Arthur L. Caplan, PhD: Hi. I’m Art Caplan, and welcome to another edition of Both Sides Now. I’m your host as well as director of the Division of Medical Ethics at New York University Grossman School of Medicine. I’m excited to be here for what I think you’ll find a very interesting and enlightening discussion. It’s about a much-debated topic that has been in the news quite a bit lately and has all sorts of nuances, twists, and turns: vaccine mandates.
Recently, Houston Methodist Hospital became the de facto epicenter of this battle after they decided to require vaccination of all their staff under the penalty of firing. A group of over 100 healthcare workers there, mainly nurses, organized and went to court to fight this requirement. A federal judge dismissed their lawsuit, basically saying that the hospital was within its rights to try to promulgate health and safety to protect patients. Yet many employees still said they weren’t going to do it, and over 150 were either fired or quit. Houston Methodist Hospital has not backed down, and the mandate is still set to go.
Similar mandates are starting to be seen in other institutions around the United States, including Barnes Hospital in St. Louis, Columbia University in New York, and the Inova Health System. Even the city of San Francisco has said it’s going to mandate vaccinations for city employees, including first responders, firefighters, and police.
Although such mandates are becoming increasingly common, they remain contentious. There are still lawsuits being filed against them in different parts of the country beyond what we’ve already seen play out in Houston.
This brings us to today’s question: Should COVID-19 vaccinations be mandatory for healthcare workers? I’m pleased to be joined by two great guests who will help us think through some of the nuances around this issue. Judy Stone is an infectious disease physician and contributing author to numerous publications, including Medscape. David Grabowski is a professor in the Department of Health Care Policy at Harvard Medical School, as well as a member of the Medicare Payment Advisory Commission. Thanks for joining me on Both Sides Now.
Let’s get under way with a kind of self-declaration question. David, are you vaccinated? And more to the point, if you are, why?
David Grabowski, PhD: I’m definitely vaccinated. Unfortunately, I didn’t get rewarded with any beer or any donuts for doing so. I was lower in the queue here in Massachusetts. I’m not a physician but instead have a PhD. Even though I work at Harvard Medical School, and unlike a lot of the healthcare workers we’re going to talk about who were prioritized, I had to wait.
I couldn’t wait to get vaccinated, to protect myself and my family members. That’s why I got vaccinated.
Caplan: So, you chose to? No one made you?
Grabowski: Absolutely. There were no mandates. I would have loved to have gotten vaccinated even earlier, to be honest, but I’m happy to be fully vaccinated today.
Caplan: Judy, what about you? You’re probably vaccinated, but tell me why.
Judy Stone, MD: Like David, I felt the need to protect myself and my family. I’m not active in patient care at the moment, but again, I feel a responsibility toward others.
Caplan: So it was a duty to others as much as to protect yourself?
Stone: Absolutely. And like David, I was lower down on the list. As soon as I was able to, I jumped at the opportunity to get vaccinated.
Caplan: I’m vaccinated too. I do have patient contact. Some of you may be wondering why that’s so for an ethicist, but occasionally I still need to mediate end-of-life-care cases, not often during COVID, but I did have to go in a few times. I too was at the end of the list, appropriately, but I am vaccinated.
I was not mandated to do so; I chose to do so. It seemed like the moral, prudent, responsible thing to do, both to protect me and to protect colleagues, patients, or families that I might come in contact with. But not everybody is choosing to do so, even some of our coworkers.
Stone: I’d add that since I counsel a number of people in my community about vaccinations, I felt an obligation to set an example for them too.
Caplan: To be a good role model?
Stone: Right. Absolutely.
Convincing Vaccine-Hesitant Healthcare Workers
Caplan: Judy, I’ll throw this question to you first. If people aren’t choosing to vaccinate — doctors, nurses, respiratory therapists, people who transport patients, handle food, clean the rooms — what would you say to them? Would you tell them that they ought to do it?
Stone: I absolutely would. While I don’t do well with authority, people telling me what to do, that’s exactly what I would do in this case. I try to reason with people. I try to ask them what they’re afraid of and address their concerns. But the bottom line for me is that healthcare workers have a responsibility to protect their patients in any way they can.
Caplan: Do you think it’s a special responsibility unique to the role?
Stone: Well, I believe that everybody should care for people around them. Particularly when your career is taking care of vulnerable patients, I think that you have a moral obligation to protect them by taking a vaccine that is safe.
So, I would try to reassure people. I would try to explain to them. But if that doesn’t work and they insist that the vaccine is the mark of the beast or think that it’s a conspiracy to place microchips in them, I’d say, “I’m sorry. You need to take this vaccine to protect others.”
Caplan: David, up where you are at Harvard, have you encountered people who say no?
Grabowski: Most of my colleagues are vaccinated, like all of us here. Through my work in the long-term care setting, however, I have encountered quite a bit of hesitancy, even here in Massachusetts. Among nursing home staff, there’s a range of different positions, from physicians to therapists, registered nurses to licensed practical nurses.
Unfortunately, vaccination rates have been lowest among those with the most direct contact with the residents, specifically among those nurse aides. That’s where the hesitancy is most concerning and strongest. To me, the greatest policy challenge has been how to move the needle with that group. I think among physician colleagues, I’ve encountered very little hesitancy, but quite a bit in other parts of the healthcare workforce.
Why Long-term Care and Nursing Home Facility Workers Are Particularly Hesitant
Caplan: Although I know the surveys that have been done in this area do not include extensive numbers, they do seem to show more resistance among nurses and nurse aides than among doctors.
One thing I’m interested in, David, is what those in the long-term care setting who are resistant to vaccination are saying. What kinds of worries do they express, or do they just say, “I’m not doing it and buzz off”?
Grabowski: I think it’s really an issue of trust. They don’t trust the vaccine. Speaking specifically about the nurse aides, they’re making close to minimum wage. Oftentimes they don’t trust management or leadership at these facilities. They’re very resistant, as Judy just said, to authority and being told what to do, because there’s not a strong relationship between labor and management in this setting. This is not the same as you’d see among physicians and leadership at somewhere like Massachusetts General Hospital. This applies to the workforce in a for-profit nursing home that hasn’t been treated very well historically.
And by the way, they also weren’t treated very well during this pandemic. Direct caregivers in nursing homes had among the highest death rate of any profession in the United States during the pandemic, more so than commercial fishermen, logging workers. You usually don’t group nurse aides in with those professions. But this was a really challenging time. This workforce was incredibly stressed. Now you’re telling them, “Guess what, this will really benefit you and potentially save your life,” and there’s just not that strong relationship or trust there.
I’ve also heard concerns about side effects, although hopefully some of that has since receded.
Caplan: I’m assuming they mean long-term side effects?
Grabowski: It’s short- and long-term side effects. When it comes to the short-term side effects, hopefully that’s declined as they’ve seen their colleagues getting vaccinated. We saw very few of the staff in the long-term care settings calling out of work after receiving the vaccine. There were only a few side effects, which was really encouraging. But you’re right — there’s a lot of concern about these longer-term side effects and just the overall safety associated with the vaccine.
Caplan: Judy, I’m curious: Do you think the hesitant healthcare workers you encounter, in the public or among your own friends, are persuaded by these incentive ideas? Do you think if we paid more, gave them free meals, or offered them some kind of a reward, would that move those people? Or are their hesitancies and concerns deeper?
Stone: I don’t think that it would move them. Particularly among nursing home workers, there is a level of suspicion around coercion. If you’re offering them a $20 gift card, they may think, “Well, why do you have to give me a gift card to take this?”
Caplan: Do you think that sows suspicion?
Stone: I do. I think that one of the problems here, at least at the hospital I worked in for 25 years, carries over from penalizing people for taking sick time. They call them “occasions.” If you had a certain number of occasions, then you were disciplined or fired. So, I think that makes it more difficult to offer a vaccine that may make people feel unwell for a couple of days.
Caplan: We made a strong point at NYU about trying to give staff extra days off for the same reason; they’re very worried about biting into their sick time.
Stone: Following up on what David said about the lack of trust between management and the staff, one of the interesting things that I came across was that mandates could lead some people to feel that they were accepting a riskier choice. This comes back to the fact that offering healthcare workers adequate personal protective equipment (PPE) was not a priority during the pandemic. They worry that if they’re vaccinated, they’ll be forced to work in a higher-risk setting.
Caplan: Interesting. That’s the old worry about risk reduction, and that if you adjust one variable, you’re going to increase the risk in another way.
Stone: That’s right. Certainly, I was torn between feeling an obligation to take care of patients and feeling like it would be suicidal, at my age and with underlying health conditions, to go work in a place where there’s not adequate PPE. The vaccine changed that perspective, and I’d jump in now.
Is It Time to Move to Vaccine Mandates?
Caplan: Let’s presume that we’re not going to be able to change conditions relative to vaccination tomorrow and start paying people a better wage, although I think it’s pretty clear we could and should do better by those who have pretty tough work. And let’s assume that little incentives are also not going to move the needle for our healthcare workforce. Yet healthcare workers may also have a special obligation, because they deal with vulnerable residents in nursing homes, people who have cancer, transplant recipients, those with immune diseases, newborns.
With that being said, what’s your attitude about doing what Houston Methodist did and just saying, “Look, if you want to work here, you’re going to have to accept vaccination”? We do mandate other things that healthcare workers have to do to hold a job. I’ve seen arguments about hairnets or tuberculosis testing, and most places have put in a flu vaccine mandate for being on the workforce. But if we can’t persuade, educate, or incentivize right away, what’s your thought about going to a mandate? Dave, what do you think?
Grabowski: Let’s be very direct: Mandates solve a lot of things. There’s no doubt that the rates of vaccinations will go way up. And I think the hospital in Houston is a good example. There will be some resistance, but that would be an effective policy. The only catch here — and I really want to stress this point — is the potential for unintended consequences.
Consider the example of a well-heeled hospital, and again I’ll return to Massachusetts General Hospital, MGH, here in Boston. The joke here is that MGH stands for “man’s greatest hospital.” They have a lot of resources and they’re able to pay their staff well. You hope that allows them to have built a level of trust in that relationship with their workforce.
But as I suggested earlier, many nursing homes don’t have that trust in those relationships with their workforce. This mandate will inevitably increase vaccination rates, which is the intended effect. But it also will have this unintended effect of potentially having some workers say, “I’ll just go work elsewhere.”
Caplan: And by the way, the market is such at the current moment where they could easily go work elsewhere.
Grabowski: They often do just that. As we showed in a recent paper, the workforce is highly fluid, there’s tremendous turnover, and these individuals often work at multiple facilities. So, I could completely see some of the workforce just deciding to work elsewhere, even outside the healthcare sector.
Caplan: To that very point, a couple of journalists down in Texas told me that of the 150 or so who quit or got fired from Houston Methodist, all of them said they had jobs lined up elsewhere. I don’t know if they were in healthcare or working somewhere else.
Grabowski: We’ve seen that about 1 in 5 nursing homes had a staffing shortage during the pandemic. Now if you’re going to put this mandate on top of that, I just worry about whether they’re going to be able to find the individuals that are willing to work and willing to get vaccinated. I appreciate that it will protect individuals on the one side. I’m all for getting as many of our workers vaccinated as possible. I just worry about how we do that without having a lot of the workforce decide to leave.
Caplan: I heard of one institution that was going to put the mandate in but only for new employees. Is that a less painful, less risky idea?
Grabowski: Absolutely, in that it’s part of the terms of employment. By signing that, I understand that I need to get vaccinated in order to start working here. However, the numbers we’re seeing nationally are that 40%-50% of nursing home staff are vaccinated. A lot of the staff members working in those settings every day are then going home to their family and coming back in.
Judy mentioned the problem of ineffective PPE. We also don’t have rapid testing in most facilities. So, I think there’s real potential, especially with the Delta variant, for this to grow if we don’t have more of our staff vaccinated.
Caplan: I’m somewhat familiar with nursing homes; I studied them a little bit over the years, have had relatives in them. I’ve noticed that there’s a lot of rotation of staff from institution to institution. That’s a natural way to spread disease. People have this idea that if someone’s hired at a particular nursing home, that’s the only place where they work. But there’s a lot of moving around, picking up swing shifts and night shifts, filling in when someone’s sick. That’s another reason to be concerned.
Certain Exemptions May Be Valid, But the Difficultly Is Accommodating Them Safely
Caplan: Another thing that’s interesting to consider is the wide variety of mandates that exist. One mandate may state, “You’re going to do this or you’re fired.” A different mandate may say, “You’re going to do this, but if you have a religious, personal, or health reason, well, maybe we’ll try to accommodate you. Maybe we’ll move you to a non-patient contact area, ask you to wear a mask, perhaps undergo frequent testing.”
Judy, what do you think about weak vs strong mandates for healthcare workers? Should we try to accommodate those who have objections?
Stone: It depends on what their objection is. But first let me take a minute to go back to what David said. With the nursing homes, you have an obligation to treat the staff better. You wouldn’t have as much resistance to the mandates if they weren’t working in such poor conditions.
One of the things that I saw happen in my community is that the University of Pittsburgh Medical Center (UPMC) has taken over our community hospital. They’re buying up a number of rural hospitals, including ours. And although the Maryland Hospital Association called for mandates in a consensus statement released in June, UPMC is saying, “No, we’re not going to do that.” I think they’re sowing doubt among the staff and the healthcare workers by saying that although the vaccines may protect you, there’s not enough evidence that they prevent transmission. So we’re not going to have a mandate, but I don’t think that people will understand that nuance. And it sets a bad example.
But going back to whether there should be a carve-out, I honestly don’t understand the idea of religious exemptions that are being claimed for this. So I guess there needs to be better communication and education on both sides.
Caplan: I’ll reveal a little bit of bias on my part. I’ve studied the positions of all major religions, including Christian Science, which is a small religion relative to others. I’m not seeing that any of these religions are anti-vaccine. In fact, most religions are pro-vaccine; they want you to get vaccinated.
Stone: And they’re also “pro” taking care of other people. All major religions essentially say, do unto others as you would have them do unto you. So why wouldn’t you get a vaccine, given the imperative to save a life?
I can see a carve-out for medical reasons in combination with wearing a mask. However, I don’t necessarily see that having them work in another area will be effective, because we know that a lot of the SARS-CoV-2 virus is airborne transmitted. Unless they’re in a very isolated space, they could still infect others. But otherwise, I don’t understand some of the exemptions, and other than for medical reasons I don’t think I’d go along with them.
Caplan: Do you agree with that, Dave?
Grabowski: It’s really challenging. I completely agree with Judy about having those with medical reasons wear masks or be placed in more remote parts of the healthcare facility. But it just doesn’t work in practice very well. It gets really, really challenging. I’m thinking of examples of where that would possibly work in hospitals or nursing homes, and short of being in, I don’t know, a records room or something like that, it doesn’t seem like they’d really be able to offer direct patient care anymore.
Should We Require Vaccines for Anyone Entering Long-term Healthcare Facilities?
Caplan: There are a lot of people coming to hospitals and nursing homes — visitors, families, people delivering flowers, setting up your TV or cable. Should they be vaccinated?
Grabowski: I think so. There were many sad aspects of the pandemic that occurred in nursing homes, a major one certainly being the exclusion of visitors, family, and essential care partners. This basically led to the isolation of our older adults in these facilities. I support anything that would allow family members to reconnect with their loved ones in these nursing homes, and absolutely having visitors and volunteers show their proof of vaccination.
That kind of mandate is just as challenging as mandating staff right now. But I would love to see nursing homes and hospitals mandate that everyone that comes in is vaccinated, whether it’s a repairman, a family visitor, a volunteer. That’s a great goal. I’d hope that they’re willing to enforce that and see it through, but whether they will or can is less clear to me.
Stone: There was no reason to exclude family members, even before the vaccines became widely available. They could have simply asked the family to wear a mask. It was just barbaric and infuriating to me.
Grabowski: It was easy for us to follow the number of cases or deaths on the nightly news, in The New York Times, or wherever. But this isolation and loneliness was sort of the hidden cost of COVID-19 in nursing homes and long-term care settings. It had a huge impact on the older adults living in these settings.
Stone: And in hospitals where, essentially, if you don’t have an advocate, you’re dead.
Seeking More Persuasive Pro-Vaccine Voices
Caplan: We don’t want to decimate the workforce and make patients worse off. If people are told that they have to vaccinate, they may simply decide that they no longer want to be in that line of work. There are days when I think, if you don’t want to vaccinate against COVID, then you should be in another line of work. But at the same time, I’d like to know that somebody’s there to deliver food to a nursing home patient, clean the room, or do the other things that have to be done.
Should we think about not just firing people, but perhaps suspending them or coming up with other penalties for noncompliance? This might keep us from severing the connection and creating what we’re all worried about, which is diminishing the workforce in a time of crisis. After all, COVID is still very much with us. We could be facing new strains and new challenges, find ourselves looking for people to go on the front lines, be brave, sometimes be underprotected, and all the rest of it. David, do you think there’s some other way to sort of make the mandate have teeth?
Grabowski: We’re clearly building up to more mandates, and I don’t want to lose those workers either. In thinking about this, I’ll return to the same point I’ve made a few times: Are there ways in the short term to improve trust and relationships?
It’s not just an information problem. CMS was nearly bombarding these facilities and their workforce with information, which I think they understand. I just think they need to hear it from a different voice. That may be somebody trusted in the community, such as a religious leader, a clinical leader, or maybe somebody from their national association. The National Association of Health Care Assistants has been really great about encouraging vaccinations. They’ve had much higher vaccination rates in their facilities vs facilities where they’re not involved.
I do think there are other strategies that can be used in conjunction in leading up to the mandate so that we don’t have this big exit of workers. That’s what keeps me up nights about a mandate. I think the mandates are coming and that it’s probably good, but I just really worry about that unintended consequence.
Caplan: What do you think, Judy?
Stone: I agree with David that it would be nice if we could find an alternative to firing somebody, but I’m simply at my wits’ end about how to communicate with people. I think having, for example, the barbershops in the Black community or the religious community step in would be very helpful. But unfortunately, what I see in my community is that it’s very much a political decision. Until you overcome that political divide, I don’t see an alternative.
Caplan: I want to thank you both. This was very illuminating and instructive.
I hope we helped you, the viewer, think about some of the various nuances that arise when you’re talking about different kinds of mandates, enforcing them, and what the unexpected consequences might be if we’re too aggressive with mandates and do damage to the workforce.
I learned a lot from the both of you and appreciate your time. And I appreciate you, the viewers, for spending some time with us on Both Sides Now. Thanks for watching.
Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.