This column is a collaboration between AGD and the American College of Dentists. 

Many challenging questions have arisen since the onset of the COVID-19 pandemic. Mask or no mask? Should social distancing be by six feet or 10? Can I treat patients safely? 

These questions are difficult because they lie at the intersection of science, law, individual opinion and personal preferences. Viewing these and other decisions through an ethical lens can offer clarity and balance in deciding between conflicting viewpoints. 

As the pandemic continues and practices reopen, many dentists are facing additional difficult questions regarding their teams: “How should I deal with a valuable team member who refuses to be vaccinated? What do I do after discussions and even incentives fail to persuade this team member to be vaccinated?” 

How does the prudent dentist decide what to do? “It is beyond question that the pandemic has presented some of the most critical, intensive and urgent workplace issues HR professionals have ever experienced,” said Johnny C. Taylor Jr., president of the Society for Human Resource Management.¹ Because of the human resources aspects of the problem, the decision has three general considerations: legal and risk management, regulatory compliance, and ethical aspects. Title VII of the Civil Rights Act requires reasonable accommodations if an employee refuses vaccination due to religious, disability-related or other protected objections. If any of these apply, the decision has been made for you.² 

Equal Employment Opportunity Commission guidance permits employers to mandate vaccination if they comply with federal law. But a mandate is ineffective without repercussions for noncompliance, and taking action against a recusant employee carries risks for the employer. If dentists exercise this option, it could put them at risk for wrongful termination charges. A mandatory vaccine policy should be the last resort for both employers and the government. The least restrictive and least invasive interventions should be used whenever possible.³ 

A core requirement of the Occupational Safety and Health Administration is that the dentist provides a safe workplace with adequate protocols and controls, but the mandate leaves many of the details up to the individual dentist. The Centers for Disease Control and Prevention does not recommend mandatory vaccination and has relegated that decision to local authorities.⁴ A reasonable basis for mandatory vaccination must be established before an employer requires it of his or her employees. A dentist would do well to examine his or her motivation for requiring that all employees be vaccinated. 

For example, if a dentist advertises that his or her office staff is fully vaccinated, a reasonable potential patient might assume that the quality of care is higher compared with another practice where some staff are resisting vaccination. Although it is a true statement, it might create unwarranted expectations and suggest superior care, even if that is not the intent.⁵ 

In an opinion piece for JAMA, Lawrence O. Gostin, JD, et al. suggest that healthcare employers must weigh employee safety and public safety as they consider whether they should mandate the COVID-19 vaccine for employees.⁶ The American Dental Association’s “Ethics of Vaccination” inconclusively suggests that dentists need to consider how to deal with their staff who cannot be or choose not to be vaccinated.⁷ The California Dental Association’s Practice Support Center suggests that the dentist should encourage, but not mandate, COVID-19 vaccination, citing legal risks.⁸ 

Ethical considerations help to bring the decision into sharper focus. 

The dentist’s duty to care for his or her patients is an overarching principle of the ethics of dentistry. This is part of the implied contract with the public in return for the privileges granted to the dental professional. Requiring the COVID-19 vaccine would provide maximum benefit to the public, but it conflicts with the autonomy of the individual dental provider.³ 

The principle of autonomy describes the individual’s right to determine what will be done with his or her own body. This lies at the heart of the conflict. The utilitarian notion that an individual’s actions should contribute to the greater good of society can be construed as denying the right of self-determination.

One may argue that, because infection control precautions are accepted as the standard of care in dentistry, a safe, less invasive alternative to vaccination exists for dental personnel and patients who object to waiving their autonomy. 

The twin principles of beneficence and nonmaleficence are accepted by dental professionals who wish to do good and to avoid harm. The dentist must consider whether universal precaution practices are an effective means to fulfilling these obligations if an employee is unwilling or unable to be vaccinated. Justice, or the principle of fairness, should motivate the employer dentist in his or her professional relationship with employees. Each employee should be regarded without prejudice. A supportive and collaborative workplace should exist, regardless of vaccination status. 

In conclusion, I believe that the autonomy of individual employees must be respected, even when the employer disagrees with their choices. The right to self-determination is a powerful principle. Each employee should be treated fairly, regardless of his or her choice. The conflict over vaccination status could impair the harmonious function of the dental team, and this is not a desirable outcome. Finally, consider that legal considerations vary from one location to another. Dentists should consult with employment law attorneys or human resources or risk management specialists for appropriate local advice before making the decision to mandate COVID-19 vaccines. 

Robert D. Stevenson, DDS, FAGD, is an assistant professor who teaches preclinical dentistry and ethics at Western University College of Dental Medicine. He graduated from the University of Texas Dental School at San Antonio in 1988. 

To comment on this article, email impact@agd.org. 

References 
1. “EEOC Examines Connections Between COVID-19 and Civil Rights.” U.S. Equal Employment Opportunity Commission, 28 April 2021, eeoc.gov/newsroom/eeoc-examines-connections-between-covid-19-and-civil-rights. Accessed 12 June 2021. 
2. “What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws.” U.S. Equal Employment Opportunity Commission, 28 May 2021, eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-act-and-other-eeo-laws. Accessed 10 June 2021. 
3. Gur-Arie, Rachel, et al. “No Jab, No Job? Ethical Issues in Mandatory COVID-19 Vaccination of Healthcare Personnel.” BMJ Global Health, 2021;6:e004877, DOI: 10.1136/bmjgh-2020-004877.
4. “Workplace Vaccination Program.” Centers for Disease Control and Prevention, 25 March 2021, cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/essentialworker/workplace-vaccination-program.html. Accessed 12 June 2021. 
5. “Examples of ‘False or Misleading.’” Principles of Ethics & Code of Professional Conduct, American Dental Association, ada.org/~/media/ADA/Member%20Center/Ethics/ADA_Code_Of_Ethics_November_2020.pdf?la=en. Accessed 6 July 2021. 
6. Gostin, Lawrence O., et al. “Mandating COVID-19 Vaccines.” Journal of the American Medical Association, vol. 325, no. 6, pp. 532-533, DOI: 10.1001/jama.2020.26553. Accessed 1 June 2021. 
7. “Ethics of Vaccination.” American Dental Association Council on Ethics, Bylaws & Judicial Affairs, ada.org/~/media/ADA/About%20the%20ADA/Files/The_Ethics_of_Vaccination.pdf. Accessed 6 July 2021. 
8. “Employer Best Practices and Policies.” California Dental Association, 8 June 2021, cda.org/Home/Resource-Library/Resources/category/environment-and-radiation/employer-bestpractices-and-policies. Accessed 2 June 2021.