COVID Vaccine Mandates: How Strong Is Too Strong?

This transcript has been edited for clarity.

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.

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 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?

David Grabowski, PhD: 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.

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?

Judy Stone, MD: 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.

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.

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