Vaccine Mandates: My Evolving View on an Evolving Situation

By Sarah Delgado, MSN, RN, ACNP Sep 30, 2021

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I described vaccination as an autonomous decision and stated, “Ultimately, this is an individual decision."

In my first blog on COVID-19 vaccines in January 2021, I described vaccination as an autonomous decision and stated, “Ultimately, this is an individual decision. The most important opinion is your own, and in the swirl and stress of this moment, make sure that your decision aligns with what you know and what you value.” The context in which I wrote those words was very different from our present circumstances. The rapid spread of a more contagious variant of the virus and the data from more than 175 million vaccine recipients have created a new set of circumstances. So, my view has also changed.

Rather than seeing vaccination as a purely individual choice, I support AACN’s recent statement that healthcare organizations should require all employees, and credentialed and contracted providers to be vaccinated against the virus that causes COVID-19. This position also aligns with a joint statement from more than 80 professional organizations and with the actions taken by a growing list of hospitals and health systems around the country. In this blog, I’ll describe some of the specific reasons I previously felt vaccination mandates were not a good idea, and why my thinking changed.

It’s better to build trust

I don’t like mandates. In my 25-plus years of nursing (and in my life as a daughter, spouse, parent and friend) I’ve never found that telling people what to do builds a trusting relationship. The decision to get vaccinated is a healthcare decision, and decisions about health are best made in the context of a trusting relationship between patients, families and their healthcare team. The patient and family are experts in their wishes, goals and beliefs, while the healthcare team brings expertise in disease processes, health promotion strategies and treatment options. Bringing those elements together in a space that promotes active listening and respectful dialogue is the ideal strategy to ensure the best decisions are made. In my experience, it did not always happen that way — but when it did, I felt like I was the nurse I wanted to be.

Part of the problem with building trust as a strategy to increase vaccination rates is that the virus has created a time crunch. Unfortunately, this pandemic hit during one of the most divisive sociopolitical periods we’ve ever faced. In the time we spend addressing that divide, more people are becoming infected, more people are dying of COVID-19 and more nurses are exposed to untenable workloads. Our healthcare workforce is justifiably exhausted. Yes, we must work to build trust within our communities and our nation. In the meantime, we also need mandates to increase the number of people who have protection against illness and death from COVID-19. Increasing the vaccination rate means less chaos and fewer overwhelming challenges in our hospitals and health systems.

Is a mandate legal?

When the first vaccine was offered through Emergency Use Authorization (EUA), I wondered if it could be legally mandated. I knew, based on my experience as a nurse and as a parent, that hospitals and schools have routinely required vaccinations for many years. I needed to be vaccinated for hepatitis B to work in the hospital; my kids needed proof of measles vaccinations to attend kindergarten. But was it different because those vaccines had full FDA approval?

It turns out the answer is no. The U.S Equal Employment Opportunity Commission and the U.S. Department of Justice both offer the opinion that businesses can require their employees to get vaccines that have EUA approval. In June, a Texas court dismissed a lawsuit filed against Houston Methodist that challenged their vaccine mandate. While the FDA is still working through the process for full approval for two of the COVID-19 vaccines (the Pfizer mRNA vaccine is now fully approved at the time of writing this blog), it is important to note that the EUA process has its own level of rigor to ensure the benefit of receiving a vaccine exceeds its risk.

My Body, My Choice

The “my body, my choice” argument against mandates is compelling. Mandates feel like an infringement on our basic right of self-determination, and the belief that we have inherent rights as individuals is a founding principle of our nation.

I’ve struggled a bit with the ideal of self-determination because of an experience I had early in my nursing career, caring for a patient with lung cancer. The patient was deeply sedated, dependent on mechanical ventilation and seemed unlikely, in my view, to resume a high quality of life. I asked the patient’s spouse, “What would he say he wants?” and her deadpan reply was, “He would say he wants to not be sick.” I was humbled as I realized the profound impact of acute and chronic illness on a person’s self-determination. When we seek to promote a patient’s individual rights, we cannot ignore the context, and in particular the limitations imposed by the reality of a situation. Rather than asking my patient’s spouse, “What would he say he wants?” I should have asked, “Given the circumstances we face with this illness, what would he say he wants?”

Similarly, we cannot look at vaccination mandates without considering our present reality. We know the SARS-CoV-2 virus has developed at least one variant, delta, that is more contagious than the original version. We also know our healthcare workforce is experiencing high rates of stress and burnout from their extraordinary efforts to address this pandemic. Additionally, over 175 million people in this country are fully vaccinated, and reports of serious adverse reactions remain extremely rare. Our experience with the vaccines demonstrates that they are safe and effective. These circumstances are crucial when we consider the value of vaccine mandates.

Vaccines won’t stop the spread of the virus

Early on, when healthcare workers and older adults were receiving the first vaccinations, public health experts supported the continued use of masks. This advice was because clinical trials demonstrated vaccine efficacy in preventing severe illness but did not test the vaccine’s impact on viral transmission. Data published in March 2021 showed that vaccinated individuals were less likely to spread SARS-CoV-2. The CDC then advised that members of the community who were vaccinated could stop wearing masks.

That advice, however, did not hold once the delta variant became the predominant strain in the United States. Data collected in July 2021 showed that vaccinated individuals can carry significant viral loads when infected with that strain, although they are far less likely than unvaccinated individuals to get seriously ill or die from infection with any viral variant that causes COVID-19. So, the CDC reversed course and now advises that everyone, regardless of vaccination status, wear a mask in public indoor spaces in areas of substantial or high transmission.

So, just as we faced an evolving situation regarding the treatment of COVID-19 throughout 2020, we face an evolving situation with the delta variant. To make evidence-based decisions, we need to be willing to change our actions when the evidence changes. We know now that being vaccinated dramatically reduces the chances of becoming seriously ill, being admitted to the hospital or dying from COVID-19. And that data compels me to support vaccine mandates. In addition, vaccinations reduce the workload on nurses in this pandemic and therefore we need more people to be vaccinated. Because nurses cannot do more than they already have.

What can we do, aside from mandates to increase vaccination rates? Share your thoughts below.