COVID-19 Vaccination: Ethical Considerations

Jan 13, 2021

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As more COVID-19 vaccines become available for healthcare workers, nurses may want to seek guidance in deciding whether to receive the vaccine. Gathering information from reliable resources and considering the ethical elements involved can help ensure that your decision reflects your knowledge and values.

AACN President Elizabeth Bridges spoke with Christine Grady, a nurse bioethicist and a senior investigator who currently serves as chief of the Department of Bioethics at the National Institutes of Health Clinical Center, about the ethical considerations involved in making decisions about COVID-19 vaccination, including the hospital's obligations and relevant provisions from the Nursing Code of Ethics. View the video and the transcript below. You can also review “AACN Statement on COVID-19 Vaccination”.

Liz Bridges: Hi, I'm Dr. Liz Bridges. I am the current president of the American Association of Critical Care Nurses. I'm pleased to be here today to talk about ethical considerations for the COVID-19 vaccine, with my colleague, Dr. Christine Grady.

Dr. Grady is a nurse bioethicist. She's a senior investigator at the National Institutes of Health, and she currently serves as the chief of the Department of Bioethics at the National Institutes of Health. Dr. Grady's work is predominantly related to ethics and clinical trials, and also the ethics of clinical care specifically as related to nursing. So we're very pleased to have you here today, Dr. Grady.

Christine Grady: Thank you, Dr. Bridges. It's a pleasure to be here. Thank you for inviting me.

Liz Bridges: So as a nurse and a bioethicist, I'm sure the pandemic has... I know the pandemic has had you in overdrive about the huge number of ethical issues that nurses are facing. As we are now in the initiation of vaccinations, what are some of the key ethical issues that you think healthcare organizations will face as related to the vaccines?

Christine Grady: Healthcare organizations of course have to figure out the who, what, when, where, and how of vaccinating employees and patients eventually. I think ethically the complicated place that we're beginning is because there is insufficient amount of vaccine for everyone who might appropriately be vaccinated. As many of you know, there've been a number of groups who have spent some time over the last several months – including the National Academy of Science and Engineering and Medicine, the Advisory Committee on Immunization Practices that advises the CDC, the Strategic Advisory Committee of Experts for the WHO, and a number of academics – to sort out a framework for ethically allocating vaccine, appreciating or anticipating that at the beginning, we won't have enough.

Christine Grady: They all sort of agree on the main values, which is kind of interesting, the main values and goals of ethical allocation. That the primary value should be maximizing benefit. Reducing disease, reducing serious disease, but that that's not the only principle or value. The other ones are making sure that we pay attention to how to keep society running in ways that preserve function. Another one is paying attention to equity, and the kinds of disadvantages that are showing up, and how we can address or mitigate them in terms of allocating vaccines. All of these are really important and very useful values that guide the determinations that healthcare organizations are going to have to make, or are making. It's interesting too, though, that it doesn't stop there.

Christine Grady: Once you say “maximizing benefit,” who comes to the top of the list are healthcare providers. And especially health care providers who have contact, direct contact with patients who are in high risk occupations in terms of their contact with patients, maybe exposure prone procedures, and activities. Critical care nurses are way at the top of that list. Healthcare organizations have to make further granular decisions about, okay, among the healthcare workers that work in our institutions or institution, how do we prioritize them? Who gets the top priority? How do we roll this out in a fair way, over time as more vaccine becomes available? How do we protect the staff that we have, and give them the option of volunteering to be vaccinated?

Liz Bridges: I think it's an interesting point about the transparency of those decisions as well, that individuals see, not only on a national level, but at an organizational level, how those decisions are being made. One of the things you mentioned is, is that the frontline healthcare providers are going to be... Are now already being vaccinated. But we know from surveys that providers, both nurses and physicians, that they have legitimate concerns about the vaccine. So what are some of the ethical considerations that nurses need to ponder as they make their choices about receiving the vaccine?

Christine Grady: That's a wonderful question, because I think as we all know, I mean, nurses are so essential to the response, to this pandemic in so many ways. Although nurses are very highly respected profession all the time, I think this year, people have begun to really appreciate the value of having nurses in various places. Nurses are at the frontline and they should be at the front of the line for vaccines as well. And yet there are data that show that nurses, as well as other healthcare professionals, and members of the public, are hesitant to take vaccines.

When asked further why they didn't want to, or they weren't so sure about it, they said they had a very low level of confidence in the process, and confidence in the science. They were also were concerned about the speed with which things have occurred. You asked, what do individual nurses, how should they consider the ethics of deciding for themselves whether to get vaccinated? The first thing I think nurses need to think about is, why are we at the front of the line? We're at the front of the line because we're in positions where we are exposed, not all of us, but many of us, exposed to risks in our profession, and we are needed. We're needed to respond to the patient care needs in this pandemic and many other things that nurses are doing.

Secondly, I think that we should all appreciate the benefits of getting vaccinated. The benefits of getting vaccinated are: it reduces COVID disease and including severe disease. So that's really important. Secondly, it's certainly a lot safer than getting infected with the virus itself and getting sick from the virus itself. And third, it's a way to contribute to resolving this pandemic, both for ourselves, for our families, for our friends, for our patients and for the society at large. So those are really three really important things that nurses should keep in mind. Then nurses like everybody else, need information. They need information in order to make an informed decision about whether or not to take a vaccine. And that information should include things about the process by which these vaccines were developed. The research studies that were done. Nurses need information about what those data are, how they were granted an emergency use authorization, what an emergency use authorization means, what the side effects or a lack of serious side effects that the data show, but that both of these vaccines are reactogenic, and what that means. Then in the end, each person, each nurse makes their own choice about whether or not to get vaccinated.

Liz Bridges: I think one of the most important things you've said there, and the theme that seems to run through that is nurses are evidence driven. And this is yet one more place where we need to make sure that we continue that evidence driven practice, not only for our patients, but for our ourselves and to hold it to the same standard that we do for any other clinical decision, or clinical practice, albeit that this one is a very personal decision.

Christine Grady: Absolutely. I can't agree more with you.

Liz Bridges: So can you talk a little bit about how we need to think about applying the code of ethics during the COVID pandemic, as it applies particularly to the vaccinations?

Christine Grady: I think the ANA code of ethics for nurses really provides very valuable guidance for nurses about their ethical responsibilities. As everybody probably knows, there are nine tenets in the most recent version of the ANA code for nurses. I think all of them apply in a certain way to this understanding of how you respond in a pandemic and whether or not, and how you decide about taking a vaccine. But I think there are two in particular that speak to this directly. And that's number four and number five. Number four, I'm just going to read them just so... Because I think it's helpful to think about them. Number four says, "The nurse has authority, accountability, and responsibility for nursing practice. Makes decisions and takes action consistent with the obligation to promote health and to provide optimal care." There is a way in which getting vaccinated so that you can be safe in your own profession, in your own job, and in your own life fulfills this commitment that's in the code for nurses.

Next one, number five also speaks to this I think. And number five says, "The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence and continue personal and professional growth." So in duties to self. We have a responsibility to ourselves to protect ourselves from getting sick, from spreading virus, from being unable to take care of our patients or our families.

Liz Bridges: So, Dr. Grady, as we think about moving forward, is there any other additional guidance you have for nurses as they weigh the risks and benefits of vaccination against COVID-19?

Christine Grady: I think we've already said it, is each of us needs to keep our own well-being at the forefront, and that's really important. We can't take good care of patients if we don't take good care of ourselves. And in order to do that, we need to make informed decisions about vaccination. We need to know the evidence, we need to know our own situations, and we need to make informed decision. A third thing that I would say, and I'm not sure we mentioned it before is I think we need to keep in mind that nurses have a lot of respect in society. People respect nurses very highly, and trust them. Therefore we're in a position as nurses to help others understand what's going on. We always need to remember that our words and our actions really matter. We can counter some of the scientific misinformation or false information. We can offer people resources and ways to find information. And those, not only patients, but families, and friends and others that we encounter so that others can also make informed decisions about vaccinations for themselves.

Liz Bridges: So let me ask you the last question. When it is your turn, will you be receiving the vaccine?

Christine Grady: I will, absolutely.

Liz Bridges: Me too. I will be right there in line. Absolutely. Dr. Grady, I want to thank you for taking time out of your busy schedule, but I think also for bringing us yet one more source of evidence and a framework to think about this experience that we were all going through, and to help nurses make some decisions about how they're going to proceed with the vaccine.

Christine Grady: Thank you very much for asking me to speak with you. I hope that every nurse has the information and the support that they need to be able to make a good decision.