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 https://doi.org/10.47488/dhrp.v1iS4.17 

  
 

http://dhrproceedings.org 1 © DHR Health Institute for Research and Development 
 

 

EDITORIAL 

Should Healthcare Facilities Mandate COVID-19 Vaccination of its 
Employees?

 
There has been a lot of controversy recently 
surrounding the decision by a major healthcare 
facility in Houston, Texas mandating that all of its 
26,000 employees must be vaccinated against 
SARS-CoV-2 virus by June 07, 2021, or else face 
suspension and/or dismissal (1).  It was the first 
major hospital system in the U.S., to take this rather 
bold decision particularly since the COVID-19 
vaccine is currently being administered under an 
Emergency Use Authorization (EUA) issued on 
December 11, 2020, by the U.S. Food and Drug 
Administration (2). Houston Methodist Hospital 
has taken this decision in the best interest of patient 
safety arguing that it is a complex, team-oriented 
responsibility requiring active effort of every 
member of the healthcare team. Needless to say, 
patient safety is the most vital and tacit contract 
between the healthcare providers and the patients 
and it is the core element of the principle of non-
malfeasance – do no harm which dictates the 
practice of medicine and is the legal and ethical 
framework to which all healthcare workers ascribe.  

What has been the outcome of this decision and 
what are its ethical and legal manifestations? Since 
Houston Methodist announced their decision to 
mandate COVID-19 vaccination for all of its 
employees, over 1,200 employees have voluntarily 
left the organization and another 117 have filed a 
lawsuit against the healthcare facility in the Texas 
High Court challenging this directive (3). In this 
lawsuit, the employees have argued that their 
employer's compulsory immunization requirement 
violated the Nuremberg Code, a set of standards 
designed after World War Two to prevent 
experimentation on human subjects without their 
consent (4). They have also declared that the 
hospital presented them with the choice of either 
getting a vaccine or losing their job, which violated 
state law, and demanded that the court prevent 
Houston Methodist from firing unvaccinated 
staffers. 

It has been argued that since the COVID-19 
vaccines are being administered under an EUA, 
therefore their use must be considered 
experimental. It is important to emphasize that the 
process to issue EUA for COVID-19 vaccines 
involved a very rigorous scientific review by a panel 
of independent experts both at the level of the FDA 
and the Centers for Disease Control & Prevention. 
In this process, data from randomized placebo-
controlled studies involving over 100,000 adults 
using various COVID-19 vaccines was 
meticulously evaluated for both safety and efficacy 
(5, 6). Subsequently, similar randomized placebo-
controlled studies in pregnant women and 
adolescents also yielded analogous outcomes and 
confirmed the safety and the efficacy of these 
vaccines (7, 8). The safety and efficacy of the 
COVID-19 vaccines has also been confirmed by 
mass vaccinations in the U.S. As of June 7, 2021, 
over 301 million doses of vaccines have been 
administered in the U.S. with minimal adverse 
events (9). In Texas alone, as of June 07, 2021, over 
22 million doses of COVID-19 vaccines have been 
administered with similar safety outcomes (10). It is 
noteworthy that safety and efficacy of two of the 
three approved COVID-19 vaccines in the U.S., has 
also prompted both Pfizer-BioNTech and Moderna 
to apply for full FDA approval of their respective 
vaccines (11, 12).  

The issue of legality of mandating vaccination in the 
face of a public health crisis was addressed by the 
U.S. Supreme Court during the smallpox epidemic 
in the city of Cambridge, Massachusetts in 1905 
(13). In the case Jacobson v. Massachusetts, the 
U.S. Supreme Court upheld the right of the city of 
Cambridge, Massachusetts, to mandate vaccination 
against smallpox. Rejecting the contention that 
mandatory vaccination violated an individual's 
rights to due process and equal protection as 
guaranteed by the 14th Amendment of the U.S. 
Constitution, the Court held that states may limit 

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DHRP, 2021, Vol. 1 (S4) 1-3  Editorial 

  
 

http://dhrproceedings.org 2 © DHR Health Institute for Research and Development 
    
 

individual liberty in the service of well-established 
public health interventions. For over 100 years, this 
seminal opinion has served as the constitutional 
foundation for state actions limiting liberty in the 
name of public health.  

Additionally, on May 28, 2021, the U.S. Equal 
Employment Opportunity Commission (EEOC) 
provided an updated guidance for COVID-19 
vaccination (14). In this guidance, EEOC provided 
four key updates which included the following 
(adopted from the EEOC guidance): 

a) Federal EEO laws do not prevent an 
employer from requiring all employees 
physically entering the workplace to be 
vaccinated for COVID-19, so long as 
employers comply with the reasonable 
accommodation provisions of the American 
with Disabilities Act and Title VII of the 
Civil Rights Act of 1964 and other EEO 
considerations 

b) Federal EEO laws do not prevent or limit 
employers from offering incentives to 
employees to voluntarily provide 
documentation or other confirmation of 
vaccination obtained from a third party (not 
the employer) in the community, such as a 
pharmacy, personal health care provider, or 
public clinic 

c) Employers that are administering vaccines 
to their employees may offer incentives for 
employees to be vaccinated, as long as the 
incentives are not coercive 

d) Employers may provide employees and 
their family members with information to 
educate them about COVID-19 vaccines 
and raise awareness about the benefits of 
vaccination 

It is predictable that to ensure patient safety, 
conversations to mandate COVID-19 vaccinations 
for workers are ongoing in many healthcare 
facilities across the U.S.  A recent CNN report also 
implied that using rationale similar to that adopted 
by the Houston Methodist Hospital, two other major 
healthcare organizations in Houston, Texas are 
seriously considering implementing this mandate 
(15).  Physicians, policymakers, and public health 
officials must engage in robust discussions related 

to legal and ethical issues encompassing mandated 
COVID-19 vaccination of healthcare employees. 
These intrepid actions are vital to protect the public 
and the patients from emerging and reemerging 
infectious diseases and other similar threats. In this 
informed decision-making process, it will be 
instructive to revisit lessons learned from current 
and previous pandemics and to use them as a guide 
to design and implement an effective, scalable and 
a sustainable model that is in the best interest of the 
public and the patients. 

References  

1.  Medley, A. Houston Methodist Hospital makes COVID-19 
vaccination mandatory for all employees. April 1, 2021. 
https://www.chron.com/coronavirus/article/Houston-
Methodist-COVID-19-mandatory-vaccine-16070061.php 

2. Pfizer-BioNTech COVID-19 Vaccine Emergency Use 
Authorization – Letter of Authorization. 
https://www.fda.gov/media/144412/download  

3. Harkins, D. 117 staffers sue over Houston hospital’s vaccine 
mandate, saying they don’t want to be ‘guinea pigs’. May 29, 
2021. https://news.yahoo.com/117-staffers-sue-over-houston-
210313560.html  

4. Trials of War Criminals before the Nuremberg Military 
Tribunals under Control Council Law No. 10", Vol. 2, pp. 181-
182. Washington, D.C.: U.S. Government Printing Office, 1949. 
https://archive.org/details/TrialsOfWarCriminalsBeforeTheNur
embergMilitaryTribunalsUnderControlCouncil/Trials%20of%
20war%20criminals%20before%20the%20Nuremberg%20Mil
itary%20Tribunals%20under%20Control%20Council%20law
%20no.%2010.%20-
%20Nuremberg%2C%20October%201946-
%20April%2C%201949%20Volume%2010/page/n3/mode/2up  

5. Polack, F.P., Thomas, S.J., Kitchin, N., et al., for the C4591001 
Clinical Trial Group Safety and Efficacy of the BNT162b2 
mRNA Covid-19 Vaccine. December 31, 2020. N Engl J Med 
2020; 383:2603-2615. DOI: 10.1056/NEJMoa2034577  

6. Baden, L. R., El Sahly, H.M., Essink, B., et al. Efficacy and 
Safety of the mRNA-1273 SARS-CoV-2 Vaccine. N Engl J 
Med. 2021 Feb 4;384(5):403-416. doi: 
10.1056/NEJMoa2035389. Epub 2020 Dec 30. 

7. Shimabukuro, T.T., Kim, S.Y., Myers, T.R., et al., for the CDC 
v-safe COVID-19 Pregnancy Registry Team.Preliminary 
Findings of mRNA Covid-19 Vaccine Safety in Pregnant 
Persons.  April 21, 2021. N Engl J Med 2021: 1-10. DOI: 
10.1056/NEJMoa2104983 

8. Frenck, Jr, R.W., Klein, N.P., Kitchin, N., et.al., for the 
C4591001 Clinical Trial Group, Safety, Immunogenicity, and 
Efficacy of the BNT162b2 Covid-19 Vaccine in Adolescents. 
May 27, 2021. N Engl J Med 2021: 1-10. DOI: 
10.1056/NEJMoa2107456 

9. Centers for Disease Control & Prevention COVID-19 Data 
Tracker. June 07, 2021. https://covid.cdc.gov/covid-data-
tracker/#vaccinations  



DHRP, 2021, Vol. 1 (S4) 1-3  Editorial 

  
 

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10. Texas Health & Human Services COVID-19 Vaccination 
Dashboard. June 03, 2021. 
https://tabexternal.dshs.texas.gov/t/THD/views/COVID-
19VaccineinTexasDashboard/Summary?:origin=card_share_li
nk&:embed=y&:isGuestRedirectFromVizportal=y  

11. Edwards, E. Pfizer, BioNTech ask FDA for full approval of 
COVID-19 vaccine. May 07, 2021. 
https://www.nbcnews.com/health/health-news/pfizer-asks-fda-
full-approval-its-covid-19-vaccine-n1266569  

12. Lovelace, B., Jr. Moderna applies for full FDA approval of its 
COVID-19 vaccine. June 01, 2021. 
https://www.nbcnews.com/health/health-news/pfizer-asks-fda-
full-approval-its-covid-19-vaccine-n1266569 

13. Jacobson v. Massachusetts, 197 U.S. 11 (1905) 
https://supreme.justia.com/cases/federal/us/197/11/   

14. EEOC Issues Updated COVID-19 Technical Assistance. 
https://www.eeoc.gov/newsroom/eeoc-issues-updated-covid-
19-technical-assistance   

15. Andrew, S. A Texas hospital system will require employees to 
get the Covid-19 vaccine and could fire them if they don't 
comply. CNN: Updated 3:44 PM ET, Mon April 26, 2021. 
https://www.cnn.com/2021/04/26/us/houston-methodist-covid-
vaccine-mandate-trnd/index.html, et.al. Recent combined 
hormonal contraceptives (CHCs) and the risk of 
thromboembolism and other cardiovascular events in new users. 
Contraception. 2013 Jan;87(1):93-100. doi: 
10.1016/j.contraception.2012.09.015. Epub 2012 Oct 19. 
PMID: 23083525. 

9. Cheng Y-J, Liu Z-H, Yao F-J, Zeng W-T, Zheng D-D, Dong Y-
G, et al. (2013) Current and Former Smoking and Risk for 
Venous Thromboembolism: A Systematic Review and Meta-
Analysis. PLoS Med 10(9): e1001515. 
https://doi.org/10.1371/journal.pmed.1001515  

 

Sohail Rao, MD, MA, DPhil 

Executive Vice President, DHR Health, 5501 S. McColl 
Road, Edinburg, Texas 

President & Chief Executive Officer, DHR Health 
Institute for Research & Development, 5323 S. McColl 
Road, Edinburg, Texas 

Corresponding author email: s.rao@dhr-rgv.com 

Disclosures: None 

ORCID: Sohail Rao: https://orcid.org/0000-0001-5027-
9992 

Manish Singh, MD, FACS 

Chief Executive Officer, DHR Health, 5501 S. McColl 
Road, Edinburg, Texas 

Disclosures: None 

ORCID: Manish Singh: https://orcid.org/0000-0003-
4146-3282  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

https://doi.org/10.1371/journal.pmed.1001515
https://orcid.org/0000-0001-5027-9992
https://orcid.org/0000-0001-5027-9992
https://orcid.org/0000-0003-4146-3282
https://orcid.org/0000-0003-4146-3282

