The UK government has announced that COVID-19 vaccination will become mandatory for staff working in care homes for older people in England. Staff will be given 16 weeks to get the vaccine. If they don’t get the jab, they will be redeployed from frontline care or lose their job.

Mandating vaccination would increase vaccine uptake in care home workers, but it would be a significant intrusion into individual freedom. Is it ethically justifiable?

Yes – Professor Dominic Wilkinson

In the early phase of the pandemic, some of the most medically vulnerable people ended up catching coronavirus from those caring for them; 40,000 patients in England are said to have caught COVID while in hospital. Some patients and care home residents died from infections that they caught from their caregivers. We must do everything possible to avoid repeating this tragic and distressing situation.

First, we should ensure that all those who are at a high risk of dying from COVID have access to the vaccine. About 10% of older adult care home residents have still not had a second dose of the vaccine.

Second, those who work in the frontline with vulnerable high-risk patients have an ethical obligation to take all reasonable measures to prevent the spread of the virus to those they are caring for. They must follow the guidance on things like hand washing and PPE. They should take part in lateral flow testing schemes. And they should be vaccinated.

Mandating vaccination can be ethical if it is both necessary and proportionate. A mandate is not necessary if there are less intrusive means of effectively increasing uptake, such as persuasion and incentives. The problem is that less intrusive means may be much less effective.

Persuasion has so far failed. There is strong evidence to suggest that vaccine mandates are the most effective way to increase uptake.

A mandate could be proportionate if the public health benefit of increasing uptake among staff would outweigh the harms. Given the considerable vulnerability of care home residents, this seems to be the case. Care home residents can’t choose who cares for them. Some remain only partly protected after vaccination. The risks of vaccination for workers are exceptionally low.

However, if vaccines are made mandatory for care home workers (or healthcare workers), they should be able to choose from available vaccines. Every effort possible should be made to address any concerns that they have about the vaccines. A conditional vaccination policy would be ethical.

Care home workers – and NHS staff – who have not had the COVID vaccine should be redeployed to areas other than frontline care. In the absence of a medical exemption, COVID vaccination should be a condition of employment in the same way that hepatitis B vaccination is currently for some health professionals.

No – Professor Julian Savulescu

Mandatory vaccination policies can sometimes be ethical. But the proposal to make vaccination mandatory for care home workers is muddle-headed.

There are rare but serious risks of vaccination: blood clots for AstraZeneca and probable myocarditis in Pfizer. COVID-19 deaths are predominantly in the elderly, while rare side-effects are mostly in the young.

For most, these small risks won’t change the risk-benefit ratio. But for some, the risk-benefit ratio looks very different.

Imagine a 20-year-old care worker on a zero-hours contract, like 24% of her colleagues, who worked through the pandemic and gained natural immunity from becoming infected. She, and those in her care, have little to gain from her undergoing vaccination to gain additional immunity.

A Public Health England study compared vaccine and natural immunity and found “equal or higher protection from natural infection, both for symptomatic and asymptomatic infection”. But under this scheme, our care worker would still be exposed to the additional risks of vaccination. Moreover, if she has to take time off sick with the common side-effects, thanks to her zero-hours contract, she won’t be eligible for sick pay for four days – and perhaps not then.

This won’t be the case for everyone. But it should be up to the individual who will suffer the outcome to make an informed choice. That is perhaps the most basic tenet of medical ethics: respect for autonomy.

It is true that autonomy is not always decisive in public health and that care workers have professional responsibilities to those in their care. But to justifiably override autonomy and remove someone’s livelihood, we need to know that doing so will be an effective measure and that it is necessary.

Increasing vaccine uptake may only have a limited effect in preventing transmission. The very limited data available suggests only a limited effect (as low as 35% and up to 50%). There are also confirmed reports of breakthrough infections, and even outbreaks, among fully vaccinated staff and patients.

Vaccination will confer some protection. But, at best, mandatory vaccination won’t stop family and friends from transmitting the virus while visiting care homes. Singling out one group for the coercive measure will be divisive and may lead many staff to leave the already-understaffed profession.

The policy is also unnecessary. Half of care homes have hit the target level of staff vaccination through voluntary means. Staff could be offered incentives to be vaccinated.

We should ensure the risks the vulnerable face are reasonable. But this isn’t a vaccine with the safety track record of the flu or hepatitis vaccine. I think the COVID vaccines are in most people’s best interests. But that’s a decision people should make for themselves.

Dominic Wilkinson, Consultant Neonatologist and Professor of Ethics, University of Oxford and Julian Savulescu, Visiting Professor in Biomedical Ethics, Murdoch Children's Research Institute; Distinguished Visiting Professor in Law, University of Melbourne; Uehiro Chair in Practical Ethics, University of Oxford

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