ReviewNudges or mandates? The ethics of mandatory flu vaccination
Introduction
According to the CDC report for the 2012–2013 influenza season, there was a modest increase in the vaccination coverage rate among healthcare workers from 67% in 2011–2012, to 72% in 2012–2013 to the current 75% coverage [1]. This is still far from reaching the US National Healthy People 2020 goal of 90% hospitals vaccination rates. The reported increase in coverage is attributed to the growing number of healthcare facilities with vaccination requirements with average rates of 96.5%. However, a few other public health interventions stir so much controversy and debate as vaccination mandates. When Rhode Island introduced a mandatory influenza vaccination policy on state level, more than 1000 workers signed a petition opposing the policy that is now challenged in court by a healthcare workers union. Professional organizations have voiced their concerns regarding vaccination mandates. The American Nursing Association, for instance, considers influenza vaccination “an ethical duty of every nurse,” while refusing to support a mandatory policy.
As shown historically, there needs to be a push for high vaccination rates to reach herd immunity. Mandatory vaccination has proven to work and accomplish more vaccination, but causes disturbance in medical ethics for healthcare workers. Mandatory vaccination can be positively enforced by nudge strategies adopted from behavioral economics research.
Section snippets
Healthcare mandates
Since 1984, the Advisory Committee on Immunization Practices of the Center for Disease Control and Prevention has issued guidelines containing a provision for annual influenza vaccination of healthcare workers. Initially these recommendations targeted healthcare workers with direct patient contact; in 1993 the guidelines were expanded to include all healthcare workers [2]. In 2003 the National Foundation for Infectious Diseases held a roundtable meeting with 24 professional organizations aimed
Influenza vaccination mandates and ethical issues
As hospitals, healthcare systems and even states tighten their policies around flu vaccinations, nurses associations have grown vocal in their resistance to yearly influenza vaccinations requirements. For instance, on September 22 of 2014, the Massachusetts Nurses Association filed a lawsuit against Boston's Brigham and Women's Hospital in Suffolk Superior Court. Similar cases and opposition to mandates have been playing out in other parts of the country. The opposition stems from the belief
Nudging for high immunization coverage
If staff immunity can be achieved through vaccination mandates, is there a need to look for approaches that preserve freedom of choice? Public health researchers increasingly apply concepts from the field of behavioral economics to design and evaluate choice-preserving alternatives to health mandates. They call these alternatives nudges or “any aspect of the choice architecture that alters people's behavior in a predictable way without forbidding any options or significantly changing their
Conclusion
Behavioral economics is attracting the attention of policy-makers because of its potential to offer unobtrusive solutions to problems in healthcare that have proved resistant to other approaches. Influenza vaccination of healthcare workers is one of these problems. Behavioral economics posits that people do not always behave in their own best interests. They can be nudged to make better decisions by offering encouragements that take into account psychological barriers preventing better choices
Conflict of interest statement
None.
References (45)
- et al.
State law and influenza vaccination of health care personnel
Vaccine
(2013) - et al.
Influenza in the acute hospital setting
Lancet Infect Dis
(2002) - et al.
Influenza vaccine coverage and presenteeism in Sedgwick County, Kansas
Am J Infect Control
(2008) - et al.
Cognitive processes and the decisions of some parents to forego pertussis vaccination for their children
J Clin Epidemiol
(1996) - et al.
Omission bias and vaccine rejection by parents of healthy children: implications for the influenza A/H1N1 vaccination programme
Vaccine
(2010) - et al.
Parental decision-making in childhood vaccination
Vaccine
(2006) Risk perception and communication in vaccination decisions: a fuzzy-trace theory approach
Vaccine
(2012)- et al.
Rising rates of vaccine exemptions: problems with current policy and more promising remedies
Vaccine
(2014) - Health personnel still not receiving flu vaccine. JAMA...
Influenza vaccination of health-care personnel, recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP)
Morb Mortal Wkly Rep
(2006)
Influenza immunization among health care workers: a call to action
Revised SHEA position paper: influenza vaccination of healthcare personnel
Infect Control Hosp Epidemiol
ACP board of regents endorses health care worker vaccination
Joint Commission establishes Infection Control Standard to address influenza vaccines for staff
Mandatory influenza vaccination of healthcare workers: a 5-year study
Infect Control Hosp Epidemiol
Bulletin to All Minnesota Health care organization managers: MDH formally recommends influenza vaccination for all health care personnel
Patterson announces suspension of flu shot mandate for health care employees due to shortage of vaccine [press release]
Mandated influenza vaccines and health care workers’ autonomy
Virtual Mentor
Influenza vaccination for healthcare workers who care for people aged 60 or older living in long term care institutions
Cochrane Database Syst Rev
Effect of influenza vaccination of healthcare personnel on morbidity and mortality among patients: systematic review and grading of evidence
Clin Infect Dis
Personal choice or evidence-based nursing intervention: nurses’ decision-making about influenza vaccination
Worldviews Evid Based Nurs
Cited by (63)
Reducing COVID vaccine hesitancy by inducing a comparative mindset
2022, VaccineCitation Excerpt :Vaccine hesitancy has been defined by the WHO as “delay in acceptance or refusal of vaccination despite availability of vaccination services” [15], p. 4163). Many cognitive biases are involved in vaccine hesitancy [7], such as the bias to prefer potentially more harmful inaction over potentially harmful action (omission bias). Several behavioral science-based approaches have been advocated to overcome these biases, ranging from emphasizing loss aversion to collective responsibility [12].
Healthcare workers’ acceptability of influenza vaccination nudges: Evaluation of a real-world intervention
2022, Preventive Medicine ReportsVaccine hesitancy and cognitive biases: Evidence for tailored communication with parents
2022, Vaccine: XCitation Excerpt :The selection of the cognitive biases was based on the existing literature. In Dubov and Phung [25], the following biases were identified: the omission bias (the tendency to prefer potentially harmful inaction to a potentially less harmful act); the ambiguity aversion (the tendency to prefer a known risk to an unknown risk); the availability bias (the tendency to judge the occurrence of side effects as likely or frequent if it is easy to imagine or recall), the optimism bias (the tendency to be more optimistic about a particular health risk, believing it is greater for other people than for themselves) and the naturalness bias (the tendency to prefer natural products or substances even when they are identical or worse than synthetic alternatives). Another bias found to be involved in the decision of whether to accept the vaccination is the confirmation bias.