Nudges or mandates? The ethics of mandatory flu vaccination

Vaccine. 2015 May 21;33(22):2530-5. doi: 10.1016/j.vaccine.2015.03.048. Epub 2015 Apr 11.


According to the CDC report for the 2012-2013 influenza season, there was a modest increase in the vaccination coverage rate among healthcare workers from 67% in 2011-2012, to 72% in 2012-2013 to the current 75% coverage. This is still far from reaching the US National Healthy People 2020 goal of 90% hospitals vaccination rates. The reported increase in coverage is attributed to the growing number of healthcare facilities with vaccination requirements with average rates of 96.5%. However, a few other public health interventions stir so much controversy and debate as vaccination mandates. The opposition stems from the belief that a mandatory flu shot policy violates an individual right to refuse unwanted treatment. This article outlines the historic push to achieve higher vaccination rates among healthcare professionals and a number of ethical issues arising from attempts to implement vaccination mandates. It then turns to a review of cognitive biases relevant in the context of decisions about influenza vaccination (omission bias, ambiguity aversion, present bias etc.) The article suggests that a successful strategy for policy-makers and others hoping to increase vaccination rates is to design a "choice architecture" that influences behavior of healthcare professionals without foreclosing other options. Nudges incentivize vaccinations and help better align vaccination intentions with near-term actions.

Keywords: Behavioral economics; Choice architecture; Healthcare professionals; Influenza vaccination; Vaccination mandates.

Publication types

  • Review

MeSH terms

  • Health Personnel / psychology*
  • Health Policy* / legislation & jurisprudence
  • Humans
  • Influenza Vaccines / administration & dosage*
  • Influenza, Human / prevention & control*
  • Mandatory Programs / ethics*
  • Time Factors
  • Vaccination / ethics*
  • Vaccination / statistics & numerical data


  • Influenza Vaccines