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Ethics Talk: COVID-19 Vaccine Hesitancy in the Health Care Workforce

Learning Objective
Identify key ethical values or principles at stake, as described in the program
0.25 Credit CME

In this video edition of Ethics Talk, journal editor in chief, Dr Audiey Kao, talks with Dr Arthur Caplan about hesitancy among US health care workers to take COVID-19 vaccines.

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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more

Video Transcript

Tim Hoff: [bright theme music] Welcome to another special edition of Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff. This episode is an audio version of a video interview conducted by the Journal's Editor in Chief, Dr. Audiey Kao, with Dr. Arthur Caplan. Dr. Caplan is Head of the Division of Medical Ethics at NYU Grossman School of Medicine, and he joined us to talk about hesitancy among U.S. health care workers to take COVID-19 vaccines. To watch the full video interview, head to our site, JournalOfEthics.org, or check out our YouTube channel.

Dr. Audiey Kao: Art, welcome back to Ethics Talk. [music fades out]

Dr. Arthur Caplan: Thank you for having me.

Kao: So, despite their increased occupational risk, upwards of 40 percent of health care workers in some hospitals have chosen not to be vaccinated against COVID-19. It may be that some are distrustful, skeptical because the vaccines have only been authorized by the FDA for emergency use. Can you help our audience, some of whom would not hesitate to get the COVID vaccine, understand why some health care workers would choose not to get vaccinated?

Caplan: Well, Audiey, let me begin by saying I am strongly pro-vaccination, and I myself have had at least my first shot. So, I'm absolutely in the camp that says vaccination against COVID is the prudent thing to do. That said, we have done studies at NYU of vaccine resistance prior to COVID—flu vaccine, other vaccines—and we found some patterns that extend into COVID. Women in the workforce, health care workers, tend to be worried about fertility and pregnancy. They just worry about it. It's understandable that they're concerned, and they are. They say these vaccines have not been tested adequately on pregnant women. I think still, we know it's better to get vaccinated against viral diseases when you're pregnant than not because it can harm the fetus. But nonetheless, that's a concern.

You also see people saying, “Look, I'm not in need of a vaccine. I've been exposed to the flu. I've been exposed to COVID. I'm a frontline worker. It's probably my fifth exposure. I'm sure I have antibodies.” Well, they don't actually know whether they've been exposed. They haven't been tested, and they don't know how long the antibodies might last. Vaccines would still be prudent. But there is this line of thinking, by the way, you also see it among first responders, firemen, and police.

The last reason, interestingly enough, that we hear is that the vaccine was rushed. You don't get that as much on flu, but you do get it with COVID. People hear “Warp Speed,” they hear that the president pushed to get these vaccines approved and was trying to arm twist, and they don't like that. They worry that corners were cut, studies were stopped prematurely to give emergency use, and it makes them nervous.

Kao: So, reflecting on what you just said, it seems that no one is immune to bad information, even among highly-trained health care professionals. Given that the public relies on the advice of professionals like physicians and nurses, how should health professions such as nursing and medicine address vaccine hesitancy among its members?

Caplan: Well, I think you're right. Bad information is out there, incomplete information. And sometimes it's stoked up by people who've made a career out of opposing all vaccines. They're all over the Internet, too. I don't think the health care workforce is as amenable to anti-vax propaganda, but, you know, it's omnipresent. So, it could be corroding some of the trust that health care workers have in vaccination. So, I think there are some things that can be done, though.

First, I do think institutions need to spend more time educating the health care workforce, not assuming that they're going to know what's best: more webinars, more seminars, more educational activities, and outreach to say, “Here's what we know, here's what we don't know, but this is why we're certain that vaccination is better.”

I also think it's important to monitor the social media, anti-vax websites just to see what's going on out there. And I think professional organizations, Infectious Disease Society, AMA, any number of groups that, American Academy of Pediatrics, that people turn to for reliable information, they should say, “We've seen, for example, a lot of stuff on the Internet about fertility, and it's bogus. There's nothing to worry about. The current vaccines aren't going to get in your DNA. They can't modify anything in your embryo or your child.” It may seem unnecessary to say that, but it is necessary to say that.

And I think using spokespersons that can appeal to communities that are concerned. What I mean there is if you have a strong minority workforce, getting the right spokesperson to speak up and address concerns that might be there, not because they're different, but just because there's more trust sometimes in someone who seems to be a peer than someone who seems to be perhaps—and I'll indite myself here—a gray-bearded old expert telling you what to do. So, sometimes peer to peer, age group to age group, culture to culture, diversity to diversity, I think that helps get the message listened to.

Kao: Yeah. So, at a time when we need all hands on deck in dealing with the devastating health impacts of COVID-19, firing health care workers who refuse to get vaccinated because of violating terms of employment would have serious unintended consequences. So, how should employers like hospitals and long-term care facilities that need to establish a safe work environment address health care workers that, as you alluded to earlier, is a diverse group of people with different backgrounds and experiences with the health care system? How do we address those who do not want to get vaccinated?

Caplan: You know, it's a great problem, and I'm glad you brought it up. There are small numbers of people who even worry about things like are vaccines acceptable to vegetarians? Are vaccines acceptable because maybe they have fetal cells in them? And you hear some religious objection or pork products, I've heard. So, these are tiny, tiny percentages of people. But nonetheless, how you respond to them becomes important, both because others are watching, and, as you said, Audiey, you don't really want to lose workers from the workforce. So, I think what you need to do is make it clear first, that you do expect people to get vaccinated. That should be the default. The burden is on those who don't want to, to say so and to explain why. At NYU, we require people to go through compulsory education, not firing, but we make you go to seminars, try to address your concerns, explain issues like is there meat products or pork products in the vaccine, that sort of thing to clear away any doubts. We may have religious figures, rabbis, priests, explain why vaccination is a duty, which nearly every religion sees it as. So, that education can really help.

It is possible sometimes to move workers so that they can mask and still work. It is possible sometimes to accommodate them by taking them into different environments. We even occasionally see some remote work, telling people work from home until this is over, but don't disappear on us. So, obviously, firing, you know, it's a last resort. You don't really want to do it. You try to accommodate. You try to educate.

Kao: So, given that, what do you think about reports that some hospitals are paying their workers to get vaccinated against COVID-19?

Caplan: This is another really, it's a great, timely question. Because places are already doing it. I've seen institutions in the Houston, Texas area offering as much as $500 to get vaccinated. I keep thinking, I got to get down there and bring a couple of my pals. That's a very high compensation! I understand why people want to do it, but I think it's a bad idea. I think anti-vaxxers will quickly say, “If you have to pay people large amounts of money to get vaccinated, how safe can they be?” I think it undercuts trust. It looks like something that might be an incentive, but it can easily be turned on its head. I'm all for giving people some free days off post-vaccination to recover if they get a sore arm or fatigue. I don't think that should be charged against their sick days or family time. That seems reasonable. Occasionally, you do see people saying something like how about a ticket to get lunch? We used to do that in the olden days of trying to encourage vaccination. Nothing changed there. But big money payouts, I think, are going to actually undercut trust more than they help.

Kao: So, as we near the end of our conversation, I wanted to get your thoughts about potential vaccine hesitancy among workers that come from minority populations that have had a history of distrust with the health care system. How do you think we should specifically address that important group in the health care workforce?

Caplan: Well, there certainly are groups that have higher rates of hesitancy just in the general population: African-American community, some Native Americans, too. Not so much present in the Hispanic community. But be that as it may, wherever the resistance is, the first way to cement trust is to admit that there has been problems in the past that have extended right into the present. Occasionally, people will say to me, “Well, African Americans are concerned because they know about the Tuskegee study,” where cures were deliberately withheld from African-American men, and they were lied to. And there may be concerned about that. But I believe that it's just as concerning to the African-American community that they didn't have any health care in their neighborhood yesterday, or that it was hard for them to get primary care access in poor neighborhoods. And we should admit that.

Somebody may be thinking, yeah, now that you're worried about me giving COVID to you, all of a sudden you're concerned that I get vaccinated. Whereas last year, you didn't care if I couldn't get my medicine, or I couldn't get an obstetrician to help my pregnant wife or whatever. So, we have to be honest and say, “System's been unfair. There have been wrongs.” Acknowledge that.

I think also it's important to say, “You have greater exposure because of the nature of your work and employment.” There are people who go in and clean the ICU and the surgical suites. They're getting exposed more, and they need more protection. It's not just me trying to protect myself. It's really trying to protect you.

And the third factor is, look, we don't want to be racist. I don't think there's any data that says any ethnic group is more prone to getting COVID. What I think we see is poor people are more prone to getting COVID because they have bad health care. And that turns out frequently to associate or correlate with minority status. It is poverty. And we're reaching out. We're making it free. It's a good thing. We acknowledge the fact that poverty drives risk, and we're going to try and do something about it with COVID.

Kao: So, with that, I want to thank Dr. Art Caplan for sharing his insights with our audience today. Art, thanks again for being a guest on Ethics Talk.

Caplan: Thank you so much. It is a pleasure. And thank you for having me again.

Kao: For more COVID ethics resources, please visit the AMA Journal of Ethics at JournalOfEthics.org. And finally, to our viewing audience, be safe and be well. We'll see you next time on Ethics Talk. [bright theme music plays]

Video Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .25 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

If applicable, all relevant financial relationships have been mitigated.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Enduring Material activity for a maximum of 0.25  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 0.25 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 0.25 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 0.25 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 0.25 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 0.25 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.


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