A long-term care patient receives the Pfizer-BioNTech COVID-19 vaccine from a licensed vocational ... [+]

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A surprising number of healthcare workers, including physicians and registered nurses, refuse COVID vaccinations. Reports cite several factors, but the principal issue may come down to trust. What does this say about healthcare generally, and what does it mean for mandatory vaccination of healthcare workers?

Weighing Costs And Benefits

Like many people, I got vaccinated against COVID as soon as I could. I assumed that Israel would not rush to inoculate its entire population without reasonable belief in the Pfizer vaccine’s safety and efficacy. So, I made sure I got the Pfizer vaccine.

Time also mattered. CDC guidelines did not place me in a high-risk or occupational-priority category. But, beyond the benefits to myself, I had no desire to infect high-risk individuals from whom I could not practically isolate.

What’s In It For Me?”

Not everyone faced the same calculation, of course. Age and/or co-morbidities can make COVID quite deadly. But, for the young and healthy, egocentric cost-benefit might find a point at which the risks of vaccination exceed the risks from catching COVID, particularly as more of the population gets inoculated.

For such low-risk individuals, familial and civic duties still argue for vaccination. With societal discourse having focused for so long on “rights,” though, persuading some people with a “civic duty” argument may prove difficult.

Hesitancy Among Health Care Workers

As governments, employers, and businesses contemplate mandatory vaccination, some healthcare workers have dug in their heels. The unvaccinated include nearly 1 in 3 workers at the nation’s 50 largest hospitals. Reasons cited include uncertainty over safety, preference for physiological immunity, distrust of government and health organizations, and autonomy/personal freedom.

Monthly survey data gathered through Facebook suggests that vaccine hesitancy ranges from 9% among pharmacists to 20%-23% among nursing aides and emergency medical technicians. About 1 out of 8 registered nurses and doctors hesitate to get a COVID vaccine.

These healthcare workers don’t want to take the vaccine, and fight efforts to make them do so. What should we make of their position?

Do They Know Something We Don’t?

The AMA Code of Medical Ethics states that: “Informed consent to medical treatment is fundamental in both ethics and law. Patients have the right to receive information and ask questions about recommended treatments so that they can make well-considered decisions about care.”

1 in 8 doctors and nurses hesitating to get vaccinated raises the question whether they know something the rest of us don’t. And if so, can we say with confidence that current risk disclosures create informed consent?

Disclosure for the Pfizer vaccine have no doubt been parsed by doctors and lawyers within and without the company and government. In one place, the disclosure says, “There is a remote chance that the Pfizer-BioNTech COVID-19 Vaccine could cause a severe allergic reaction.”

Do the words “remote” and “severe” inform or obscure? “Remote” seems to connote, “too small to worry about,” while “severe” represents an adjective so squishy that it overwhelms the noun it modifies.

Is the disclosure therefore a loaded phrase? Would we say, for example, that for otherwise healthy people under the age of 30, there is a “remote” chance that catching COVID will result in “severe” illness?

Pfizer has hard numbers from its clinical trials. Would its disclosures be more informative if they recited these numbers?

Relying On Someone Else

Of course, most people don’t read the disclosures carefully. And many people, if they tried, might not know what to make of them.

We would expect pharmacists and physicians, however, to parse vaccine disclosures the way accountants review financial statements. With 9 out of 10 pharmacists, and 7 out of 8 physicians apparently expressing no hesitancy over the vaccine, the holdouts among their peers may simply represent the most cautious, rather than the best informed.

Still, it would be desirable if the hesitant explained their reasoning without fear of ridicule or retaliation. In medicine, as in other fields of science, minority views have been proven right often enough that they should be encouraged.

Lack of thoughtful discussion also yields the floor to the cranks, while feeding their claims of conspiracy or cover-up.

An Erosion Of Trust?

Survey data generally shows that among healthcare workers, vaccine hesitancy is greatest among lower-ranked, lower-paid staff. A Harvard Health Blog contributor cites staff’s lack of trust in the healthcare system as the prime cause of vaccine hesitancy.

This lack of trust should concern everybody. What staff knows that we don’t are the everyday workings of the healthcare system. What does it say about the system if the people working in it don’t trust it?

In addition, trust drives motivation. How well do unmotivated employees do their jobs? If a significant percentage of healthcare workers won’t avoid spreading a deadly virus by getting vaccinated, how well can we expect them to perform mundane-but-critical tasks like washing their own hands or sterilizing equipment and surfaces?

When Employers Can Mandate Employee Vaccination

We seem to be moving towards mandated vaccinations. Generally, employers may require vaccinations which are job-related and consistent with business necessity, assuming exceptions exist for religious and medical reasons.

Increasingly, not just employment but access to education, and freedom to engage in everyday commerce may require COVID vaccination. And short of mandates, onerous testing or other requirements may achieve a similar result.

An open question is how many healthcare workers will quit rather than submit. Follow-on questions include how much further trust will erode among those who submit, and how such erosion will impact our healthcare system.

“Can We Get Serious Now?”

In the movie, “Sully,” an airline pilot has his split-second emergency decisions picked apart in leisurely hindsight by a committee. He finally retorts, “Can we get serious now?”

The COVID pandemic and its consequences are serious. Large numbers of unvaccinated healthcare workers represent a paradox, as well as a public-health challenge. But simply treating them like nails to be hammered down may do more harm than good.

There seems to be a trust gap in healthcare as well as a vaccination gap. Each needs to be addressed in light of the other.