ensure that the greatest number of people possible avoid contracting COVID-19.
Dovetailing this point, another argument in favor of public health centers on employees as a group. Mandating vaccines at a given organization can reduce the risk of COVID-19 infections across the employee population, especially for onsite employees.
With a caveat
While vaccines generally have long been widely recognized and proven as a safe and effective means to prevent the contraction and spread of disease, only one of the multiple COVID-19 vaccines in use today has been formally approved by the U.S. Food and Drug Administration; the FDA recently approved the Pfizer-BioNTech COVID-19 Vaccine in August, but the others are still under emergency use authorization. Public health ethics are ideally grounded in scientific evidence (assuming evidence exists), and a lack of evidence for the vaccine has the potential to undermine public health arguments in favor of mandatory vaccination. While a lack of evidence isn’t exactly the case here, the clinical evidence that exists for the unapproved COVID-19 vaccines has yet to reach the FDA’s threshold for approval.
My Rights as an Individual
While vaccine mandates may serve public health goals, they may not always serve the goals of individuals or meet their individual preferences. This introduces the concept of autonomy. Derived from classic libertarianism, the primary arguments of the principle of autonomy relate to self-determination (including self-sovereignty over one’s own body), freedom, and personal choice. Within this line of thinking, we assume that all adults are autonomous beings, and the principle of autonomy demands that we respect the self-determined choices of those individuals. Insofar as we do that, we are acting ethically. Therefore, for autonomous adults, it’s up to individuals to accept or reject the benefits and risks of vaccination and contracting COVID-19; a vaccine mandate would violate the ethical principle of autonomy for adults who choose not to be vaccinated.
But not so fast…
Respecting autonomy is not a free pass to do whatever one pleases in the name of self-determination – there are limitations. The main limiting factor to autonomy is infringement. Essentially, an individual’s ability to fully exercise their rights stops where they begin to infringe upon the rights of another individual. In the context of the COVID-19 pandemic, it can be argued that one’s decision to not get vaccinated may endanger (and therefore infringe upon) the lives and health of others, especially those who are very old, very young, immunocompromised and/or who cannot get vaccinated for medical reasons.
Even so, what counts as infringement is not always a clear line in the sand. For instance, it can be argued that someone who is unvaccinated can prevent potential infringement by taking steps to limit the risk they pose to others in alternative ways such as wearing masks, social distancing, testing, and isolating. However, these steps may not always be as effective or possible.
Are Mandates Coercive?
Due to the strong belief in autonomy and self-determination among the general U.S. population, some employers may be hesitant to require vaccination of their employees, particularly when non-compliance is attached to negative consequences, such as removal from their job or higher out of pocket costs for their health care coverage. This introduces another ethical consideration under the principle of autonomy; whether the mandate “get the vaccine or lose your job” counts as ‘coercion,’ in a formal ethical sense. There is no single concept of coercion that is universally accepted; however, the definition put forth by Ruth Faden and Tom Beauchamp1 is commonly accepted. To have coercion under their model, an “agent of influence” must “intend to influence” another person “by presenting a severe threat.” This threat must be both “credible” and “irresistible.”
There are two possible interpretations when it comes to COVID-19 vaccines. The first is that vaccine mandates are coercive – the employer intends to influence employees to get vaccinated or face termination, or other penalty. Moreover, the termination or other penalty is both credible (as it comes from the employer itself) and irresistible (unvaccinated employees may face dire financial hardship if they lose their jobs).
The second interpretation focuses on the wiggle room in what makes something “irresistible.” One potential line of reasoning is that it is very difficult to create true coercion. As long as there is an element of choice, it cannot be coercion; in other words, it is the lack of alternative options that makes something “irresistible.” Even when faced with the choice of vaccination versus termination, employees still technically retain the right to refuse to get the vaccine and leave their job. Moreover, they can look for a new job. This would mean that the employer mandating the vaccine is not being unethical because creating a tough decision is not inherently coercive.
A Potential Compromise
As mentioned earlier, vaccine mandates can reduce the risk of an organization’s employee population contracting COVID-19, especially for onsite employees. Momentum is building among employers to mandate vaccination for onsite employees only or as a requirement to work onsite, while those that work remotely are exempt from the mandate (and its consequences). While this seems like a good compromise, consider that some employees by the very nature of their jobs are unable to work remotely, resulting in an unequal application of a policy across a population:
- Those that must work onsite – subject to mandate
- Those that work remotely – not subject to mandate
- Those that can work remotely – might be subject to mandate, depending on their work preferences.
Implementing this type of vaccine mandate requires the employer to make distinctions among different groups within its population and then create distinct rules for those groups. While unequal treatment of (and potentially unequal outcomes for) different groups is not inherently unethical, employers should consider principles of justice and equity in their decision whether to implement this strategy.
Where does this leave us?
Legally: It seems clear that employers have the legal standing to enact vaccine mandates and are well within their rights to impose them.
Ethically: The main arguments for and against vaccine mandates fall into two age-old opposing, and largely unresolvable, philosophies – rights of the individual (autonomy) and rights of the group (justice and utilitarianism). While these rights usually coexist in harmony, there are instances where they clash – to benefit the group, we must sacrifice the individual, or to benefit the individual, the group must compromise. There are valid arguments on either side of the debate, all of which are ethical and none of which could ever truly be the sole “right” answer. For employers looking to make ethical decisions on mandatory vaccination, perhaps what is most important is using these bioethical principles to decide in a logical and rational way.
Optics: Lastly, there is a famous distinction between what is ‘ethical’ and what is ‘decent.’ Making someone choose between getting the vaccine or keeping their job may be argued as ethical and legal, but to some, it may also seem indecent. Something can be indecent but ethical, and conversely, unethical, but decent. Figuring out how to proceed depends on both the employer’s organizational culture and how it weighs perception and potential consequences, both intended and unintended.
- Faden, Ruth R., et al.A History and Theory of Informed Consent. Oxford University Press, 1986.
Lea Tessitore, MBA, MSB wrote this blog. As a bioethicist, Lea uses her unique perspective and formal principles of health care ethics as tools to inform CPR’s work.
Photograph by CDC on Unsplash.