Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers

Seven COVID-19 vaccines are now being distributed and administered around the world (figure correct at the time of submission), with more on the horizon. It is widely accepted that healthcare workers should have high priority. However, questions have been raised about what we ought to do if members of priority groups refuse vaccination. Using the case of influenza vaccination as a comparison, we know that coercive approaches to vaccination uptake effectively increase vaccination rates among healthcare workers and reduce patient morbidity if properly implemented. Using the principle of least restrictive alternative, we have developed an intervention ladder for COVID-19 vaccination policies among healthcare workers. We argue that healthcare workers refusing vaccination without a medical reason should be temporarily redeployed and, if their refusal persists after the redeployment period, eventually suspended, in order to reduce the risk to their colleagues and patients. This ‘conditional’ policy is a compromise between entirely voluntary or entirely mandatory policies for healthcare workers, and is consistent with healthcare workers’ established professional, legal and ethical obligations to their patients and to society at large.

Legal Considerations in Sign Code Development

Legal considerations have always played a critical role in the development of a sign code, but that role has taken on renewed importance in the wake of the U.S. Supreme Court's recent ruling in Reed v. Town of Gilbert, Ariz., 135 S.Ct. 2218 (2015). A detailed analysis of Reed is obviously beyond the scope of this paper. For our purposes, it is sufficient to note that the Reed Court announced a far more stringent test to determine whether a sign code's provisions are "content-neutral" or "content-based." In short, the Court ruled that any sign code provision that "on its face" considers the message on a sign to determine how it will be regulated is content-based. The practical effect of finding that a sign code provision is content-based is to heighten the judicial scrutiny of such a provision if challenged. A provision that is content-neutral is subjected only to intermediate judicial scrutiny: the provision will be upheld if government can demonstrate that the regulation serves a substantial governmental interest and is narrowly-tailored to achieve that interest. In contrast, a provision that is content-based is subjected to strict judicial scrutiny: the provision will be upheld only if government can demonstrate that the regulation serves a compelling governmental interest and is the least restrictive alternative to achieve that interest.

Intensive home treatment, admission rates and use of mental health legislation

Aims and methodWe examined the local impact of introducing a home treatment team on the use of in-patient psychiatric resources and rates of detention under the Mental Health (Care and Treatment) (Scotland) Act 2003.ResultsRates of admission to hospital and duration of hospital stay were unchanged. However, there was an increase in episodes of detention in the year following the team's introduction.Clinical implicationsOffering home treatment as an alternative to in-patient care may be associated with an increase in compulsory treatment. If true, this is incompatible with the ‘least restrictive alternative’ principle of the recently revised mental health legislation.