When I use a word . . . . No jab, no job? A benefit:harm balance analysis

The current debate about whether individuals should be entitled to work in the healthcare sector if they decline to be vaccinated against SARS-CoV2 has been largely informed by personal opinions and argument by analogy. A benefit:harm balance analysis suggests that while vaccination has a highly favourable benefit:harm balance, the balance in instituting a “no jab, no job” policy is highly uncertain and may be unfavourable. Furthermore, there are practical difficulties and legal uncertainties. The much misunderstood precautionary principle dictates that if the benefit:harm balance of an intervention is unclear and may be unfavourable, the intervention should not be undertaken. Furthermore, the onus is on those who believe that the benefit:harm balance will be favourable to prove that it is so; it is not for the sceptics to prove that it isn’t. In the absence of good evidence in favour, this is an intervention that would be best avoided. Since the SARS-CoV2 vaccines were developed, the question of whether a policy of encouraging healthcare workers to undergo vaccination, in the absence of medical contraindications, by otherwise declining to employ them in frontline healthcare, has been the subject of a great deal of discussion, including personal opinion, sometimes tinged with emotion, and argument by analogy. Many countries have now made this mandatory for healthcare staff, including NHS staff in England, who will have to be vaccinated by 1 April 2022.1 Such discussions are by no means new, and healthcare workers are already required or encouraged to undergo some forms of vaccination against diseases such as hepatitis B as part of their employment, mandatory in some countries and recommended in others,2 3 including the UK.4 5 Every intervention we undertake in healthcare is undertaken in the expectation that it will bring benefit. Furthermore, the chance of benefit from the intervention should outweigh the possibility of harm, which can never be ruled out.6 However, failing to introduce an intervention can also lead to harm. In order to assess whether to introduce an intervention, an analysis of the benefit to harm balance is necessary. Three questions inform the assessment: 1. What is the chance of benefit from the intervention? 2. What is the chance of harm from the intervention? 3. What is the chance of harm from not intervening? When assessing these chances, the nature of the benefits and harms should be taken into account as well as the raw probabilities. So too should the availability of other interventions, which might be equally or more beneficial and less harmful. When considering any intervention in clinical practice in general, the answers to these questions should ideally come from large randomised population studies. Assessing the benefit:harm balance in an individual is more difficult because one rarely knows in advance what the likely individual response will be. Each occasion of intervention is, in effect, an experiment. That is why it is generally a good pharmacological principle, when embarking on a course of treatment, to start with a low dose of a medicine, carefully increasing the dose while monitoring for beneficial and adverse effects. But for one-off treatments, like vaccination, one has to rely on expectations from population studies. What do we find when we subject the intervention of vaccination against SARS-CoV2 and the policy of “no jab, no job” to benefit:harm balance analyses?