Coronavirus

The Unique Obligation of Healthcare Workers to Receive the COVID-19 Vaccine

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Sharon Galper Grossman and Shamai Grossman

 

“We’re the suicide squad. Isn’t it enough we were stuck on the front lines? First there was not enough personal protective equipment. Now they want us to be guinea pigs and be the first to receive the COVID-19 vaccine. I won’t take it, and nobody can force me!” lamented Nurse Rafael to Doctor Chaya.

Although the COVID-19 pandemic is now the leading cause of death in the US, not everyone will rush to take advantage of the newly released vaccine. Vaccine hesitancy is rampant in the US, Israel, and Europe. Even physicians, who will be the first to be offered the vaccine, are reluctant to take it. In an August 2020 survey, more than 20% of Israeli doctors and 40% of nurses responded that they would refuse a COVID-19 vaccine, primarily due to concerns regarding its safety.[1] Physicians caring directly for COVID-19 patients were more likely to consent to be vaccinated than were those caring for non-COVID patients. In Russia, 52% of medics said that they would refuse.[2] In England, 40% of doctors would not vaccinate immediately.[3] The American Nurses Foundation reports that 36% of nurses will refuse the vaccine and that 44% are uncomfortable even discussing the vaccine with patients.[4] Fifty-five percent of New York City firefighters won’t get vaccinated.[5] Vaccine refusal among healthcare workers is not just theoretical but has become a reality as hospitals implement vaccination and employees decline it. On December 30, 2020, the governor of Ohio reported that 60% of nursing home employees offered the vaccine had refused it.[6] In Riverside, California, 50% of healthcare workers declined the vaccine, forcing public health officials to scramble to figure out what to do with the unused doses.[7] While many professionals now work remotely to mitigate the risks of infection, most health-care workers (broadly defined as but not limited to doctors, nurses with direct patient contact, paramedics, EMTs, social workers, case managers, and physical therapists, as well as lab technicians responsible for drawing blood, radiology technicians, orderlies, housekeeping staff, and food service workers) do not have this luxury. Vaccine refusal among healthcare workers is particularly worrisome as they face an increased risk of infection in the workplace; if infected, they could spread the virus not only to their families and colleagues, but also to patients, whose weakened immune systems make them among the most vulnerable members of society. To date, the CDC reports that more than 377,000 US healthcare workers have developed COVID-19 infections.[8] Compared to the general community, frontline health care workers have an 11.6-times higher risk of testing positive, and those with inadequate access to PPE, a 23% higher risk. These results suggest that even PPE and vigilant adherence to safety guidelines cannot mitigate the risk to healthcare workers, and highlight the critical role that vaccination will play in reducing these risks.[9]

Although with rigorous adherence to infection control measures, hospital-acquired COVID-19 infection and COVID clusters are rare,[10] when such flare-ups occur they can spread rapidly. In one case, a single emergency department patient infected 119 others in one hospital, including 80 healthcare workers, many of whom did not have direct contact with COVID-19 patients.[11] An outbreak at the Brigham and Women’s Hospital, a major teaching hospital at Harvard Medical School, exemplifies the public health risk that unvaccinated healthcare workers pose. A physician treating a patient who initially tested negative for COVID-19 developed mild symptoms that he attributed to seasonal allergies. He continued to interact with patients and staff for several days until COVID-19 testing showed that he was infected. By the time the patient and treating physician tested positive and the hospital initiated contact tracing and efforts to contain the outbreak, the virus had spread to two patient units, infecting 42 employees and 15 patients.[12] Overall, this cluster ended up including 650 people. Because COVID-19 is contagious in asymptomatic or pre-symptomatic individuals, creating an absolutely risk-free environment through rigorous adherence to masking and social distancing is virtually impossible. Even with full implementation of infection control measures, there is still potential for an outbreak.

Because the vaccine has only recently received Emergency Use Authorization from the FDA, neither the government nor employers have established a policy regarding healthcare workers who refuse to be vaccinated. The U.S. Equal Employment Opportunity Commission has issued guidance that employers may require proof of COVID-19 vaccination for employment and bar those who refuse.[13] In addition, employers could compel vaccination by denying bonuses to unvaccinated workers and enforcing quarantine restrictions for unvaccinated workers exposed to the virus.

Ethicists support the morality of mandating vaccination for healthcare workers. They argue that these employees chose a profession that obligates them to prioritize the welfare of their patients over their own health and that as they must already comply with licensing and safety regulations, COVID-19 vaccination merely adds one additional safety requirement in order for them to practice their profession.[14]

In light of the reality that COVID-19 vaccination will play a central role in ending the pandemic, that a substantial percentage of healthcare workers might refuse to be vaccinated, and that this refusal might endanger them, their colleagues, and their patients, it behooves us to determine whether Dr. Chaya, Nurse Rafael, and their healthcare worker colleagues have a greater halakhic obligation to receive the vaccine than those who do not work in healthcare. Clearly, physicians have an obligation to heal and prevent harm to their patients. But what are the limits of this obligation? Does the obligation to prevent harm apply in situations when fulfilling this obligation would place the healthcare worker in possible danger due to a vaccine which carries with it some risk (albeit negligible) and which has no long-term safety data?

The Obligation to Receive the COVID-19 Vaccine: the General Population[15]

Several factors might create a halakhic obligation for the general public to receive the COVID-19 vaccine, including preventing harm to one’s self and others, and the duty to contribute to herd immunity. Halakhah requires us to protect others from danger. Sanhedrin 73a derives this obligation from the mitzvah of lo ta’amod al dam re’ekha, do not stand idly by your brother’s blood. Does this obligation persist even when rescuing leads to self-endangerment? Beit Yosef Hoshen Mishpat 427 cites Talmud Yerushalmi Terumot Chapter 8, which requires a person to place himself in possible danger to save someone else from definite danger. However, Shulhan Arukh Hoshen Mishpat 426 does not codify this position into law. Rav Yehoshua Falk Katz (Sma Hoshen Mishpat 426) attributes this omission to the fact that Rambam, Rif, and Tur do not cite the Yerushalmi.

Radbaz was asked how to respond if the government demands, “Cut off your limb or we will kill your friend.” In two places (Radbaz 3:627 (1052) and Radbaz 5 Li-leshonot ha-Rambam:218 (1582)), Radbaz discusses the obligation of rescuing despite danger to the rescuer. If one can save without incurring personal risk, for example by waking someone who is asleep against a shaky wall, he must do so. If there is a small possible risk to the rescuer, the rescuer is obligated to rescue. When the risk to the rescuer is safek shakul (50%), rescue is permitted but not required. When the risk to the rescuer is nearly certain, Radbaz considers the rescuer a hasid shoteh, a pious fool, and rescue is prohibited. Hatam Sofer Ketubot 61b holds that one is obligated to endanger one’s self to save someone else without distinguishing between levels of risk. Arukh Ha-Shulhan Hoshen Mishpat 321:8 writes, “There is no clear fundamental rule when it comes to how much danger a person should engage in to save another person. Rather it is also based on the case and should be weighed carefully, but one should not protect himself excessively or be overly cautious.” Pithei Teshuvah Hoshen Mishpat 426 states that we do not consider every remote risk as pikuah nefesh, and that if there is no risk of death, the rescuer is obligated to save. Mishnah Berurah 329:19 explains that anyone who demonstrates excessive caution at the expense of others will merit the danger from which he failed to protect them. While these poskim obligate one to incur a small risk of danger to save others, not all poskim agree.[16] Tzitz Eliezer 9:17 (5) holds that generally, one is not obligated to place one’s self in a possible danger to save those in danger, but cautions against overestimating the danger to the rescuer. However, he suggests that Halakhah approaches a physician differently. The physician must avoid being overly cautious and refraining from saving the sick due to excessive stringency. A physician who does so, according to the Tzitz Eliezer, is a hasid shoteh.

As conspiracy theories abound and misinformation regarding the dangers of the vaccine circulate, the exhortations of Mishnah Berurah and Tzitz Eliezer that one determine the true dangers of the rescue become particularly relevant to the COVID-19 vaccine. The vaccine has a 95% efficacy rate, prevents those who are vaccinated from becoming infected and infecting others, and has no known serious adverse effects. What about the concern that the vaccine is new and lacks data regarding side effects and long-term safety? We will know this answer with certainty only after millions of people have received it and have been monitored for many years. However, in general, long-term side effects of vaccines are rare (on the order of 1 in 1,000,000). There is no reason to assume that the effects of the COVID-19 vaccine will be any different. It would therefore fall into Radbaz’s definition of a minimal risk for which the rescuer is obligated to rescue. Halakhah obligates Dr. Chaya, Nurse Rafael, and their healthcare worker colleagues to assess with intellectual honesty the true risks of the vaccine and to distinguish between a known danger and a possible one. They may not justify the rejection of a beneficial therapy on the principle of avoiding potential negligible danger.

Contemporary poskim have already begun to issue rulings regarding the COVID-19 vaccine. In the haredi world, several rabbis have spoken out against vaccination. Rav Aaron Yitzchak Stern has cautioned against vaccinating until billions have been vaccinated without any evidence of side effects. However, this requirement might be both dangerous, as vaccinating billions of people will take years, and impossible, as all medical interventions have some risk, albeit minimal. Of note, he does not explain the reason behind his ruling.[17] Several haredi rabbis issued a Da’at Torah warning of “the horrible dangers” of the vaccine and instructing Jews to do everything possible to prevent vaccination. They accuse the manufacturers of bribing the press and rabbis in Israel and the United States with propaganda to seduce the public into vaccinating, and claim that the vaccine will lead to controversy and compromise shiddukhim. One of the signatories, Rav Shmuel Kaminetsky, subsequently issued a hand-written statement denying any connection to the document and encouraging people to consult with their physicians regarding the importance of vaccination.

The Orthodox Union and Rabbinical Council of America, in conjunction with Rav Mordechai Willig and Rav Hershel Shachter, have stated that getting a COVID-19 vaccination is a Torah obligation that people should perform at the first opportunity.[18] They base this obligation on the halakhic requirement to care for one’s health, protect others from harm and illness, and “defer to the consensus of medical experts in determining and prescribing appropriate medical responses to both treating and preventing illness.” Rav Yuval Cherlow also obligates COVID-19 vaccination for the following reasons: the dangers of infection and remaining unvaccinated outweigh the dangers of the vaccine; the obligation to prevent harm to others is greater than the obligation to prevent personal harm; and Halakhah obligates us to take all possible steps to end the pandemic and conserve healthcare resources for the treatment of other dangerous diseases.[19] In a five word statement, Rav Chaim Kanievsky instructed the public to get the vaccination and to not be afraid of any side effects.[20] He did not offer an explanation for his position. Rav Asher Weiss permits and strongly encourages vaccination, although he does not classify getting a COVID-19 vaccination as a halakhic obligation, because of the potential to mitigate the risks of infection by social distancing and masking.[21] Rav Mordechai Willig and Rav Yona Reiss have separately pointed out that social distancing measures are not fool-proof and that people often have temporary lapses in compliance.[22],[23] Rav Reiss adds that opting for continued social distancing over vaccination ignores the halakhic obligation incumbent upon everyone to contribute to herd immunity; the greater the number of people who vaccinate, the sooner the world will reach herd immunity, ending the pandemic. Although Rav Weiss does not directly address the obligation of a healthcare worker to receive the COVID-19 vaccine, he discusses the unique situation of physicians who are scheduled to receive the vaccine on Shabbat. He identifies two factors that might allow for leniency – their status as a high-risk population and the possibility that if they became infected they could infect many patients, including those suffering life-threatening illnesses.[24]

None of the poskim who have rendered an opinion regarding the permissibility or obligation of COVID-19 vaccination have specifically addressed the particular obligation of healthcare workers. Those poskim who permit but do not obligate COVID-19 vaccination for the general population might view healthcare workers as a separate category with a unique obligation to vaccinate. Poskim who do obligate the vaccine might see this obligation as even greater for healthcare workers. There are several reasons why healthcare workers can be viewed differently and have a unique or greater obligation to vaccinate; some apply only to physicians, while others apply to all healthcare workers.

Ve-rapo Yerape: Physicians Have a Unique Obligation to Heal

The physician’s unique obligation to heal comes from two Biblical sources: Ve-hashevota lo and lo ta’amod al dam re’ekha. Sanhedrin 73a asks, “From where is it derived that one who sees another drowning in a river, or being dragged away by a wild animal, or being attacked by bandits, is obligated to save him?” The gemara cites both verses, explaining that ve-hashevota lo teaches that one must return lost property to its rightful owner and “restore him to him,” or save his body, while lo ta’amod al dam re’ekha creates an additional obligation to hire workers to save someone in danger.

Rambam Perush Mishnayot Nedarim 4:4 writes, “It is obligatory from the Torah for a physician to heal the sick, and this is included in the explanation of the scriptural phrase ‘and thou shalt restore it to him,’ meaning to heal his body.” Torah Temimah Devarim 22, Comment 18 asks why Rambam does not cite ve-rapo yerape as the source of the obligation for the physician to heal. He answers that ve-rapo yerape merely grants the physician permission to heal, while ve-hashevota lo obligates him.

In Hilkhot Rotze’ah 1:14, Rambam codifies Sanhedrin 73a into law: “Whoever is able to save another and does not save him transgresses the commandment ‘neither shalt thou stand idly by the blood of thy neighbor.’” Dr. Fred Rosner explains the relationship between these two biblical sources: “Such a case of drowning in the sea is considered as loss of one’s body and therefore if one is obligated to save a whole body, one must certainly cure disease, which usually afflicts only one part of the body.”[25]

Shulhan Arukh Yoreh Deah 336 codifies this position into law:

The Torah has granted the physician permission to heal, and it is a religious duty that comes under the rule of saving an endangered life. If he withholds [treatment] he is regarded as one who sheds blood.

Tzitz Eliezer Ramat Rahel 21 posits that the physician’s obligation to heal is not limited to pikuah nefesh but extends to non-life-threatening situations, such as pain management “and similar situations.” Tzitz Eliezer does not define these “similar situations,” but his use of this expression suggests that the physician’s obligation to heal applies to a broad range of circumstances. Perhaps this could even include what Sefer Hasidim had said long before: that disease prevention is critical to the role of the physician. Sefer Hasidim 592 writes, “Who is the wise physician? The one who knows to warn so that one won’t come to suffer illness (even though he heals). Who is the unwise physician? The one who does not know to warn so that one won’t come to suffer illness (even though he heals).” A physician who heals but fails to prevent disease is unwise and defaults on his responsibility as a physician. In the current COVID-19 pandemic, the duty to heal requires the physician to take steps to prevent infection, which in the current circumstances includes COVID-19 vaccination.

Rav Yuval Cherlow explains that rabbis have interpreted ve-rapo yerape not just as permission for the physician to heal, but as an obligation. When asked if Halakhah obligates a physician to treat patients with COVID-19 and expose himself to infection, or whether he is merely permitted to do so, Rav Cherlow writes that ve-rapo yerape elevates the physician’s obligation to that of a soldier who must endanger himself to save others even if they face only a possible danger.[26]

Thus, once Dr. Chaya has acquired the knowledge, ability, and legal certification to heal, she has a unique obligation based on lo ta’amod al dam re’ekha, ve-hashevota lo, and ve-rapo yerape to be vaccinated, as that will promote the health and well-being of her patients by reducing their risk of infection. She will also serve as a role model in the midst of a pandemic. If physicians refuse vaccination, patients who are already skeptical of the vaccine might be even more reluctant to be vaccinated.

The Obligations of the Hippocratic Oath

Dr. Chaya’s introduction to the world of healing began with the Hippocratic Oath, and the Hippocratic Oath my also obligate physicians to receive the COVID-19 vaccination. In his statement on behalf of Tzohar regarding the obligation of the physician to treat infected patients during the COVID-19 pandemic, Rav Cherlow argues that when a physician accepts the Hippocratic Oath, she commits to caring for all patients, including those who might infect her. She may not receive the privileges of her position without fulfilling the obligations and incurring the risks associated with it. Although this teshuvah does not address the physician’s obligation to receive the COVID-19 vaccine, it establishes the Hippocratic Oath as a legitimate source for her obligation to treat infected patients. The Hippocratic Oath includes the explicit declaration, “I will prevent disease whenever I can, for prevention is preferable to cure.” Thus, the oath not only obligates the physician to treat COVID-19 patients, but also to prevent them from becoming infected. In a separate teshuvah, Rav Cherlow obligates everyone to receive the COVID-19 vaccine.[27] Based on his invocation of the Hippocratic Oath to derive a physician’s obligation to treat COVID-19 patients, Rav Cherlow would likely conclude that the oath which requires the physician to prevent disease creates an additional obligation for the physician to accept the vaccine. When she took this oath, Dr. Chaya committed to prevent disease “whenever I can,” even if such efforts put her at risk. The Hippocratic Oath certainly obligates the physician to receive a vaccine with an infinitesimal risk.

The Obligation to Treat Infectious Diseases and to Protect Oneself While Doing So

Although ve-rapo yerape, lo ta’amod al dam re’ekha, and the Hippocratic Oath obligate Dr. Chaya to treat all diseases, physicians have a unique obligation to treat patients with infectious diseases. Poskim discuss the fact that while doing so, physicians are obligated to protect themselves, which in our case would indicate that they should receive the vaccine.

Shevet Ha-Levi 8:251 forbids a physician who can treat patients suffering from a dangerous infectious disease to abandon them. When asked if a physician must care for a patient with a dangerous disease specifically in the midst of a plague or if the physician should evacuate the endemic area, Shevet Ha-Levi responds that the physician must continue to provide care. He bases his response on the example of Rabbi Akiva Eiger, who wrote that during a cholera pandemic, those who could help the sick should remain in the wards to care for them. As part of his teshuvah, Shevet Ha-Levi explicitly instructs physicians to take all available precautions to protect themselves from infection when caring for infectious patients. Applying the Shevet Ha-Levi to physicians working during the COVID-19 pandemic, this would seem to include masking, gowning, using PPE when treating infectious patients, cleaning hands with alcohol-based sanitizer, wearing clean gloves and eye protection when appropriate, avoiding direct patient contact when possible (i.e. telemedicine), showering at the end of a shift, undergoing COVID-19 testing when indicated, and especially receiving a vaccine as soon as one is available. Thus, Dr. Chaya must take all steps possible to prevent herself and her patients from contracting COVID-19, including receiving an FDA-approved vaccine that lacks long-term safety data but is likely to have few risks.

Tzitz Eliezer also offers guidance to physicians treating infectious diseases. He writes, “In principle, a person may not place himself in possibly life-threatening danger in order to save his neighbor’s life. However, when discussing physicians, this law is somewhat modified. It is permitted for a physician to assume the risk of treating patients with any type of contagious disease. Indeed, he is credited with the fulfillment of an important religious duty. When preparing to treat a patient with a contagious disease, the physician should pray to God for special guidance and protection since he is endangering his own life.”[28] Tzitz Eliezer‘s inclusion of an exhortation to pray for protection before treating an infectious patient in his discussion of the religious value of such treatment highlights the fact that protection from illness is important, especially for those treating patients. It stands to reason, then, that a physician should take active steps to prevent infection, including getting vaccinated. 

While the duty to heal, the Hippocratic Oath, and the obligation to treat infectious diseases create a unique obligation for physicians to do everything possible to prevent patients from becoming infected, several factors obligate Nurse Rafael and all healthcare workers to do so despite the potential risk.

The Obligation to Save the Community

In the midst of a pandemic, Dr. Chaya, Nurse Rafael and their healthcare worker colleagues have a unique obligation to save the community, and this obligation would also require them to get the vaccine. Taanit 11a states that one must not separate from the community in times of danger. Yam Shel Shlomo Bava Kamma 6:26 suggests that during a plague, one should escape the area, but if one has the ability to save with his money or body, he must remain to help. Magen Avraham Orah Hayyim 574:6 suggests that if one has the ability to save the community, he should remain to care for the sick. These poskim suggest that a person who can save the community must subject himself to a greater risk in order to do so, and that this obligation intensifies during a pandemic. Rav Yaakov Weiner uses an intricate analysis to define a community of sick individuals for whom a physician must care. He suggests that a minimum of two patients with infectious diseases in at least five hospitals across a city creates a community of the sick, and rules that a physician is obligated to treat even if he is treating only one sick patient.[29]

As noted, Shulhan Arukh does not codify the position of Talmud Yerushalmi that one is obligated to endanger himself in order to save someone, presumably because Talmud Bavli rules that your life takes precedence. However, Gittin 45a and Nedarim 80b suggest that when dealing with a danger to the community, the rules are different – your life might not take precedence, as the needs of the community trump those of the individual.

In a situation where the individual has the opportunity to save a community, he is obligated to do so even if his efforts will endanger him. In other words, the principle that your life takes precedence only applies when dealing with another individual. In the context of a community, the community’s needs come first. This obligation rests upon everyone who can help, not just physicians. Thus, even if the vaccine poses a small risk to Dr. Chaya, Nurse Rafael, and their healthcare worker colleagues, the importance of protecting the community from infection outweighs any risks of the vaccine. In the current COVID-19 pandemic, every member of society can protect the community by undergoing vaccination. This obligation clearly applies to and is even greater for healthcare workers than the general population as healthcare workers have a higher risk of infection and can transmit the virus to large numbers of people and to the weakest members of society.

The Healthcare Worker as Soldier

A physician on the frontlines of the COVID-19 may also have the obligation to vaccinate because of the influence their actions will have on public perception of safe health practices. During a war, Rav Zilberstein obligates the physician to place himself in danger. When asked whether a medic in a safe area who sees a wounded soldier in the line of fire must place himself in danger to rescue the soldier, Rav Zilberstien cites Rambam Hilkhot Shabbat 2 that when the enemy oppresses a Jewish city, it is a mitzvah for all Jews to help their brothers under siege and save them from their oppressor.[30] In response to the question, “But is it not prohibited to endanger oneself?” Rav Zilberstein answers that when it comes to protecting the public from danger, everyone must contribute. He reasons that if medics will not take risks to rescue the wounded, soldiers will be reluctant to fight, and the community will be in danger.

This analogy applies to all healthcare workers caring for patients during our war against COVID-19. If the public sees healthcare workers, whom they view as experts in health and disease prevention, refusing to be vaccinated, they will be reluctant to get the vaccine. In addition, fear of infection from an unvaccinated healthcare worker might deter patients from seeking medical care, thus endangering the public and increasing the morbidity of COVID-19.

Special Allowance for Occupational Risks

As we have already seen, Dr. Chaya, Nurse Rafael, and their healthcare worker colleagues may be required to receive a COVID-19 vaccine, without the potential (albeit negligible) risk being enough to forbid them to receive it. This is because the risk for healthcare workers when taking the COVID-19 vaccine would be considered an occupational risk, which Halakhah allows a worker to assume. From the phrase “for he sets his soul upon it” (Devarim 24:15), Bava Metzia 112a concludes that one must pay his worker on time, positing,

For what reason did this laborer ascend on a tall ramp or suspend himself from a tree and risk death to himself? Was it not for his wages?

Rashi explains that the worker climbed to harvest grapes or olives, risking a fall for his livelihood. From this, he suggests that one may endanger one’s self for employment. Thus, Noda B-Yehudah Tinyina Yoreh Deah 10 prohibits hunting for sport due to its danger, but permits it for employment. Similarly, Iggerot Moshe Hoshen Mishpat 1:104 permits one to participate in professional sports even though they are fraught with risk to one’s self and others. Along these lines, Tzitz Eliezer 8:15, Kuntres Refuah Be-Shabbat 5:9 rules that just as a worker may visit dangerous places for his income, a physician may place himself in possible danger to care for his patients. This is especially true if he depends on this work for income, is legally obligated to care for such patients, and abrogating this responsibility will lead to revocation of his medical license and loss of income. This leniency regarding occupational risk permits but does not obligate workers to incur such risks and suggests that Halakhah approaches work-related hazards differently than it does other dangers of daily life. Thus, Dr. Chaya may endanger herself by receiving a potentially risky vaccine (even one which carries more danger than the COVID-19 vaccine for which the risk is negligible) if vaccination is essential to performing her role as a physician and promoting the health of her patients. This special dispensation also applies to Nurse Rafael and his healthcare worker colleagues.

Incurring Risk in Daily Activities

While Halakhah merely allows workers to assume an occupational risk, physicians may be required to assume the negligible risk of the COVID-19 vaccine if it is of similar magnitude to other risks they would take. Radbaz and other poskim do not quantify the level of risk that is sufficiently low to obligate the rescuer to rescue. Instead, they propose two criteria: 1) Would Dr. Chaya, Nurse Rafael, and their colleagues incur this risk for themselves? 2) Would they incur this risk in their daily activities? If they would, then they must do the same to save others from a similar danger.

Rav Yitzchak Zilberstein was asked whether a doctor in her first trimester of pregnancy must care for someone with German measles, an infectious disease that causes birth defects or miscarriage in 20% of infected mothers.[31] In his response, he applies the standard that any level of danger that one would enter for his own personal benefit is the level at which he must save others. Someone who dives for pleasure would be obligated to dive to save another in danger. Similarly, Halakhah would require a person to rescue a neighbor from a fire if he would run into that fire to save his possessions. Conversely, if a person would never undertake such a risk for himself, he is not obligated to do so for someone else. For this reason, Radbaz did not obligate an individual to amputate his limb for someone else, because no one would do that for his own personal benefit. Applying this criterion to the pregnant doctor, Rav Zilberstein reasons that no pregnant woman would agree to expose herself to someone with German measles, even for all the money in the world, and therefore the doctor in question has no obligation to do so for the benefit of her patient. However, he suggests that if the pregnant physician were someone for whom Jewish law would permit the abortion of a defective fetus and if she would consider undergoing that abortion, she might be obligated to enter the patient’s room.

Applying these criteria to the COVID-19 vaccine, we see that if in the course of their daily activities Dr. Chaya, Nurse Rafael, and their healthcare worker colleagues would incur risks similar in magnitude to the risks of the vaccine, Halakhah would obligate them to get the vaccine. The reality that the majority of healthcare workers would consent to the vaccine despite the risk strengthens this obligation. In addition, if healthcare workers would not balk at getting a flu vaccine to protect themselves from infection or to satisfy hospital requirements to maintain their position, according to Rav Zilberstein’s criteria Halakhah might obligate them to receive the COVID-19 vaccine as well. Of course, for an individual physician with a medical contraindication to the vaccine or unique circumstances that would complicate vaccination, this obligation might be suspended.

Conclusion

In conclusion, while most poskim at least strongly encourage COVID-19 vaccination, many require it for everyone. We believe that based on the sources cited above the obligation to receive the vaccine is even greater for health care workers. This heightened obligation stems from the reality that they already incur comparable risks in their daily activities, and that Halakhah makes special allowances for occupational risks. In addition, ve-rapo yerape, lo ta’amod al dam re’ekha, and ve-hashevota lo create a unique obligation for physicians and nurses to heal, even in the face of personal danger. This obligation includes preventing an infectious disease that might endanger them, and increases when the community at large is in danger. Ultimately, healthcare workers play a vital communal role as soldiers protecting the community from infectious disease. In this capacity, they must undergo COVID-19 vaccination at the first available opportunity, even if the vaccine is associated with risk, albeit minimal, to protect themselves, their colleagues, and their patients from a pandemic that has infected more than 87,000,000 people and caused nearly 2,000,000 deaths.


[1] Ido Efrati, “A Vaccine for Coronavirus? A Large Number of Israeli Doctors Will Refuse to Get It,” Haaretz, August 17, 2020.

[2] The Moscow Times, “1 in 2 Russian Doctors Distrust New Coronavirus Vaccine – Poll,” August 14, 2020.

[3] Tim Locke, “Are UK Doctors Sceptical of COVID-19 Vaccine?Medscape, November 25, 2020.

[4] Nursing World, “Pulse on the Nation’s Nurses COVID-19 Survey Series: COVID-19 Vaccine,” January 20, 2021..

[5] NBC New York, “More Than Half of FDNY Firefighters Won’t Get Vaccinated, Union Poll Suggests,” December 6, 2020.

[6] Rick Rouan, “DeWine Says 60% of Nursing Home Workers Not Electing to Get Vaccine,” The Columbus Dispatch, December 30, 2020.

[7] Colleen Shalby and others, “Some Healthcare Workers Refuse to Take COVID-19 Vaccine, Even with Priority Access,” Los Angeles Times, December 31, 2020.

[8] CDC, “Cases & Deaths Among Healthcare Personnel,” January 17, 2020.

[9] Long H. Nguyen and others, “Risk of COVID-19 among Front-line Health-care Workers and the General Community: A Prospective Cohort Study,” The Lancet Public Health 5, no. 9 (2020).

[10] Chanu Rhee, Meghan Baker, and Vineeta Vaidya, et. al., “Incidence of Nosocomial COVID-19 in Patients Hospitalized at a Large US Academic Medical Center,” JAMA Network Open 3, no. 9 (2020).

[11] Richard Lessells, Yunus Moosa, and Tulio de Oliveira, “Report into a Nosocomial Outbreak of Coronavirus Disease 2019 (COVID-19) at Netcare St. Augustine’s Hospital,” KRISP, May 15, 2020.

[12] Brigham and Women’s Hospital, “Statement for Media Regarding COVID-19 Cluster,” October 16, 2020.

[13] U.S. Equal Employment Opportunity Commission, “What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws,” December 16, 2020.

[14] Relias Media, “Sharply Divided (and Evolving) Views on Vaccine Refusers,” July 1, 2020.

[15] For a full discussion of this topic, please see our article in Tradition Online, https://traditiononline.org/halakha-approaches-the-covid-19-vaccine/.

[16] Iggerot Moshe Yoreh Deah 2:174 (4), Tzitz Eliezer 9:17 (5).

[17] Personal Communication with Rabbanit Shani Taragin, December 2020.

[18] Orthodox Union and Rabbinical Council of America, “COVID-19 Vaccine Guidance,” December 15, 2020.

[19] Yuval Cherlow, “Is There a Halakhic Obligation Get Vaccinated Against Corona? (Hebrew),” Shabaton, December 15, 2020.

[20] Chezky Stern, “Ruling of Rav Chaim Kanievsky: We Need to Get Vaccinated (Hebrew),Kikar Shabbat, December 20, 2020.

[21] Asher Weiss, “COVID-19 Vaccine in Halacha,” Minchas Asher, December 23, 2020.

[22] Yona Reiss, “PODCAST: The COVID Vaccine and Halakha,” Tradition Online, December 23, 2020.

[23] Mordechai I. Willig, Aaron Glatt, and Yaakov Glasser, “The Covid Vaccine: Halacha and Public Policy, A Communal Conversation,” YUTorah Online, December 19, 2020.

[24] Weiss, ibid.

[25] Fred Rosner, Modern Medicine and Jewish Ethics (Hoboken, New Jersey: Ktav Publishing House,  Yeshiva University Press: New York, 1986), 11.

[26] Yuval Cherlow, “Does a Doctor Need to Put Himself in Danger in Order to Take Care of a Patient? (Hebrew),” Tzohar Ethics, March 12, 2020.

[27]Cherlow, “Obligation.”

[28] Avraham Steinberg, ed., Jewish Medical Law: A Concise Response (Beit Shammai Publications, 1989), Part 10, Chapter 11.

[29] Rabbi Yaakov Weiner, “Treatment of Contagious Diseases,” available from the Jerusalem Center for Research, P. O. Box 57058, Jerusalem, Israel.

[30] Yitzchak Zilberstein, “How Much Does a Person Need to Put Himself in Danger in Order to Save Others? (Hebrew),” Schlesinger Center for Medical Research According to Halakhah, March 2020.

[31] Ibid.

Sharon Galper Grossman, MD, MPh, is a radiation oncologist and former faculty member of Harvard Medical School where she also obtained a Masters in Public Health. She is a graduate of the Morot L’Halakha program for women’s advanced halakha learning at Matan Hasharon. She writes and lectures on women’s health and halakha and teaches for Matan, Machon Puah and the Eden Center where she is the director of community health programming. Shamai A Grossman, MD, MS, is vice chair for health care quality, Harvard Medical Faculty Physicians and Beth Israel Deaconess Medical Center, associate professor of medicine and emergency medicine at Harvard Medical School and a visiting professor at Sharrei Tzedek Medical Center. He has semicha from Yeshiva University and a master’s degree in medieval Jewish history. He is the author of over 200 peer reviewed publications and 4 books including Ethics in Emergency Medicine.