It’s Time to Require COVID Vaccination in the Workplace

Ethics taught to medical students include the right of the individual to self-determine treatment and the role of the physician do whatever is necessary for the benefit of the individual patient in the absence of doing harm. Ethics taught to public health students include doing the greatest good for the most people while balancing the need for coercion or laws to promote public health.

As the COVID-19 pandemic has swept across the world, the practice of medicine and public health have sometimes come into conflict. Patients are isolated and hospitalized, separated from their loved ones at critical moments of sickness and death, subjugating the personal need for comfort and the ethical tenet of respect for persons with the community need to protect others and prevent the spread of infection. Similarly, autonomy gives way to public good in the collection and sharing of personal information among those infected with SARS-CoV-2 in order to notify persons potentially exposed and initiate quarantine.

The marriage between public health and medical practice, when the world is at equilibrium, is one of reciprocity, where public health policies support medical work, and advances in medical technologies and innovations provide new tools for public health activities. In equilibrium, the ethics of public health and medicine are complementary. But since the COVID-19 pandemic began, the world has not been at equilibrium. And the ethics of public health have to be understood as different from that of a medical doctor when treating a patient with COVID-19.

Given the status of the COVID-19 crisis — with continued spread and emerging variants — it’s time to take the next critical step for public health: government-mandated vaccination in workplaces. A brief look back in history shows us this wouldn’t be the first time society has needed to place public health above individual rights.

In the 1850s, a severe and deadly cholera epidemic plagued London. At the time, they did not know that cholera was transmitted through water. In perhaps one of the first great unions of public health and medicine, the discovery of that connection lead to the closure of the Broad Street pump and the city-wide development of sewage systems in order to protect the water that fed the city. Many view that early union as the origin of the field of public health, and fittingly so, as it exemplifies the necessity of impeaching an individual’s right to the water from that pump in order to protect the larger population.

Again, we are faced with a similar circumstance, as the disequilibrium caused by the COVID-19 pandemic continues to reverberate around the world, and public health and medical professionals alike are now armed with multiple highly effective and safe vaccines. Vaccination has been shown to be associated with rapid declines in new SARS-CoV-2 infections, hospitalizations, and deaths. Epidemic control has been achieved in settings where vaccination has augmented natural immunity. Vaccination is clearly the public health tool we have been waiting for.

Currently, nearly 70% of the U.S. adult population has received at least one dose of a vaccine. That high coverage, however, belies pockets of vulnerability, in particular among younger people, essential and hourly workers, in lower income and less educated communities, and among people of color. Since rollout of vaccination programs, those at greatest risk for hospitalization and death have widely accepted vaccination, independent of political affiliation, with more than 88% of all those age 65 years or more having at least one dose of vaccine.

The challenge now is to ensure protection, one of the duties of public health, with vaccination for the remainder of the population. Expanding vaccination is clearly an issue of equity. In the beginning of the epidemic, we failed to protect the most vulnerable workers with testing requirements, yet, testing was required among elite colleges, some healthcare settings, and high-end businesses. We should not make this mistake again.

Given it is the ethical responsibility of public health to do what is best for the most people, it is time we require vaccination, while limiting the rights of individuals to refuse (except in certain circumstances, such as a health contraindication). Again, this wouldn’t be a first: vaccination requirements were critical in the elimination of polio and eradication of smallpox. Many of those who are hesitant to receive the COVID-19 vaccine have stated they would accept vaccination if required by their employer, and increasingly, the smartest and wealthiest places such as financial firms, law offices, airlines, institutions of higher learning, and most recently, the city and county of San Francisco have mandated vaccination for employees. Why are those protections not extended to other workers?

Government implementation of employer-based mandates might be similar to how OSHA regulates employed-based worker safety. States and local governments could issue guidance on workplace vaccination requirements, either creating their own or adopting federal standards like hepatitis B vaccination and blood borne pathogens. Governments set requirements for documentation, exemptions, deadlines for compliance, and consequences for non-compliance. Typically, the CDC articulates specific recommendations with states mandating that employers comply with those recommendations. Given the urgency of the situation, however, states and local jurisdictions may act independently and would be wise to do so given the urgency to increase protection and address the inequity in vaccination coverage now.

When a threat to an individual becomes a threat to society as a whole, that individual’s autonomy must give way to the greater good. Thus, despite the potential harms done by vaccine mandates, such as rare adverse reactions or loss of employment among those who refuse, the societal benefits to universal vaccination, including ending the pandemic, must be our moral and ethical priority. It is a calculus that we must accept and promote. It is time for our national, state, and local policymakers to endorse workplace vaccination requirements and lead the way with guidance and public declarations of support.

Lao-Tzu Allan-Blitz, MD, is a senior resident physician at Boston Children’s Hospital and Brigham and Women’s Hospital. Jeffrey D. Klausner, MD, MPH, is a former county deputy public health officer and current professor of preventive medicine and medicine, University of Southern California Keck School of Medicine.