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Should nurses take a COVID-19 vaccine?

  • Alan J. Kearns
    Correspondence
    Corresponding author: Alan J. Kearns, School of Theology, Philosophy, and Music, Dublin City University, All Hallows Campus, Dublin 9, Ireland
    Affiliations
    School of Theology, Philosophy, and Music, Dublin City University, Dublin 9, Ireland
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      Highlights

      • Uses a hypothetical example to discuss the issue as to whether there is an ethical requirement for a nurse to take a COVID-19 vaccine.
      • Utilizes the Principle of Responsive Adjustment to examine the hypothetical example.
      • Argues that although a nurse may not be morally responsible for infecting a patient, there would still be a moral expectation to take a vaccine.

      Abstract

      The issue as to whether health care professionals have a moral obligation to take a vaccine for a communicable disease is not new. Nonetheless, this issue takes on a fresh urgency within nursing practice in the context of the present COVID-19 pandemic, i.e., is there an ethical requirement for nurses to take a COVID-19 vaccine? This paper approaches the issue by using a hypothetical example of Nurse X who has inadvertently infected Patient Y. French's (1984a) Principle of Responsive Adjustment is adapted to claim that there would be a moral expectation that Nurse X takes a COVID-19 vaccine (unless there are justifiable reasons not to). The proposition is also made that, should Nurse X not take a COVID-19 vaccine, they could be morally associated with originally infecting Patient Y.

      Keywords

      Introduction

      SARS-CoV-2, and its resultant COVID-19 disease, has presented—and continues to present with its variants of concern—a major hazard to public health around the world (
      • Zhou M.
      • Zhang X.
      • Qu J.
      Coronavirus disease 2019 (COVID-19): A clinical update.
      ,
      • Shekhar R.
      • Sheikh A.B.
      • Upadhyay S.
      • Singh M.
      • Kottewar S.
      • Mir H.
      • Barrett E.
      • Pal S.
      COVID-19 vaccine acceptance among health care workers in the United States.
      ). The onset of the virus and its expeditious, widespread, infection of people has represented a climacteric event in the narrative of humanity. The present COVID-19 range of vaccines—as well as other potential vaccine candidates in the pipeline—offer a promising weapon in the public health fight against this virus and thereby providing a possible route back to some semblance of normality.
      The issue whether health care professionals have a moral obligation to take a vaccine for a communicable disease, as well as whether it should be mandatory, is not new. Nonetheless, this issue takes on a fresh urgency within nursing practice in the context of the present pandemic, i.e., is there an ethical requirement for nurses to take a COVID-19 vaccine? This question will no doubt retain its pertinence well beyond the conclusion of this present pandemic. This paper approaches the issue by using a hypothetical example of Nurse X who has inadvertently infected Patient Y.
      • French P.A.
      A principle of responsive adjustment.
      Principle of Responsive Adjustment is adapted to claim that there would be a moral expectation that Nurse X takes a COVID-19 vaccine (unless there are justifiable reasons not to)
      Medical grounds are generally included as reasons for refusing a vaccine. For instance, the

      Centers for Disease Control and Prevention. (2020). Who should not get vaccinated with these vaccines? Retrieved from https://www.cdc.gov/vaccines/vpd/should-not-vacc.html Accessed May 10, 2021

      outline a number of circumstances because of which a person should not obtain a vaccine such as their state of health. It provides a list of vaccines and circumstances in which a person should not obtain or should defer it. A common thread in the circumstances outlined by the Centers are significant allergic responses or when the person's immune system is compromised (https://www.cdc.gov/vaccines/vpd/should-not-vacc.html).
      The

      European Vaccination Information Portal. (2020). When to avoid vaccination. Retrieved from https://vaccination-info.eu/en/vaccination/when-vaccinate/when-avoid-vaccination Accessed May 10, 2021

      provides a list of situations where vaccines should not be used by a person due to, for example, significant allergic responses, or other problems in the person's immune system or as a result of medication or treatments that the person may be taking or undergoing (https://vaccination-info.eu/en/vaccination/when-vaccinate/when-avoid-vaccination).
      to prevent or reduce the possibility of infecting again. The proposition is also made that, should Nurse X not take a COVID-19 vaccine (unless there are justifiable reasons not to), they could be morally associated with originally infecting Patient Y.
      My interest here is in the philosophical idea of the Principle of Responsive Adjustment solely as a moral principle; this paper does not argue for French's positions on corporate responsibility.

      SARS-CoV-2

      SARS-CoV-2 is a highly infectious pathogenic virus that gives rise to the disease COVID-19 (
      • Boulton J.
      In search of a vaccine against COVID-19: Implications for nursing practice.
      ;

      European Centre for Disease Prevention and Control. (2021a). Questions and answers on COVID-19: Basic facts. Retrieved from https://www.ecdc.europa.eu/en/covid-19/questions-answers/questions-answers-basic-facts Accessed May 10, 2021

      ;
      • Zhou M.
      • Zhang X.
      • Qu J.
      Coronavirus disease 2019 (COVID-19): A clinical update.
      ). It is a virus that can be transmitted from one human being to another through respiratory secretions and droplets via coughing and sneezing, speaking and singing (

      European Centre for Disease Prevention and Control. (2021a). Questions and answers on COVID-19: Basic facts. Retrieved from https://www.ecdc.europa.eu/en/covid-19/questions-answers/questions-answers-basic-facts Accessed May 10, 2021

      ;

      World Health Organization (WHO). (2020). Transmission of SARS-CoV-2: Implications for infection prevention precautions. Retrieved from https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions Accessed May 10, 2021

      ;
      • Zhou M.
      • Zhang X.
      • Qu J.
      Coronavirus disease 2019 (COVID-19): A clinical update.
      ). Although the first reported case of infected persons was identified in China towards the end of 2019 (
      • Chen N.
      • Zhou M.
      • Dong X.
      • Qu J.
      • Gong F.
      • Han Y.
      • Qiu Y.
      • Wang J.
      • Liu Y.
      • Wei Y.
      • Xia J.
      • Yu T.
      • Zhang X.
      • Zhang L.
      Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study.
      ;
      • Phillis A.
      A COVID-19 vaccine-dare to dream.
      ;
      • Xafis V.
      • Schaefer G.O.
      • Labude M.K.
      • Zhu Y.
      • Hsu L.Y.
      The perfect moral storm: Diverse ethical considerations in the COVID-19 pandemic.
      ;
      • Zhu N.
      • Zhang D.
      • Wang W.
      • Li X.
      • Yang B.
      • Song J.
      • Zhao X.
      • Huang B.
      • Shi W.
      • Lu R.
      • Niu P.
      • Zhan F.
      • Ma X.
      • Wang D.
      • Xu W.
      • Wu G.
      • Gao G.F.
      • Tan W.
      A novel coronavirus from patients with pneumonia in China, 2019.
      ), much still has to be learned about the genesis of this new pathogen as well as the evolving strains and variants.
      The contagious and circulating virus SARS-CoV-2 has brought widespread mortality and morbidity and general havoc on social and economic life. On the one hand, the virus has been particularly harmful for those with vulnerable immune systems (
      • Heaton P.M.
      The Covid-19 vaccine-development multiverse.
      ). The risk of dying from the disease is especially present for those who are elderly and/or who already have other underlying health issues (
      • Walsh E.E.
      • Frenck Jr, R.W.
      • Falsey A.R.
      • Kitchin N.
      • Absalon J.
      • Gurtman A.
      • Lockhart S.
      • Neuzil K.
      • Mulligan M.J.
      • Bailey R.
      • Swanson K.A.
      • Li P.
      • Koury K.
      • Kalina W.
      • Cooper D.
      • Fontes-Garfias C.
      • Shi P-Y.
      • Türeci Ö.
      • Tompkins K.R.
      • Gruber W.C.
      Safety and immunogenicity of two RNA-based covid-19 vaccine candidates.
      ). Should an immune system react poorly to the virus SARS-CoV-2, the subsequent disease COVID-19 may lead to mortality (
      • Boulton J.
      In search of a vaccine against COVID-19: Implications for nursing practice.
      ).
      On the other hand, the public health measures to curtail and control the incidence, spread and burden of disease have demanded cohesive collective action on behalf of citizens such as maintaining good hand hygiene practices, keeping physical distance, as well as performing cough etiquette, using face masks and other coverings. Systems of test, trace and isolate, in addition to lockdowns and other suspensions of social and economic life, as well as restricting travel and imposing quarantine, have also been included among the arsenal of public health urgent response measures in the ongoing attempt to shield those who are most vulnerable and to prevent the provision of acute hospital care from becoming overwhelmed. In the face of waves and surges of the disease, humanity has proven its capacity to change and suddenly adapt to the circumstances, especially in its use of technology to maintain social contact and to continue the provision of education and other essential services. Yet living with this virus has brought dramatic upheaval and serious disruption to people's lives and caused terrible suffering and death; it has affected people existentially on varying levels in terms of their quality of life, their economic situation as well as their physical and mental health. It is unknown what the lasting health, personal, social, economic and political effects will be once the world emerges out of the shadow of the present pandemic.

      Vaccines

      Since Edward Jenner's original smallpox vaccine in 1796 (
      • Davidson T.
      Vaccines: History, science, and issues. (The Story of a Drug).
      ;
      • Greenwood B.
      The contribution of vaccination to global health: Past, present and future.
      ;
      • McAteer J.
      • Yildirim I.
      • Chahroudi A.
      The VACCINES Act: Deciphering vaccine hesitancy in the time of COVID-19.
      ;
      • Spaeder G.A.
      The moral obligation to vaccinate: Autonomy and the common good.
      ;
      • Stern A.M.
      • Markel H.
      The history of vaccines and immunization: Familiar patterns, new challenges.
      ), vaccines signify “… one of the greatest public health achievements …” (
      • Park H.S.
      • Samuels E.L.
      • Bocchini Jr., J.A.
      Vaccine development: From laboratory to policy.
      ;
      • Dubé E.
      • Laberge C.
      • Guay M.
      • Bramadat P.
      • Roy R.
      • Bettinger J.A.
      Vaccine hesitancy: An overview.
      ) and are “… one of the most effective preventive measures in the history of medicine” (
      • Prymula R.
      Controversies in vaccination.
      ).
      Vaccines “[…] stimulate the body's immune system into a response similar to that caused by invasion by the targeted pathogen, but without developing the illness” (
      • Boulton J.
      In search of a vaccine against COVID-19: Implications for nursing practice.
      ). In terms of health of populations, vaccination is considered to be a chief instrument in the fight against various diseases (
      • Carson P.J.
      • Flood A.T.
      Catholic social teaching and the duty to vaccinate.
      ;
      • Chevalier-Cottin E.P.
      • Ashbaugh H.
      • Brooke N.
      • Gavazzi G.
      • Santillana M.
      • Burlet N.
      • Htar M.T.T.
      Communicating benefits from vaccines beyond preventing infectious diseases.
      ;
      • Omer S.B.
      • Salmon D.A.
      • Orenstein W.A.
      • deHart M.P.
      • Halsey N.
      Vaccine refusal, mandatory immunization, and the risks of vaccine-preventable diseases.
      ). Vaccines have prevented deaths as well as progressing good public health (
      • Park H.S.
      • Samuels E.L.
      • Bocchini Jr., J.A.
      Vaccine development: From laboratory to policy.
      ). In short, “vaccination … saves lives” (
      • Orenstein W.A.
      • Ahmed R.
      Simply put: Vaccination saves lives.
      ). Various disabilities, which can develop because of certain viruses, as well as the spread of diseases have also been curtailed because of vaccination (
      • Orenstein W.A.
      • Ahmed R.
      Simply put: Vaccination saves lives.
      ). Yet, due to the success of public health programs of vaccinations, the devastation that can be caused by infectious diseases has been almost forgotten in some parts of the world. Strikingly, “vaccination has become a victim of its own success” (
      • Carson P.J.
      • Flood A.T.
      Catholic social teaching and the duty to vaccinate.
      ;
      • Orenstein W.A.
      • Ahmed R.
      Simply put: Vaccination saves lives.
      ;
      WHO, UNICEF, World Bank
      State of the world's vaccines and immunization.
      '
      • McAteer J.
      • Yildirim I.
      • Chahroudi A.
      The VACCINES Act: Deciphering vaccine hesitancy in the time of COVID-19.
      ).
      No vaccine offers complete protection from a targeted virus (
      • Goodman J.L.
      • Grabenstein J.D.
      • Braun M.M.
      Answering key questions about COVID-19 vaccines.
      ;
      • Asveld L.
      Mass-vaccination programmes and the value of respect for autonomy.
      ;
      • Orenstein W.A.
      • Ahmed R.
      Simply put: Vaccination saves lives.
      ). Although vaccines can protect individuals from the onset of diseases they may not inevitably inhibit the infection of the virus in the first place (
      • Andre F.E.
      • Booy R.
      • Bock H.L.
      • Clemens J.
      • Datta S.K.
      • John T.J.
      • Lee B.W.
      • Lolekha S.
      • Peltola H.
      • Ruff T.A.
      • Santosham M.
      • Schmitt H.J.
      Vaccination greatly reduces disease, disability, death, and inequity worldwide.
      ). Vaccination can lead to a lessening in the incidence of disease for those in society who are not yet immunized (or who never will be), which demonstrates the “indirect effects” and “herd protection” that can be caused by a vaccine (
      • Andre F.E.
      • Booy R.
      • Bock H.L.
      • Clemens J.
      • Datta S.K.
      • John T.J.
      • Lee B.W.
      • Lolekha S.
      • Peltola H.
      • Ruff T.A.
      • Santosham M.
      • Schmitt H.J.
      Vaccination greatly reduces disease, disability, death, and inequity worldwide.
      ). Herd immunity can be acquired by vaccine coverage rate but the rate differs according to the type of disease that is targeted by the said vaccine (
      • Giubilini A.
      • Douglas T.
      • Savulescu J.
      The moral obligation to be vaccinated: Utilitarianism, contractualism, and collective easy rescue.
      ;
      • Giubilini A.
      The ethics of vaccination.
      ) and the reproduction number (
      • Andre F.E.
      • Booy R.
      • Bock H.L.
      • Clemens J.
      • Datta S.K.
      • John T.J.
      • Lee B.W.
      • Lolekha S.
      • Peltola H.
      • Ruff T.A.
      • Santosham M.
      • Schmitt H.J.
      Vaccination greatly reduces disease, disability, death, and inequity worldwide.
      ). Although herd immunity is considered not to provide an equal level of defense against a virus for an unvaccinated individual person—as would be the case with a vaccine—it nonetheless provides a defense for people who are not able to receive a vaccine (
      • Giubilini A.
      The ethics of vaccination.
      ;
      • Orenstein W.A.
      • Ahmed R.
      Simply put: Vaccination saves lives.
      ). Persons, as individuals, can be kept safe by a vaccine and wider society can also obtain protection when more people in society are vaccinated as it lessens the possibility of the disease circulating among people (
      • Orenstein W.A.
      • Ahmed R.
      Simply put: Vaccination saves lives.
      ).
      A vaccine targeted at COVID-19 is considered to be a key approach to bringing this pandemic to a conclusion (
      • Lurie N.
      • Sharfstein J.M.
      • Goodman J.L.
      The development of COVID-19 vaccines: Safeguards needed.
      ) or, at least, to controlling it (

      European Centre for Disease Prevention and Control. (2021b). Questions and answers on COVID-19: Vaccines. Retrieved from https://www.ecdc.europa.eu/en/covid-19/questions-answers/questions-and-answers-vaccines Accessed May 10, 2021

      ;
      • Lurie N.
      • Sharfstein J.M.
      • Goodman J.L.
      The development of COVID-19 vaccines: Safeguards needed.
      ;
      • Giubilini A.
      Vaccination ethics.
      ). The rate at which scientists have progressed vaccines and vaccine candidates for COVID-19 has been exceptional. A successful roll out and coverage of a COVID-19 vaccine is seen to offer a way to lessen infection and therefore mortality rates and enable a return to some semblance of normal life (
      • Grady C.
      • Shah S.
      • Miller F.
      • Danis M.
      • Nicolini M.
      • Ochoa J.
      • Taylor H.
      • Wendler D.
      • Rid A.
      So much at stake: Ethical tradeoffs in accelerating SARSCoV-2 vaccine development.
      ;
      • Heaton P.M.
      The Covid-19 vaccine-development multiverse.
      ;
      • Schaffer DeRoo S.
      • Pudalov N.J.
      • Fu L.Y.
      Planning for a COVID-19 vaccination program.
      ). The large scale practical roll out across health care professionals, vulnerable groups, other frontline workers and wider society, paralleled with it being administered in a medically safe and ethically sound way, is complex but nonetheless urgent.

      Is There an Ethical Requirement to Take a Vaccine for a Communicable Disease?

      Whether to accept or to reject a vaccine is not only a health question but also an ethical question due to the potential benefits to the person (being vaccinated) as well as to others (
      • Giubilini A.
      The ethics of vaccination.
      ). The risk of harm from developing a disease, and spreading contagion, is diminished through the use of vaccines (
      • Verweij M.
      Individual and collective considerations in public health: Influenza vaccination in nursing homes.
      ). However, the decision not to take a vaccine may be due to medical grounds such as allergic reactions or an already compromised immune system (
      • Giubilini A.
      • Douglas T.
      • Savulescu J.
      The moral obligation to be vaccinated: Utilitarianism, contractualism, and collective easy rescue.
      ;
      • Asveld L.
      Mass-vaccination programmes and the value of respect for autonomy.
      ).
      Putting aside medical and other justifiable reasons not to take a vaccine, is there an ethical requirement to take a vaccine for a communicable disease? The question whether health care professionals have a moral obligation to take a vaccine for a communicable disease, as well as whether it should be mandatory, has been deliberated upon in the literature and continues to exercise the academic and wider health care community, especially with regard to the influenza vaccine (e.g.,
      • Anikeeva O.
      • Braunack-Mayer A.
      • Rogers W.
      Requiring influenza vaccination for health care workers.
      ;
      • Caplan A.
      Time to mandate influenza vaccination in health-care workers.
      ;
      • Cheng A.C.
      • Worth L.J.
      Mandatory influenza vaccination of healthcare workers: Is it necessary or sufficient to protect patients?.
      ;
      • Fricke K.L.
      • Gastañaduy M.M.
      • Klos R.
      • Bégué R.E.
      Correlates of improved influenza vaccination of healthcare personnel: A survey of hospitals in Louisiana.
      ;
      • Giubilini A.
      The ethics of vaccination.
      ;
      • Helms C.M.
      • Polgreen P.
      Should influenza immunisation be mandatory for healthcare workers? Yes.
      ;
      • Isaacs D.
      • Leask J.
      Should influenza immunisation be mandatory for healthcare workers? No.
      ;
      • Maltezou H.C.
      • Tsakris A.
      Vaccination of health-care workers against influenza: Our obligation to protect patients.
      ;
      • Maridor M.
      • Ruch S.
      • Bangerter A.
      • Emery V.
      Skepticism toward emerging infectious diseases and influenza vaccination intentions in nurses.
      ;
      • Ottenberg A.L.
      • Wu J.T.
      • Poland G.A.
      • Jacobson R.M.
      • Koenig B.A.
      • Tilburt J.C.
      Vaccinating health care workers against influenza: The ethical and legal rationale for a mandate.
      ;
      • Poland G.A.
      • Tosh P.
      • Jacobson R.M.
      Requiring influenza vaccination for health care workers: Seven truths we must accept.
      ;
      • Stead M.
      • Critchlow N.
      • Eadie D.
      • Sullivan F.
      • Gravenhorst K.
      • Dobbie F.
      Mandatory policies for influenza vaccination: Views of managers and healthcare workers in England.
      ;
      • Steckel C.M.
      Mandatory influenza immunization for health care workers: An ethical discussion.
      ;
      • Stewart A.M.
      Mandatory vaccination of health care workers.
      ;
      • van Delden J.J.
      • Ashcroft R.
      • Dawson A.
      • Marckmann G.
      • Upshur R.
      • Verweij M.F.
      The ethics of mandatory vaccination against influenza for health care workers.
      ;
      • Van Hooste W.L.C.
      • Bekaert M.
      To be or not to be vaccinated? The ethical aspects of influenza vaccination among healthcare workers.
      ;
      • Wicker S.
      • Marckmann G.
      Vaccination of health care workers against influenza: Is it time to think about a mandatory policy in Europe?.
      ). Considering that it is deemed to be an effective prevention mechanism (
      • Mo P.K.H.
      • Wong C.H.W.
      • Lam E.H.K.
      Can the health belief model and moral responsibility explain influenza vaccination uptake among nurses?.
      ), the influenza vaccine is deemed to be an important tool in keeping patients safe in a health care setting (
      • Haridi H.K.
      • Salman K.A.
      • Basaif E.A.
      • Al-Skaibi D.K.
      Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia.
      ). Although influenza is considered to be a vaccine-preventable sickness, nosocomial influenza can still have a significant impact on vulnerable patients (
      • Maltezou H.C.
      • Tsakris A.
      Vaccination of health-care workers against influenza: Our obligation to protect patients.
      ;
      • Helms C.M.
      • Polgreen P.
      Should influenza immunisation be mandatory for healthcare workers? Yes.
      ).
      Yet the uptake of the influenza vaccines by nurses has varied (see
      • Clark S.J.
      • Cowan A.E.
      • Wortley P.M.
      Influenza vaccination attitudes and practices among US registered nurses.
      ;
      • Dedoukou X.
      • Nikolopoulos G.
      • Maragos A.
      • Giannoulidou S.
      • Maltezou H.C.
      Attitudes towards vaccination against seasonal influenza of health-care workers in primary health-care settings in Greece.
      ;
      • Dror A.A.
      • Eisenbach N.
      • Taiber S.
      • Morozov N.G.
      • Mizrachi M.
      • Zigron A.
      • Srouji S.
      • Sela E.
      Vaccine hesitancy: The next challenge in the fight against COVID-19.
      ;
      • Halpin C.
      • Reid B.
      Attitudes and beliefs of healthcare workers about influenza vaccination.
      ;
      • Haridi H.K.
      • Salman K.A.
      • Basaif E.A.
      • Al-Skaibi D.K.
      Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia.
      ;
      • Kwok K.O.
      • Li K.K.
      • Wei W.I.
      • Tang A.
      • Wong S.Y.S.
      • Lee S.S.
      Influenza vaccine uptake, COVID-19 vaccination intention and vaccine hesitancy among nurses: A survey.
      ;
      • Mo P.K.H.
      • Wong C.H.W.
      • Lam E.H.K.
      Can the health belief model and moral responsibility explain influenza vaccination uptake among nurses?.
      ;
      • Wilson R.
      • Scronias D.
      • Zaytseva A.
      • Ferry M.A.
      • Chamboredon P.
      • Dubé E.
      • Verger P.
      Seasonal influenza self-vaccination behaviours and attitudes among nurses in Southeastern France.
      ).
      • Aguilar-Díaz F.del C.
      • Jiménez-Corona M.E.
      • Ponce-de-León-Rosales S.
      Influenza vaccine and healthcare workers.
      found worries about after-effects and safety as well as questioning the level of efficacy to be the type of reasons given for not taking a vaccine by those working in health care; there was also the view that the virus did not pose a risk to their health as well as the belief that they were not at risk of catching it (
      • Galanakis E.
      • Jansen A.
      • Lopalco P.L.
      • Giesecke J.
      Ethics of mandatory vaccination for healthcare workers.
      ;
      • Halpin C.
      • Reid B.
      Attitudes and beliefs of healthcare workers about influenza vaccination.
      ). Other reasons given for refusal of vaccines have been based on conscientious objection and beliefs of a religious persuasion (
      • Galanakis E.
      • Jansen A.
      • Lopalco P.L.
      • Giesecke J.
      Ethics of mandatory vaccination for healthcare workers.
      ;
      • Giubilini A.
      • Douglas T.
      • Savulescu J.
      The moral obligation to be vaccinated: Utilitarianism, contractualism, and collective easy rescue.
      ).
      • Galanakis E.
      • Jansen A.
      • Lopalco P.L.
      • Giesecke J.
      Ethics of mandatory vaccination for healthcare workers.
      provide a useful summary of the arguments in favor and in opposition to requiring vaccination (in general) of health care professionals from the perspective of the four main principles of bioethics (
      • Beauchamp T.L.
      • Childress J.F.
      Principles of biomedical ethics.
      ;
      • McLennan S.
      • Gillett G.
      • Celi L.A.
      Healer, heal thyself: Health care workers and the influenza vaccination.
      ;
      • Lee L.M.
      Adding justice to the clinical and public health ethics arguments for mandatory seasonal influenza immunisation for healthcare workers.
      ;
      • Mo P.K.H.
      • Wong C.H.W.
      • Lam E.H.K.
      Can the health belief model and moral responsibility explain influenza vaccination uptake among nurses?.
      ;
      • Osbourne R.M.
      • Clark S.J.
      Should the SARS-CoV-2 vaccine be mandatory for nurses? An ethical debate.
      • Osbourne R.M.
      • Clark S.J.
      Should the SARS-CoV-2 vaccine be mandatory for nurses? An ethical debate.
      examine the question whether vaccination against COVID-19 should be mandatory for nurses and those working in health care.
      ). Applying these principles of bioethics to the issue of COVID-19 vaccines, the following could be argued: The principle of respect for a patient's autonomy would normally uphold a competent person's right to accept or to reject a medical procedure. In the case of a COVID-19 vaccine, it could be argued that a nurse has an autonomous right to choose or not a vaccine for COVID-19. However, autonomy is generally limited by the risk of harm to others or when impinging on other peoples’ rights and entitlements. Therefore, a nurse's autonomous right to choose or not a vaccine for COVID-19 could be limited by the risk of harm posed to others. From the perspective of the principle of beneficence, vaccines in general can bring benefits in terms of protection to the recipient and to others. A similar point to
      • Anikeeva O.
      • Braunack-Mayer A.
      • Rogers W.
      Requiring influenza vaccination for health care workers.
      could be made about receiving a COVID-19 vaccine that it could afford a nurse the opportunity to continue to deliver care to patients in the context of high level of virus circulating. Although the obligation to increase the benefit or welfare for someone is not unrestrictive, health care professionals do have specific obligations of beneficence towards their patients; taking a vaccine for a vaccine-preventable infection has been considered to be part of this (
      • McLennan S.
      • Gillett G.
      • Celi L.A.
      Healer, heal thyself: Health care workers and the influenza vaccination.
      ;
      • Beauchamp T.L.
      • Childress J.F.
      Principles of biomedical ethics.
      ). A similar proposition could be made about taking a COVID-19 vaccine. However, having an obligation of beneficence does not imply that health care professionals should cause harm to themselves to realize a benefit for those in their care (
      • Galanakis E.
      • Jansen A.
      • Lopalco P.L.
      • Giesecke J.
      Ethics of mandatory vaccination for healthcare workers.
      ).
      Any risks of getting vaccinated that are disproportionate to the possible benefits should be taken into consideration (see
      • van Delden J.J.
      • Ashcroft R.
      • Dawson A.
      • Marckmann G.
      • Upshur R.
      • Verweij M.F.
      The ethics of mandatory vaccination against influenza for health care workers.
      ).
      For
      • Galanakis E.
      • Jansen A.
      • Lopalco P.L.
      • Giesecke J.
      Ethics of mandatory vaccination for healthcare workers.
      , the principle of nonmaleficence would stipulate not causing harm to others by transmitting an infection.
      • Harris J.
      • Holm S.
      Is there a moral obligation not to infect others?.
      have argued that there is a prima facie moral obligation not to bring about a preventable harm, such as causing others to get ill. Yet when it comes to health care workers in particular, this is a significant prima facie obligation (
      • van Delden J.J.
      • Ashcroft R.
      • Dawson A.
      • Marckmann G.
      • Upshur R.
      • Verweij M.F.
      The ethics of mandatory vaccination against influenza for health care workers.
      ). If a COVID-19 vaccine can prevent a harm of a virus being transferred from a health care professional to a patient, then the principle of nonmaleficence could be used to support the use of vaccines. If the principle of harm to others is a ground for impinging on a person's autonomy (
      • van Delden J.J.
      • Ashcroft R.
      • Dawson A.
      • Marckmann G.
      • Upshur R.
      • Verweij M.F.
      The ethics of mandatory vaccination against influenza for health care workers.
      ), then it could be proposed that should the threat of COVID-19 pose a real harm to patients and others, then a nurse's autonomous decision to reject a COVID-19 vaccine could be limited by this harm. However, in the case of general vaccination, it is pointed out that evidence would be needed to claim that a patient was harmed by a particular health care professional who had not been vaccinated. In other words, direct causal links need to be shown with evidence (
      • Galanakis E.
      • Jansen A.
      • Lopalco P.L.
      • Giesecke J.
      Ethics of mandatory vaccination for healthcare workers.
      ). Finally, in terms of the principle of justice, for those patients who cannot be recipients of vaccines in general, due to medical reasons, would it be fair that they receive treatment by those who are not vaccinated but could be vaccinated (see
      • Galanakis E.
      • Jansen A.
      • Lopalco P.L.
      • Giesecke J.
      Ethics of mandatory vaccination for healthcare workers.
      )? A comparable argument could be made in the case of a COVID-19 vaccine.
      Although
      • Beauchamp T.L.
      • Childress J.F.
      Principles of biomedical ethics.
      seminal principles could be used and further developed to argue for and against the ethical requirement to take a COVID-19 vaccine, this paper now approaches the issue by using and adapting the Principle of Responsive Adjustment to examine a hypothetical example of Nurse X who has inadvertently infected Patient Y.

      Principle of Responsive Adjustment

      The Principle of Responsive Adjustment encompasses the view that if someone was the inadvertent cause of something harmful happening or of a negative event, then there is the expectation that they adjust their behavior to ensure that a repetition of the event will not happen (
      • French P.A.
      A principle of responsive adjustment.
      ).
      • French P.A.
      A principle of responsive adjustment.
      traces the roots of this expected change in present behavior to Aristotle (p. 498). In the Nicomachean Ethics,
      Aristotle
      Nicomachean ethics.
      writes that “Still they are themselves by their slack lives responsible for becoming men of that kind, and men make themselves responsible for being unjust or self-indulgent, in the one case by cheating and in the other by spending their time in drinking bouts and the like …” (p. 30, Book 3:5;
      • French P.A.
      Collective and corporate responsibility.
      , p. 164). The Principle of Responsive Adjustment addresses a fundamental question in the aftermath of a harmful event: Has the person changed their behavior? Have actions been taken to stop the harm that is being caused or is the harm continuing to be caused? Therefore, what the person does after the original action (i.e., do they continue it or do they adjust their behavior) becomes important. What is essential is that remedial measures are taken to stop the recurrence of any harm. At a very minimum, there is an expectation that the action will not happen again.
      • French P.A.
      A principle of responsive adjustment.
      development of this position transcends the expectation of change in behavior to the view that if such a change is not initiated, the person can then be held morally responsible for the harmful effect of their past behavior.
      • French P.A.
      A principle of responsive adjustment.
      explains that this does not imply that the earlier nonintentional harm has now become an intentional harm. Rather, if there is no adjustment in behavior, then the person can now be associated with the original harmful occurrence.
      • French P.A.
      A principle of responsive adjustment.
      contends that “… a person's past actions (even if unintentional) can be (and often are) taken into the scope of the intentions that motivate that person's present and future actions” (p. 498). Although the person did not originally intend a harmful action, they now intend not to adjust their actions to prevent or stop such actions from continuing to happen (
      • French P.A.
      A principle of responsive adjustment.
      ).
      Under the Principle of Responsive Adjustment, the past behavior is still part of the narrative that constitutes the present moral life of the individual; the person can decide whether to intentionally change their ways to prevent the moral wrong being committed again (
      • French P.A.
      A principle of responsive adjustment.
      ). By not making the necessary changes to present behavior, the past nonintentional harmful behavior is now connected to the present intentional behavior not to change (
      • French P.A.
      A principle of responsive adjustment.
      ). This encapsulates the Aristotelian insight of the person acting within or outside of character: If I did do something unintentionally wrong, the fact that I won't change my ways demonstrates that although the original wrong was not intentional, it was not out of character (
      • French P.A.
      A principle of responsive adjustment.
      ). In other words, the past action was in line with the character of the person and not out of step. Normally, a person is not morally blamed for unintentional action yet there is an expectation that the unintentional action will not be repeated and become part of the person's character (
      • French P.A.
      A principle of responsive adjustment.
      ). In short, a basic intuition in morality that lessons need to be learned from mistakes made is encapsulated in the Principle of Responsive Adjustment (
      • French P.A.
      A principle of responsive adjustment.
      ) and furthermore that such mistakes should be avoided. There may still, however, be factors that would mitigate nonresponsive adjustments (
      • French P.A.
      A principle of responsive adjustment.
      ).
      If the Principle of Responsive Adjustment is adapted and applied to examine our hypothetical example of Nurse X who has inadvertently infected Patient Y, the following can be put forward:
      Firstly, although Nurse X may not be morally responsible for inadvertently transmitting SARS-CoV-2 to Patient Y there is still a moral expectation that some change in behavior needs to be taken to prevent or reduce the possibility of the virus being transmitted again. What is important is that remedial measures are taken by Nurse X to stop or reduce the recurrence of a possible infection. If a COVID-19 vaccine presents one of the most effective means of reducing the possibility of transmitting the virus, then it could be contended that there is a moral expectation that Nurse X takes a vaccine (unless there are justifiable reasons not to).
      This will depend on the effectiveness of the vaccine to decrease the possibility of viral load and transmission, for example (see
      European Centre for Disease Prevention and Control
      Interim guidance on the benefits of full vaccination against COVID-19 for transmission and implications for non-pharmaceutical interventions.
      ). The vaccine schedule would depend on the immunisation guidelines/recommendations at the time in the respective state.
      Secondly, if Nurse X refuses to make any adjustment to their behavior and does not take a COVID-19 vaccine (without justifiable reason), then they could now be morally associated with the original harmful occurrence of infection. By not making the necessary changes to their present behavior and by not taking a vaccine, their past actions could now be connected to the present intentional behavior of not changing. The action that Nurse X now takes—i.e., whether they continue as they are or whether they adjust their behavior by taking a vaccine—becomes important. It may be more appropriate to speak of being morally associated (rather than responsible) for the following reasons:
      In the context of vaccination for influenza,
      • Verweij M.
      Individual and collective considerations in public health: Influenza vaccination in nursing homes.
      ) argues that there are issues of an epistemological nature with attempting to identify who was the originating cause of a person catching a virus. In a similar manner, is it possible to know that Nurse X passed on the virus to Patient Y? If Nurse X did pass on the virus to Patient Y, can we really claim that this act of transmission belongs to Nurse X (
      • Verweij M.
      Individual and collective considerations in public health: Influenza vaccination in nursing homes.
      )? It is not an ‘act’ that Nurse X can necessarily control: They may be able to follow infection control measures but they are not able to deliberately control whether the virus is spread or not. There is the view that in order to establish a full human act for moral evaluation, we would have to ascertain whether Nurse X had knowledge of possessing the virus, had an intention to pass it on to Patient Y and freely wanted to do so (e.g.,

      Aquinas, T. (2017). The summa theologiæ of St. Thomas Aquinas. Second and Revised Edition, 1920. Translated by Fathers of the English Dominican Province. Online Edition by K. Knight. Retrieved from https://www.newadvent.org/summa/2.htm Accessed May 10, 2021

      , I.II;
      Aristotle
      Nicomachean ethics.
      ;
      • Campbell J.K.
      Free will.
      ;
      • Davies B.
      Thomas Aquinas's summa theologiae: A guide and commentary.
      . Secondly, although Nurse X may have passed on the virus to Patient Y, it was not Nurse X who made Patient Y subsequently sick but rather the virus (
      • Verweij M.
      Individual and collective considerations in public health: Influenza vaccination in nursing homes.
      ). Thirdly, in their discussion of vaccination in general and moral responsibility,
      • Jamrozik E.
      • Handfield T.
      • Selgelid M.J.
      Victims, vectors and villains: Are those who opt out of vaccination morally responsible for the deaths of others?.
      state that a person may be held morally responsible for their behavior but, at the same time, they may be held only morally responsible for some of the consequences arising from that behavior (pp. 764–765). This takes into account the fact that a person may not have full control over the consequences that stem from their behavior (
      • Jamrozik E.
      • Handfield T.
      • Selgelid M.J.
      Victims, vectors and villains: Are those who opt out of vaccination morally responsible for the deaths of others?.
      ). Two people could behave in the same way but the consequences that stem from their behavior may differ and they may be held morally responsible to a different extent, which could depend on the ‘moral luck’ of how the situation is evaluated (
      • Jamrozik E.
      • Handfield T.
      • Selgelid M.J.
      Victims, vectors and villains: Are those who opt out of vaccination morally responsible for the deaths of others?.
      ;
      • Anderson M.B.
      Moral luck as moral lack of control.
      ;
      • Andre J.
      Nagel, Williams, and moral luck.
      ;
      • Athanassoulis N.
      Common-sense virtue ethics and moral luck.
      ; ;
      • Nagel T.
      Mortal questions.
      ;
      • Williams B.A.O.
      • Nagel T.
      Moral luck.
      ). Following this line of thought, it could be said that if Nurse X and Nurse Z behaved in the same way but only Nurse X ended up infecting Patient Y, it may be claimed that luck is part of whether or not there was a resulting harm, and therefore the evaluation of the Nurse X's resulting harm is open to moral luck (
      • Jamrozik E.
      • Handfield T.
      • Selgelid M.J.
      Victims, vectors and villains: Are those who opt out of vaccination morally responsible for the deaths of others?.
      ), i.e., luck signifies that there is no control on Nurse X's part (
      • Athanassoulis N.
      Common-sense virtue ethics and moral luck.
      ). It is a quite a different situation if Nurse X takes actions to infect Patient Y.
      To argue that Nurse X could be deemed to be morally associated with inadvertently transmitting the virus to Patient Y because they do not intend to adjust their behavior to reduce or prevent the possibility of transmitting the virus from happening again, would not remove the possibility that there may be factors that would mitigate nonadjustments to actions (
      • French P.A.
      A principle of responsive adjustment.
      ). In addition, it could also be claimed that there is a difference between intending not to adjust behavior and genuinely attempting, but not being able, to adjust behavior. For example, Nurse X may not be able to obtain a COVID-19 vaccine because of access and supply issues.
      The adapted Principle of Responsive Adjustment, however, faces challenges with the following hypothetical scenarios: (1) where Nurse X was asymptomatic but a carrier of the virus and infected Patient Y and (2) where Nurse X was not asymptomatic or a carrier of the virus and did not infect Patient Y (or any other patient for that matter). (1) One aspect of COVID-19 is the presence of asymptomatic transmissions (
      • Zhang J.
      • Wu S.
      • Xu L.
      Asymptomatic carriers of COVID-19 as a concern for disease prevention and control: More testing, more follow-up.
      ). A person, who is asymptomatic, may still pass on the virus, which has made the impediment of the spread of the virus difficult (
      • Bai Y.
      • Yao L.
      • Wei T.
      • Tian F.
      • Jin D.Y.
      • Chen L.
      • Wang M.
      Presumed asymptomatic carrier transmission of COVID-19.
      ;
      • Velavan T.P.
      • Meyer C.G.
      The COVID-19 epidemic.
      ;
      • Zhao H.
      • Lu X.
      • Deng Y.
      • Tang Y.
      • Lu J.
      COVID-19: Asymptomatic carrier transmission is an underestimated problem.
      ). In the case where Nurse X was asymptomatic but still passed on the virus to Patient Y, then although they may not be aware of contributing to the spread of the infection and may not consider that there is anything that needs to be adjusted, there still remains an adjustment to behavior that needs to be made. This would be similar to the situation in which Nurse X had a confirmed diagnosis of the virus. Although they may have had the virus, they still may not be aware that they may have infected Patient Y. Nonetheless, there would be a need to make adjustment in their behavior. (2) On a surface level, it could be said that if Nurse X was not asymptomatic or a carrier of the virus and did not infect Patient Y with COVID-19, then there is nothing for which to make an adjustment. Therefore, there may be no ethical requirement to take a COVID-19 vaccine. Yet, public health advice has included the view that people should behave as if they had the virus (

      Augusta Health. (2020). COVID-19 asymptomatic carriers and antibody tests. Retrieved from https://www.augustahealth.com/health-focused/covid-19-asymptomatic-carriers-and-antibody-tests Accessed May 10, 2021

      ;
      • McGreevy R.
      Covid-19: Dr Ronan Glynn pleads with Dubliners as virus spreads in household.
      ). Considering that Nurse X was not asymptomatic or a virus carrier but nonetheless heeded public health advice to act as if they were a vector of the virus, then it could be claimed that one way to make adjustment to this “as if behavior” is still to take a vaccine. Although there are no past harms, taking a vaccine would remove or reduce remote, but still significant, possible harms.

      Conclusion

      Ethical questions seem unlimited in health care practice and solutions can greatly diverge; even more so in profound crisis situations and emergencies. The present pandemic has raised numerous ethical questions and, no doubt, further questions will continue to emerge in a post-pandemic world. This paper has approached the issue of whether there is an ethical requirement for nurses to take a COVID-19 vaccine by philosophically using a hypothetical example of Nurse X who has inadvertently infected Patient Y. By adapting the Principle of Responsive Adjustment, it is proposed that there would be a moral expectation that Nurse X takes a COVID-19 vaccine (unless there are justifiable reasons not to). Furthermore, should Nurse X not take a COVID-19 vaccine (without justifiable reasons), then it could be argued that Nurse X could be now morally associated with infecting Patient Y.
      Nurses in acute hospital and in long-term residential care settings have found themselves in the eye of the COVID-19 storm. Considering that there is great expectation that COVID-19 vaccines will reduce the risk of disease
      According to the
      European Centre for Disease Prevention and Control
      Interim guidance on the benefits of full vaccination against COVID-19 for transmission and implications for non-pharmaceutical interventions.
      , “the impact of developing severe disease in a fully vaccinated individual who is infected with SARS-CoV-2 is likely to be very low in younger and middle-aged adults specifically” (p. 7).
      , it would be easy to assume that there would be a positive attitude towards an uptake of a vaccine among nurses. At time of writing, it still has to be ascertained how long a COVID-19 vaccine will be effective and whether routine vaccination may be needed as is the case for influenza (see
      • Goodman J.L.
      • Grabenstein J.D.
      • Braun M.M.
      Answering key questions about COVID-19 vaccines.
      ). Therefore, should the necessity of a more routine uptake of a COVID-19 vaccine to keep the virus and further mutations at bay become a reality, it will be important to monitor levels of uptake among nurses (and other health care workers) going forward, just as in the case of the influenza vaccines. The broader topic of nurses taking other vaccines for communicable diseases may receive a renewed debate with the issue of the new COVID-19 vaccines. The Principle of Responsive Adjustment may also receive further debate in the context of whether nurses and other health care professionals should take vaccines for communicable diseases.

      Author Contribution

      Alan J. Kearns is the sole author of the paper performing Conceptualization, Methodology, Software, Data cura tion, Writing – Original draft preparation and Editing.

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