Nurses' Ethical Obligations Toward Unvaccinated Individuals.

Abstract

Simon is a nurse in the COVID-19 intensive care unit (ICU). The unit’s census has been steadily increasing, and the unit has been short-staffed because many nurses have decided to resign, citing burnout. During shift report, he notices that vaccination status is usually mentioned in the one-liners nurses use while presenting their patients (eg, “This 56-year-old unvaccinated patient was admitted with COVID-19 pneumonia …”). He has also noticed an increase in frustration among his peers, especially toward patients who are admitted with COVID-19 and are not vaccinated. At the nurses’ station, he has heard his colleagues speaking negatively about unvaccinated patients and their families, expressing dismay over the patients’ “choice” not to get vaccinated, and the burden the nurses believe this choice is placing on the health care system. Simon is concerned that the quality of care received by unvaccinated individuals may be worse than, or different from, the quality of care received by vaccinated individuals, because of clinicians’ frustration about the perceived personal choice not to be vaccinated.As the COVID-19 pandemic surges again across the United States, nurses are being confronted with ethical challenges that did not arise during previous waves. In particular, although nearly 60% of the US population has been vaccinated, most patients being admitted to hospitals with COVID-19 are unvaccinated and are more susceptible to severe disease, at times requiring critical care.1 In this article we first review the current status of the COVID-19 pandemic and vaccine rollout. We then discuss the challenge of nurse burnout and the related issue of moral outrage, which have been widely covered as the pandemic has continued. In this context, we review the ethical question Simon raises and the related ethical obligations he and his nurse colleagues might consider when caring for this patient population.As of September 2021, COVID-19 had killed 1 in 500 Americans.2 Although death rates are highest among people older than 85 years, the pandemic has simultaneously and disproportionately affected other vulnerable populations, in particular communities of color.3 Among younger individuals (aged 40-64 years), the pandemic has killed 1 in 480 Black Americans, 1 in 390 Hispanic Americans, and 1 in 240 Native Americans. These numbers stand in contrast to the 1 in 1300 white or Asian Americans in the same age range.2In December 2020, the US Food and Drug Administration approved COVID-19 vaccines for emergency use. By October 2021, more than 6 billion doses of the vaccine had been administered across 184 countries, including 397 million doses in the United States.4 Despite initial concerns about limited supply, vaccines are now widely available in the United States. However, equity concerns, which initially focused on the virus’s effects on morbidity and mortality, persisted as mass vaccination began, and disparities in vaccination status are becoming evident. The Centers for Disease Control and Prevention report that non-Hispanic Black Americans are currently the least-vaccinated group of Americans: only 32% of Black Americans have been fully vaccinated, compared with nearly 40% of white Americans, a trend that has persisted as vaccination efforts have increased.5 Early interventions focused on education and targeted demographic groups that may be vaccine hesitant, including Black and Latinx populations, in order to avoid the disparity in vaccination rates we are now experiencing.As the vaccine supply became more abundant, however, strategies shifted from education and “nudges” to vaccine mandates across the United States and worldwide.6 As mandates were issued nationally and internationally, media coverage increased about the seemingly growing groups of protesting “antivaxxers.”7 Much of the “antivax” rhetoric has been fueled by disinformation spread on social media and by conspiracy theories widely circulated as factual information.7 Indeed, a small but notable portion of antivax activity has even involved nurses protesting hospital vaccine mandates.8 Many of these nurses have been terminated by their employers, or will face termination, for refusing to comply with mandates. This refusal has the potential to worsen hospital staffing, which is already dire in certain parts of the country.In this context, public health messaging has continued to emphasize the importance of being vaccinated, with government officials calling COVID-19 a “pandemic of the unvaccinated.”9 Although this framing probably was meant to highlight the risk that unvaccinated individuals face, it also had the unintended consequence of stigmatizing unvaccinated people.9 This stigmatization may have contributed to a dynamic in which people who might have eventually considered getting vaccinated felt judged and, as such, became unwilling to engage in further conversation about the issue.Further, there has been discussion about whether crisis standards of care algorithms, designed to provide guidance for triaging scarce resources, ought to incorporate vaccine status into triage scoring metrics.10 Original crisis standards of care guidelines, issued during the first wave of the pandemic, have been widely criticized for their potential to worsen existing inequities.3 Given existing disparities in vaccination status, it stands to reason that considering vaccination status in crisis standards of care guidelines could worsen this problem.In addition, media coverage has highlighted providers who have opted to stop serving unvaccinated patients in their clinics. Some have argued that this practice is an ethically supportable one if the rationale is to protect members of the health care team and other patients who may be exposed.11 However, patients with limited access to preventive care (which increases the likelihood that they will be unvaccinated) may have few opportunities to engage with care and information that could change their mind about vaccination. The practice of refusing to serve unvaccinated patients may also be a sign of growing exhaustion and burnout among clinicians.Amid the vaccine rollout and the pandemic’s impact on health care and public life, mental health effects on clinicians, especially nurses, have become evident. It is still too soon to quantify fully the pandemic’s lasting effects on the nursing profession, but burnout in nursing was a significant source of attrition before the pandemic, with nearly a third of nurses reportedly leaving their most recent job because of burnout.12Burnout has been defined as a constellation of symptoms: exhaustion, depersonalization, and a reduced sense of personal accomplishment.13 The experience of burnout can result in various physical and psychological symptoms or manifestations, including frustration, anger, anxiety, unprofessional actions, a lack of empathy, exhaustion, fatigue, and insomnia.13 Burnout often occurs with secondary traumatic stress, which is “a gradual reduction in compassion over time that results from a cumulative and persistent desire to help suffering patients.”13(p1416)Given the prevalence of burnout among nurses and other clinicians before the pandemic, the effects of COVID-19–specific challenges such as personal protective equipment shortages, limited family visitation in the inpatient setting, the potential need to ration scarce resources, and staffing shortages have probably amplified the problem.14 This confluence of events has, unsurprisingly, led to widespread calls for urgent intervention for clinicians on the pandemic’s front lines— clinicians who are reporting increasing frustration and even anger about the ongoing pandemic and specifically about people who remain unvaccinated despite robust safety and efficacy data.15,16 In a recent survey by the American Association of Critical-Care Nurses, 92% of nurse respondents believe that the pandemic has depleted nurses to the point where they believe their careers will be shortened, 66% have considered leaving nursing as a result of the pandemic, and 76% view unvaccinated patients as a threat to their own well-being.17 As one clinician wrote: The anger that many clinicians are now experiencing can be described as moral outrage,18,19 or “justifiable anger, disgust, or frustration directed toward others who violate ethical values or standards.”18(p536) At the beginning of the pandemic, there was widespread optimism that the pandemic would end when a vaccine became available and that things would return to normal. This hope allowed many clinicians to push through the initial phases of the crisis. Now that a safe and effective vaccine is available, nurses may view vaccine refusal as an affront to their hard work and sacrifice during the pandemic, particularly in light of the tragedies and challenges nurses have experienced at the bedside. Anger is a natural and in fact expected reaction to a violation of one’s ethical values.18 Anger can, however, also heighten clinicians’ experience of burnout and related sequelae and can limit their capacity for empathy, thereby detrimentally affecting patient care.Interventions are necessary on a wide scale in order to address both the deleterious effects of unmitigated burnout and the public health consequences of the complicated vaccine roll-out. It is also important to critically assess our assumptions as clinicians. Just as COVID-19 has disproportionately affected certain vulnerable demographic groups, multiple factors including social determinants of health may also impact whether or not a person choses to be vaccinated. As such, a one-size-fits-all approach is insufficient to fully understand and address vaccine hesitancy.Though it may seem that antivaccine sentiments have been on the rise since COVID-19 vaccines became available, the “antivax movement” has existed since vaccines were first developed.20 The modern antivax movement, however, was especially fueled by unfounded assertions regarding vaccine safety, such as the widely publicized, and disproven, claim by former physician Andrew Wakefield that certain childhood vaccines are linked to autism spectrum disorder.20,21 Although Wakefield’s study was ultimately debunked and retracted from publication, the damaging impact had already taken hold among members of the public.21 Antivaxxers are a demographically heterogenous group, but data show that countries with a high gross domestic product, such as the United States and Britain, tend to have higher levels of vaccine refusal.20 In particular, children’s vaccines are more likely to be refused by mothers who are wealthy, highly educated, white women.21 Members of the antivax movement often identify their position as a personal or political choice, or both.22 In particular, the right to refuse a vaccine may be considered an exercise of individual liberty or an act of defiance or resistance against government mandates.Not all people who are unvaccinated fall into the antivax category, however. As many authors have noted, a large proportion of unvaccinated individuals are instead “vaccine hesitant” (Table).23 Vaccine-hesitant individuals do not necessarily identify with the antivax movement; instead, they are disproportionately people of color who may have, as a function of structural racism and other social determinants of health, limited access to preventive care or to trusted medical professionals with whom they can discuss their concerns.23 Communities of color face significant provider shortages—they did so even before this pandemic—which have only worsened the issue.2 The consequences of such structural issues are evident in the lower vaccination rates among people of color, especially Black Americans.5Individuals who are vaccine hesitant may not worry about a vaccine’s safety or efficacy per se, but they may experience barriers to accessing the vaccine despite its widespread availability. For example, essential workers, a large proportion of whom are people of color, may not be able to miss work for appointments or if they feel unwell after receiving the vaccine.23 Others may be unable to find childcare or assistance caring for aging family members. Language barriers or concerns about deportation among undocumented individuals might also make accessing the vaccine more challenging.2Given these important distinctions, it is evident that people who refuse vaccines are not a uniform group. In any given patient care situation, clinicians cannot know whether social determinants of health, structural inequity, or institutional racism (or all 3) may have affected a patient’s choice to be vaccinated or not. Disparate treatments at the point of care have the potential to worsen the aforementioned disparities, which the COVID-19 pandemic and the vaccine rollout have exacerbated. As such, it is critical that Simon and his nursing colleagues examine their professional ethical obligations as they care for this complex patient population.As Simon considers how to address his peers’ attitudes toward unvaccinated patients in the COVID-19 ICU and potentially disparate levels of care, he may be guided by several nursing-related policy statements and codes. For example, as outlined in the American Nurses Association (ANA) Social Policy Statement, the nursing profession’s obligations are not only to protect, promote, and optimize health; to prevent illness and injury; and to alleviate suffering, but also to advocate for those they care for, whether individuals, families, communities, or populations.24 As such, nurses are expected to use their theory- and evidence-based knowledge to carry out nursing interventions, with the aim of promoting beneficial effects and quality outcomes for those in their care. This policy statement further describes the social contract that exists between the nursing profession and society as one in which society trusts the nursing profession to conduct its own affairs, and in return, the nursing profession is expected to act responsibly, keeping in mind the public’s trust.24Delivery of care, as outlined in the ANA Social Policy Statement, relies on nurses who are guided by an established professional code of ethics that defines what beneficial or “good” care looks like. Several provisions of the ANA Code of Ethics for Nurses inform what good care might entail when provided by Simon and his colleagues. The first provision of the ANA Code of Ethics calls on the nurse to practice with compassion and respect for the inherent dignity, worth, and unique attributes of every person.25 On the basis of this provision, all individuals—whether vaccinated against COVID-19 or not—can expect nurses to provide care that incorporates the individual’s values, preferences, or unique situation within society. Furthermore, this provision requires the nurse to give attention to the full range of human experiences and responses to health, and to respond with an attitude of respect toward both those who hold to anti-vax preferences (even if the nurse does not agree) and those who are vaccine hesitant. In addition, this provision may inspire Simon and his colleagues to delve into the narratives of their unvaccinated patients in an effort to understand what factors may have affected the patients’ decisions regarding vaccination. In some instances, especially for those who are vaccine hesitant, misinformation or misperceptions can be corrected when they are discussed with a trusted health care professional.The obligation for Simon and his colleagues to address the culture of blame toward those who are unvaccinated is highlighted in provision 6 of the ANA Code of Ethics for Nurses. This provision calls on the nurse to be involved, through individual and collective effort, in improving the ethical environment of the work setting and promoting conditions that are conducive to safe, quality health care. Shift report is one example of when a cultural shift away from blaming unvaccinated patients might take place. The everyday practice of shift report involves nurses sharing relevant details pertaining to a patient’s care; however, it is also a time when they share opinions and impressions that, if not ethically grounded, can lead to disrespectful communication and blame.26 One action Simon and his colleagues could take is to remove the word unvaccinated from their descriptions of patients during shift report; repeatedly modeling this change might begin to change the unit’s shift report culture. Although describing a patient as unvaccinated is likely meant to convey potentially relevant clinical information about the patient’s history, this framing could create biases that may affect providers’ perspectives about the patient.27 Simon could go a step further and intentionally explain to his colleagues the detrimental impact of highlighting a patient’s unvaccinated status during shift report. He could take a similar approach when he hears negative conversations about unvaccinated patients at the nurses’ station. A more collective approach might be to enlist the support of the unit manager, the unit educator, or a member of the ethics consult service who could help facilitate a formal discussion about ethically informed attitudes toward unvaccinated patients during a planned staff meeting. It is important to acknowledge that instances may occur where knowing or discussing vaccination status is clinically relevant, and during such conversations, paying particular attention to biases and unfounded assumptions may be helpful.When considering how to address attitudes toward unvaccinated patients, Simon and his colleagues might also keep at the forefront provisions 8 and 9 of the Code of Ethics. These provisions call on the nurse to take the lead on issues of public health and to collaborate with other health professionals to address health disparities, which includes helping to change unjust structures and address social justice issues.25 The disparate impact of COVID-19 on communities of color is one such issue. Successful collaboration requires responding to diversity by recognizing and adapting the nature of working relationships with individuals, populations, and other health professionals and health workers.24 These provisions also prompt consideration of how social determinants of health—non-medical factors that affect health outcomes, such as where people live, work, and age—impact decisions that patients make in terms of vaccination status. Because nurses working in the COVID-19 ICU may not understand the potential impacts of social determinants on vaccine decision-making, Simon could help them “connect the dots” between issues such as public education, housing, urban development, and vaccination tendencies.28 If time and interest allow, Simon might advocate beyond his ICU by serving on local, state, or federal commissions that draft policy and legislation to address social determinants of health.28Finally, it is critical that Simon and his colleagues have outlets through which they can express and reflect on their anger and moral outrage—for example, facilitated discussions, opportunities for reflective practice, and debriefing sessions, such as those offered through Schwartz Rounds.29 Some authors have argued that moral outrage can be a catalyst for change.18 The American Association of Critical-Care Nurses recently launched the Hear Us Out Campaign, which is a “nationwide effort to report nurses’ reality from the front lines of the COVID-19 pandemic and urge those who have yet to be vaccinated to reconsider.”17 Engagement in campaigns such as this may help Simon and his colleagues feel as though they have a productive outlet for their anger. Other nurses have attempted to engage in public discourse through writing opinion pieces and by sharing their experiences on social media.It is natural and understandable that, facing burnout and exhaustion, Simon and his colleagues are frustrated and morally outraged. The demands on nurses and other frontline workers have been unrelenting since the spring of 2020 and have recently worsened because of slow vaccine uptake in many communities. Vaccine refusal is a complex issue that is affected by a variety of factors including socioeconomic vulnerability, structural racism, and other social determinants of health. Although the decision to be vaccinated is indeed a personal one, factors outside of an individual’s control may impact their agency in making this decision. Nursing’s codes of ethics and related policy statements are not a fix for this challenge, but they serve as helpful reminders of our professional obligations, and they call on us to examine and reflect on our frustrations and to consider proactive and productive ways of addressing vaccine refusal.