Ethical Review of COVID-19 Vaccination Requirements for Transplant Center Staff and Patients

Olivia S. Kates; Peter G. Stock; Michael G. Ison; Richard D. M. Allen; Patrizia Burra; Jong Cheol Jeong; Vivek Kute; Elmi Muller; Alejandro Nino-Murcia; Haibo Wang; Anji Wall


American Journal of Transplantation. 2022;22(2):371-380. 

In This Article

Abstract and Introduction


Transplant centers seeking to increase coronavirus disease 2019 (COVID-19) vaccine coverage may consider requiring vaccination for healthcare workers or for candidates. The authors summarize current data to inform an ethical analysis of the harms, benefits, and individual and societal impact of mandatory vaccination, concluding that vaccine requirements for healthcare workers and transplant candidates are ethically justified by beneficence, net utility, and fiduciary duty to patients and public health. Implementation strategies should mitigate concerns about respect for autonomy and transparency for both groups. We clarify how the same arguments might be applied to related questions of caregiver vaccination, allocation of other healthcare resources, and mandates for non-COVID-19 vaccines. Finally, we call for effort to achieve global equity in vaccination as soon as possible.


Coronavirus disease 2019 (COVID-19) vaccine mandates have been proposed in a wide range of contexts. COVID-19 vaccines decrease the risk of acquiring COVID-19, experiencing severe disease or death, and passing COVID-19 to others, whereas reports of serious harm from vaccines are extremely rare.[1] Transplant centers responsible for the care of vulnerable patients and for stewardship of donor organs are among the institutions contemplating vaccine mandates. For transplant center staff, as for all healthcare workers, there is a familiar precedent in mandatory influenza vaccination.[2] Many healthcare organizations have already imposed COVID-19 vaccine mandates, and countries like Italy and France have imposed healthcare worker vaccine mandates at the national level.[3–7] Other countries including South Africa do not constitutionally allow for vaccine mandates.[8]

Mandatory vaccination for transplant candidates may also be ethically justifiable. A recent manuscript summarized ethical arguments in favor of and against requiring routine vaccines prior to solid organ transplant listing citing net utility, stewardship, and beneficence in the justification of mandates versus justice and respect for persons in arguments against mandates.[9] At least one transplant center in the United States has been named in the media as denying liver transplantation to a candidate who refused pretransplant COVID-19 vaccination.[10]

We believe that it is essential to specify the ethical analysis of vaccine mandates for staff and candidates to the novel context of COVID-19 vaccination. Such policies have individual and public health implications, so we present an analysis incorporating individual- and public health-oriented bioethics principles, including non-maleficence, beneficence, and respect for autonomy; net utility, transparency, and justice.[11,12] We first address COVID-19 vaccine mandates for transplant center staff, drawing on previous literature for influenza vaccines. Indeed, many of the ethical arguments supporting COVID-19 vaccine mandates for transplant center staff apply equally to all healthcare workers. We then address requirements for transplant candidates. We conclude by acknowledging the broader context surrounding proposed COVID-19 vaccine mandates, including vaccination of caregivers, use of vaccination status in allocation of other healthcare resources, mandates for other vaccines, and stark inequities in vaccine availability around the world.