Public Health

Audiey Kao, MD, PhD, on mandating vaccines for health care workers


Watch the AMA's COVID-19 Update, with insights from AMA leaders and experts about the pandemic.



In today’s COVID-19 Update, Audiey Kao, MD, PhD, AMA’s vice president of ethics, discusses the ethical considerations in mandating vaccines for health care workers.

Learn more at the AMA COVID-19 resource center.


  • Audiey Kao, MD, PhD, vice president, ethics, AMA

AMA COVID-19 Daily Video Update

AMA’s video collection features experts and physician leaders discussing the latest on the pandemic.

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today we're talking with Dr. Audiey Kao, the AMA's vice president of ethics in Chicago about the ethical consideration of vaccine mandates for health care workers. I'm Todd Unger, AMA's chief experience officer in Chicago.

Dr. Kao, thanks for joining us. Not surprisingly, this whole idea of returning to the office is a big topic of discussion, broad scale across all employers. Why don't we just start by talking about what are some of the ethical considerations broadly, across all sectors, that employers need to think through in regard to decisions like this?

Dr. Kao: So during normal times, Todd, employers have responsibilities to their employees, customers and, depending on the company, to their investors. During this pandemic, however, employers have to make decisions that not only have business and financial implications for their stakeholders but also in the case of employees and customers have personal health consequences. And some employers see mandating COVID vaccinations for employees as an appropriate occupational health strategy while allowing for medical and nonmedical exemptions.

AMA's position is that nonmedical exemptions, such as religious or philosophic objections to vaccinations, endanger the health of the unvaccinated individual and those whom the individual comes in contact with, so the AMA supports legislation eliminating nonmedical exemptions from immunizations.

It's also worth noting that a recent survey by the Harvard School of Public Health found that 53% of respondents were in favor of employers requiring all their employees be vaccinated against COVID-19. Probably no surprise though, there is a partisan difference with 64% of Democrats favoring such a requirement while 56% of Republicans are opposed. These findings would suggest that employers in so-called red states face greater opposition to COVID vaccine mandates than in blue states.

Unger: And that's a tough challenge, especially what we're seeing right now in a lot of red states where this experience of the unvaccinated population...

Dr. Kao: Right.

Unger: ... is very, very different than what we're seeing with vaccinated groups. So you're talking more broadly across different sectors. Let's zero in a little bit on health care workers in particular. Should they be held to a higher, different standard than other workers?

Dr. Kao: Yeah. So first "do no harm" is a core ethic for all those who care for the sick and injured. So yes, I think that physicians and, frankly, all those working in the health care system, have a fundamental obligation to patients by getting vaccinated for preventable diseases, such as COVID-19. Both the AMA and the American Nurses Association have called on all health care professionals to get their COVID-19 vaccinations to protect their patients and themselves.

And a recent AMA survey found that more than 96% of physicians reported having received the COVID-19 vaccine. So it's good to see that the great majority of my colleagues are setting an important example and practicing what we've been preaching.

Unger: That is very heartening to hear that news. So it is kind of surprising, given "do no harm" as the underpinning. This field that we've seen cases in which hospital workers have sued administrators for mandating vaccinations, including a really high-profile case in Houston. What are the implications of this?

Dr. Kao: Yeah. So you're right, Todd. A Texas federal court recently sided with a Houston hospital that required workers to get a COVID-19 vaccine and more than a hundred workers at Houston Methodist Hospital, who had been put on leave without pay for refusing to accept a hospital supplied vaccination, filed a lawsuit claiming their suspension and potential firing constituted wrongful termination. A U.S. District Judge, however, rejected the case, arguing in a June 12 ruling that if the hospital's employees didn't want to receive a COVID-19 shot, they were free to work elsewhere.

Unger: It's also kind of surprising because aren't there precedents already for mandating vaccination among the health care workforce?

Dr. Kao: You're right. And the annual flu shot, for example, has long been required by hospitals for its employees, as are immunizations for measles, hepatitis B and other infectious diseases. And over the decades, health care employees have filed dozens of legal cases against those requirements, but like the Texas hospital case, courts have routinely dismissed them.

Unger: And a lot of those things that you just mentioned, they're highly transmissible and already require vaccinations. And so something like COVID, it's surprising to see similar resistance. That goes back to different states, different opinions. Some states are enacting laws now limiting mandatory COVID-19 shots. How's that apply to that health care workforce?

Dr. Kao: Yeah. So at least six states have enacted new laws limiting mandatory COVID-19 shots. Fortunately, many of these states have not prohibited employers from requiring workers to get a vaccine but do carve out an exception for health care and public health workers. These new laws, however, only further contribute to politicizing a public health emergency that should not be a red versus blue or a left versus right issue.

Unger: Well said. The other kind of issue that I've heard, and I think I heard it connected to armed forces first, was this idea that the vaccines in the U.S. were authorized by the FDA under an Emergency Use Authorization, or EUA. Should health care systems be kind of waiting for full approval before making vaccines mandatory?

Dr. Kao: Yeah. I mean, that's a good point. In June, the AMA adopted a position that recommends COVID-19 vaccine mandates be implemented only after a vaccine has received full approval from the FDA. So as you mentioned, COVID vaccines in the U.S. are currently administered under Emergency Use Authorization, but we've seen very strong real-world efficacy and safety data and we've given COVID vaccines to nearly 70% of the U.S. adult population and its safety and efficacy are holding up well even against the variants that have emerged. So COVID vaccines from Pfizer-BioNTech and Moderna are expected to receive full approval from the FDA in the coming weeks and months, and having COVID 19 vaccines fully approved by the FDA should help to get some people who are currently on the fence get vaccinated.

Unger: Well, we talked earlier about, and it was a large health system down in the Houston area, and this issue, very complex for a large health system like that with many employees. When you think of smaller, private practices, how do the rules change in your mind, ethically?

Dr. Kao: Yeah. So I think the ethical rationale I mentioned earlier in our conversation, the first "do no harm," should really be no different whether you're a large hospital system or a small private practice, but from an access to care standpoint, I would argue that solo and smaller practices may have a greater need to ensure that their staff are vaccinated because their ability to deliver care can be severely compromised if just one or two individuals don't show up for work because of COVID.

Unger: Well, some health systems are stopping short of issuing mandates, and like states and other entities are incentivizing employees to get vaccinated, are there ethical considerations in these incentives?

Dr. Kao: Okay. So I think giving someone a nudge through a modest incentive seems reasonable. A modest incentive could be a lunch voucher as a thank you for getting vaccinated, but I think the larger the incentives, the greater the likelihood that one is making a financial decision rather than a health decision. And we don't want to put people in a position to be making personal health decisions that are unduly influenced by personal economic reasons.

Unger: And interesting, I think the jury is still out, but some of the early returns on these kind of large state-based systems of large financial incentives still not definitive as to whether that's moving the needle or not.

Just finally, last question, what kind of guidance would you offer individuals and groups that are struggling with this decision about mandatory vaccination?

Dr. Kao: Yeah. So, can you imagine where we would be in this country if we did not have safe and effective COVID-19 vaccines? Physicians and health systems need to continue to get the message out that COVID vaccinations save lives. And COVID vaccinations have prevented nearly 280,000 deaths and more than 1.5 million hospitalizations in the U.S. according to a recent study from the Yale School of Public Health.

And over the past couple of weeks, however, areas lagging in vaccinations are seeing an alarming rise in COVID cases. And there is usually a time lag between rising COVID cases and increased hospitalizations. Therefore, physicians and health care employers need to act with urgency to address concerns and encourage vaccinations among those in the health care workforce who remain unvaccinated.

And finally, many hospitals and health systems seem hesitant to mandate vaccinations until COVID-19 vaccines are fully approved by the FDA. So I would end by simply saying that if and when hospitals and health systems decide to mandate COVID vaccinations, they will be standing on solid, ethical and legal grounds to do so.

Unger: Dr. Kao, thank you so much for being here. It's always fascinating to hear your perspective on ethical considerations on a variety of different topics and this one included. That's it for today's COVID-19 Update, we'll be back with another segment shortly. In the meantime for resources on COVID-19, visit Thanks for joining us, please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.