Bioethics Forum Essay

Ashamed to Be Vaccinated? The Ethics of Health Care Employees Forgoing Unfair Priority

Now that two coronavirus vaccines are available for emergency use in the United States, the federal government is distributing allotments to states.  Those allotments are accompanied by recommendations from the Advisory Committee on Immunization Practices (ACIP), but it is left to each state to guide the supply it receives. Unsurprisingly, there is variability in how states are prioritizing populations within their borders, giving rise to a new round of heated debates about macro-allocation schemes and their rationales. But as doses inch closer to arms, various actors shape their fates and micro-allocation problems are triggered. 

Vaccines are—as they will be for some time—under the control of institutions. Those institutions must decide how to allocate their supply and must do so in a way that falls under reasonable interpretations of political authorities’ mandates. In addition, individuals who stand to benefit from those decisions must decide whether the opportunity is worth taking.  

Many types of employees find themselves within a hospital system’s ambit.  They vary by age, health status, professional background, and whether their work can be done from home or requires being in or near a clinical setting. Hospital systems employ biostatisticians, IT personnel, custodial staff, security guards, clergy, line cooks, lab scientists, marketing and communications professionals, and even philosophers. This diversity gets discussed at the macro-level in the form of the question, “Who counts as an essential health care worker?” But whatever the answer to that question, another remains.

After a hospital system has offered vaccine to all of its frontline staff and administered doses to the willing, what should it do with remaining doses?  Some hospital systems are receiving supply in excess of first-phase allocation’s demand. Those institutions are now pivoting toward vaccinating all of their employees, even those who, but for employment in that system, would not be vaccinated until later phases. And it is here, faced with the opportunity to be vaccinated, that confusion and apparent ethical dilemmas arise.

Suppose you are young, healthy, employed in a health care system and that your line of work does not require leaving the low-risk comfort of your home.  Now suppose that your employer offers you a vaccine. You know there are others in your community who are at greater risk of contracting and dying from Covid-19 than you. Should you accept the dose? 

Before attempting to answer, let’s refine the question. Let’s ignore versions of the refuse-or-accept dilemma which arise from worries about safety and efficacy. Let’s also set aside versions born out of moral concerns about the vaccine itself.  No, the agents we have in mind are not worried about safety or efficacy. Nor are they morally opposed to the vaccine itself. Instead, they are morally opposed to their receiving it at this time. Such agents endorse vaccinations generally, just not these doses for themselves right now.

But why are they morally opposed to—or morally disturbed by—their opportunity to be vaccinated? They think refusing the vaccine is required by justice, that accepting the dose now would be unjust. They are asking, “Should I accept the vaccine when the very opportunity to do so is, by my own lights, unjust?” These potential recipients see themselves as unworthy of the scarce resource since others in the community need it more urgently.  In their view, they are cutting the line and benefitting from luck, or worse, being complicit in injustice. In this light, refusal might look like the right and honorable action.

In a way, this is a new variant of vaccine hesitancy. Here, one refuses—or is at least hesitant to accept—an available vaccine even though one believes it is safe, effective, and necessary. The hesitancy stems from thinking that one’s own vaccination would be morally wrong because the opportunity itself is unfair. 

What should one do in this scenario?  

We think the employee should accept the vaccine. What goals would be furthered by refusal?  Those who feel the dilemma’s force assume that their refusal would free up a scarce resource, that the liberated dose would end up in the arm of someone who needs it more urgently. But that is dubitable.  It is likely that the vaccine will not leave the institution. Handling the current vaccines is very difficult, making reshipping hugely unlikely. Thus, it is unlikely that the dose would go to the individuals or populations the refusers have in mind.  Instead, it would trickle down or move horizontally to another similarly low-priority employee in the system. Thus, refusal would not achieve a more just outcome.

Another possible goal furthered by refusal is psychological. Here, one maintains—by self-deception?—a sense of moral purity by avoiding the guilt or shame that comes from benefitting from opportunities one judges to be unfair.

Is this psychological benefit a valuable goal? Here, we detect a spurious exceptionalism about Covid-19 vaccines. Our lives are built on unlevel ground.  We regularly enjoy the fruits of unfairness. Should one abandon Manhattan since it is stolen land?  Should one forgo employment-based health insurance if it is a fixture of an unjust health care system? These are neither “gotcha” questions nor experiments in whataboutism. Rather, they are reminders that we make choices—morally good choices—within an unfair world.  Often, if not always, the opportunities before us are the outputs of unjust systems. The right and the good choices we make often mean benefiting from unfairness. Sometimes the best we can do is recognize the meaningful moral difference between creating unfair opportunities and taking them.  The former is objectionable; the latter, unavoidable.

Given that institutional gravity and practical limitations will keep refused doses in a hospital system’s orbit, the only justice-related achievement is phenomenological.  One just feels better by refusing. A sincere concern about justice is not an emotion-laden illusion, but conceiving of refusal as furthering justice in this case is.

Guilt and shame are powerful features of our moral psychology and important tools in moral education. But these feelings are not always reliable.  And they are no substitute for moral reasoning. These moral emotions must always be thoughtfully and thoroughly vetted before handing them the reins. 

Is there any other goal furthered by refusal? One possibility is that by refusing the dose, the refuser communicates that this particular allocation and the allocation schema leading to it are unjust. Could this justify refusal? 

There are three reasons to think not. First, the expression may not reach anyone and the moral message could go unnoticed. Second, the message may be misconstrued. Anti-vaxxers and purveyors of misinformation would delight at hospital employees refusing vaccines, data which they would predictably and nefariously spin. Third, one can communicate the same message while accepting the vaccine.  . 

So, refusal either fails to further goals, furthers goals of little value, or furthers goals that may be achieved by other means. Given the poor reasons for refusal, consider the value of vaccination even when one judges the opportunity to be unfair. We suggest reinterpreting the act so that this value shows itself more clearly.

By taking the unfair vaccination opportunity, one contributes to our collectively achieving a community-level good. That good inheres not only in the individual and the institution but also in the community—or set of communities—in which they are housed. Seen in this light, taking the opportunity is responsibly intervening in one of the small ways an individual can.

What is that community-level good?  Its nature depends on empirical matters that are still unknown. If the vaccines prevent infectivity, then one’s vaccination is a step, albeit a small one, towards herd immunity. If the vaccines don’t prevent transmission, there is still a community-level good in the works. Let’s call it herd durability. The herd is durable when it can withstand pressure from infectious disease. As more people are vaccinated, fewer people are at risk of illness that results in consumption of scarce resources healthcare systems need to withstand pandemic pressure.  An individual’s accepting vaccination contributes to either goal, even when the opportunity is unfair. Either goal is worthy of pursuit, much more so than anything refusal might achieve. Plus, there is the happy byproduct of preserving one’s own life and health, thus achieving what is in one’s enlightened self-interest. 

One might object that our argument justifies letting the rich and powerful monetarily muscle their way to the front of the line. After all, they can just as well achieve the goods of self-preservation and contributing to herd immunity or durability. Does our argument pave the way to such an absurd conclusion?

It does not.  First, as suggested above, there’s a moral difference between creating unfair opportunities and taking them.  A rich person who is not an employee of a health care institution would create unfair opportunities, which we do not endorse. Our claim is that given the goods vaccination achieves and given the poverty of goals refusals achieve, it is permissible—or perhaps even obligatory—for employees to take the opportunity. Those goods are sufficient reasons in this scenario, not in all scenarios. Second, no one can make a good-faith claim that the rich buying early access is consistent with ACIP’s recommendations or states’ distribution plans.  Institutions vaccinating their employees can make such claims in good faith. Thus, an employee’s accepting the vaccine is an implication of a publicly expressed, communally shared practical commitment. A wealthy, powerful nonemployee buying access cannot be interpreted in this way.  One begins with “We.”  The other begins with “Me.”

So, even though some of the same goods could be achieved by either individual being vaccinated, the two cases involve different sets of harms, wrongs, and responsibilities. The employee benefits from an unfair opportunity she did not create. Although it perhaps reveals failures of justice in our shared distribution plans, it does not follow that accepting the vaccine is morally wrong. The wealthy nonemployee, on the other hand, creates an unfair opportunity for her own benefit, undermines cooperation, and leads astray a shared public health endeavor.

In the end, the question “Should I accept or refuse the vaccine when the opportunity is unfair?” becomes “Should I a) protect myself from Covid-19 and potential death while contributing to a valuable communal good, or b) protect myself from shame and guilt, sustain risks to my health, contributing nothing to herd immunity or durability, while doing nothing concrete to correct injustice?” That question is much easier to answer.

Kyle Ferguson, PhD, is a postdoctoral fellow in the Division of Medical Ethics at NYU Grossman School of Medicine, Twitter: @thekyleferguson. Arthur Caplan, PhD, is the Drs. William F. and Virginia Connolly Mitty Professor of Bioethics and the founding director of the Division of Medical Ethics at NYU Grossman School of Medicine.  He is a Hastings Center fellow and a member of the Hastings Center’s advisory council, Twitter @ArthurCaplan.