Is it an ethical duty to mandate flu shot?

Critic: A 'disingenuous veneer of safety'

More and more hospitals are adopting a policy that mandates influenza immunization for their employees with patient safety as the primary rationale. But some ethical questions linger: What is the balance between the potential risk to patients from unvaccinated health care workers and the rights of health care workers to refuse a vaccine? How are the ethics of a mandate affected by the drawbacks of the vaccine — such as its variable effectiveness and occasional supply shortages?

Experts in bioethics and occupational health from the Mayo Clinic in Rochester, MN, recently wrote articles reflecting on the health care worker responsibilities and rights.

'First, do no harm'

This maxim of medical ethics underlies the push for influenza vaccination. Complications from influenza can be life-threatening for some elderly or vulnerable patients. Since there is a vaccine that can reduce the risk of nosocomial transmission, health care workers should have it, says Abigale Ottenberg, MA, a medical bioethicist with the Mayo Clinic who was the lead author of a paper on "the ethical and legal rationale for a mandate" in the American Journal of Public Health.1

"I'm not sure I see it as [an ethical] balance but instead as two obligations that health care workers have that are in sync with one another," Ottenberg told HEH. "Health care workers have an individual professional obligation to become vaccinated against influenza. They also have an obligation in the public health perspective — the organizational commitment to their profession and to their patients.

"Health care workers freely choose their profession. They're not required to become health care workers," she says. "With the privilege of being a health care worker, they also have obligations to their patients and the public."

Ottenberg and her colleagues conclude that states have the authority to mandate influenza immunization of health care workers based on protection of the public health. Fifteen states require at least one immunization of health care workers, although none currently mandate influenza immunization.

Health care workers should be able to avoid immunization due to medical contraindications or religious or philosophic objections, but the employer can require alternative measures to protect patients, she says. Many hospitals require unvaccinated health care workers to wear surgical masks during patient care throughout the flu season. (Infectious disease societies do not endorse exemptions for personal belief, but some do allow for religious objections.)

Yet there are obligations that employers have to their employees, as well, Ottenberg says. For example, employers must provide information about influenza and the vaccine and answer questions that health care workers may have. The vaccine should be free of charge and employers should make vaccination convenient, she says.

"An organization that implements a mandate does have a responsibility to their workforce to make it as easy as possible to fulfill those obligations," she says.

Flaws in the logic

Everyone agrees that the influenza vaccine is an imperfect vaccine. It has to be produced every year, grown in chicken eggs in a cumbersome process. Glitches in the manufacturing process have occasionally led to delays or shortages. Because the effectiveness varies significantly, even people who are vaccinated sometimes get influenza and can transmit the virus. And when a new strain emerges, as with H1N1, a vaccine is not available for about six months.

The drawbacks of this particular vaccine makes it hard to justify a vaccination mandate, says Bill Buchta, MD, MPH, medical director of the Occupational Health Service at the Mayo Clinic, in an online opinion piece on the Pediatric Supersite.

"It's a simple strategy for giving the veneer of safety," says Buchta, who advocates strong but voluntary health care worker vaccination programs. "You can measure it. You can crow about it to the public, saying 100% of our staff are vaccinated against influenza, without telling them what that means and what it doesn't mean. To me that is disingenuous."

Most of the respiratory disease circulating in the winter is actually "influenza-like illness," (ILI) but not influenza, says Buchta. The vaccine has no effect on non-influenza viruses. Meanwhile, hospitals rarely require patients or visitors to be vaccinated, leaving patients vulnerable even if health care workers have been vaccinated.

"The implication is that if you get this vaccine you are protecting your patients from ILI. It's a false sense of security. It also sends the message that if you get this vaccine, you will not shed vaccine," he says.

The Centers for Disease Control and Prevention recommends vaccination of health care workers as one part of a comprehensive strategy to prevent health care-associated transmission. But Buchta worries that the push for mandatory vaccination overshadows the importance of the other infection control precautions, such as encouraging health care workers to stay home if they're sick and isolating patients or placing a mask on coughing patients, if possible.

Yet Buchta does see room for compromise. "If we chose specific units in the hospital with patients who are at high-risk, [a vaccine mandate] makes sense and it's ethical. You do everything reasonable to protect those patients," he says.

The mandatory programs put employee health professionals in a difficult position of becoming "enforcers," rather than protectors of employees, he says. "These kinds of policies could change the nature of occupational health," he says. "This trend of placing patient safety over employee rights and safety portends a negative perception of occupational health amongst our employees."

Policies that require employees to wear a mask during patient care activities if they're not vaccinated also are problematic, he says. After all, even vaccinated employees are not 100% protected from influenza, and they still can transmit other respiratory viruses.

"If I end up in a system that requires mandatory vaccination or wearing a mask, I will get vaccinated and wear the mask as a civil protest," he says. "Those are not mutually exclusive alternatives. If the protection of patients is that important, we should all be wearing masks. The vaccine is not a sufficient alternative to being masked."

A bright spot for the future: The development of an effective, one-time-only influenza vaccine would change the conversation and make mandatory vaccination an easy decision, says Buchta. "The problem is the product we are mandating isn't worthy of that status," he says.


1. Ottenberg AL, Wu KT, Poland GA, et al. Vaccinating health care workers against influenza: The ethical and legal rationale for a mandate. Am J Public Health 2011; 101:212–216.

2. Buchta WG. The current influenza vaccine: Best defense from flu? Infectious Diseases in Children 2011. Available online at