Elsevier

Vaccine

Volume 33, Issue 22, 21 May 2015, Pages 2530-2535
Vaccine

Review
Nudges or mandates? The ethics of mandatory flu vaccination

https://doi.org/10.1016/j.vaccine.2015.03.048Get rights and content

Highlights

  • Influenza vaccination mandates are very effective but controversial.

  • Those opposing mandates believe it is unethical to remove one's choice about own health.

  • Behavioral economics offers choice-preserving strategies to increase vaccination.

  • These strategies incentivize vaccinations and help better align intentions with actions.

Abstract

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. 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. The opposition stems from the belief that a mandatory flu shot policy violates an individual right to refuse unwanted treatment. This article outlines the historic push to achieve higher vaccination rates among healthcare professionals and a number of ethical issues arising from attempts to implement vaccination mandates. It then turns to a review of cognitive biases relevant in the context of decisions about influenza vaccination (omission bias, ambiguity aversion, present bias etc.) The article suggests that a successful strategy for policy-makers and others hoping to increase vaccination rates is to design a “choice architecture” that influences behavior of healthcare professionals without foreclosing other options. Nudges incentivize vaccinations and help better align vaccination intentions with near-term actions.

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.

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