Ought to health-care employees be required to get coronavirus photographs? Firms grapple with mandates.

Silverado medical directors and nurses, human resource specialists and lawyers teased out the pros and cons of a mandate. Initially, they rejected that idea in favor of long, frequent webinars urging the shots and on-site vaccination clinics starting the first week of January at the company’s Austin, Dallas and Houston facilities.

Then, Silverado pivoted. When the first round of vaccination clinics companywide ended, no site had more than about 80 percent of the staff immunized, and a few were at barely half. The pandemic’s winter surge, meanwhile, brought frightening coronavirus variants into a half-dozen California facilities. On March 1, Silverado, with 1,340 memory-care workers and 1,100 cognitively impaired people in locations from Los Angeles to Alexandria, Va., became the nation’s first long-term care company to require that employees have at least an appointment for a shot as a condition of their job.

The question of whether employers should compel their workforces to be immunized against the coronavirus is rippling through the health-care industry and beyond. It is a question of uncommon intricacy, involving public health, ethics, law, labor relations and ingrained American values.

Largely hypothetical while the three coronavirus vaccines allowed in the United States were in scarce supply, the debate is building in intensity as doses become more plentiful and as President Biden says every U.S. adult should be able to sign up by May 1 to be immunized.

Whether bosses should be able to dictate a protective shot is a polarizing matter among front-line health-care workers, according to a recent Washington Post-Kaiser Family Foundation poll. Among health-care workers who have an employer, rather than being self-employed, nearly 6 in 10 said they would support their boss requiring vaccination for all employees who work with patients. Slightly more than 4 in 10 said they would oppose such a mandate.

Objections are considerably greater among the roughly 3 in 10 health-care employees who said they did not intend to get vaccinated or had not decided by the time the survey was conducted, Feb. 11 to March 7. Within that group, more than 8 in 10 said they would oppose a vaccine requirement, and nearly two-thirds said they would leave their job rather than get a shot.

The schism in attitudes plays out against a reality that is beginning to shift on the ground. At least a half-dozen other companies that house the elderly or infirm have announced imminent vaccine mandates. Atria Senior Living has said a “Sleeve Up” campaign will require its 10,000 employees to have at least one shot by May 1. Sunrise Senior Living just announced that all of its workers must be fully vaccinated by the end of July.

Among health systems, Houston Methodist last week became the nation’s first to announce that vaccination would be mandatory for the 26,000 employees at its eight hospitals and many outpatient settings, starting with managers, who must get at least one shot by April 15, or risk suspension or layoff.

The mandate-or-not debate has spread beyond health-care companies, whose workers have been caring for patients throughout the pandemic, to other businesses now considering when and how to reopen offices shuttered for the past year while employees worked from home.

“Everybody is thinking about it,” said Lorraine M. Martin, president of the National Safety Council, a group of 16,000 U.S. businesses and organizations. “A lot of companies are calling each other, trading notes, trying to land in the right place.”

According to the poll, the general public is more receptive than health-care personnel to bosses telling workers they must get a shot. The survey included adults who are not health-care workers, and 7 in 10 of them said they would support a vaccine requirement for health-care employees who work with patients, while 3 in 10 said they were opposed.

At Silverado, president and chief executive Loren Shook knew the workforce needed to get to a company equivalent of herd immunity, with hugs and hands-on care embedded in its approach to housing people with dementia and other cognitive decline — “the most vulnerable population there is,” he said.

The stakes were large. Each time someone tested positive for the coronavirus, a facility went on lockdown. No family visits. Uncomfortable nasal swabs to test residents who might not understand what was being done to them.

And yet Shook and other senior leaders feared employees would quit over a mandate — something the company could ill afford after a year of worker stress, burnout, long leaves to be with children schooled at home.

The afternoon of Feb. 9, more than 1,000 Silverado employees were on an all-staff webinar when the March 1 mandate was announced.

Shook said he believes it was the right, hard decision.

“We’ve suffered losses of people getting sick and going to the hospital, and that’s not okay,” he said in an interview. “When we can do something about it, and we have a gift of a lifesaving vaccine, it is our responsibility to have the courage to use it.”

An ethical quandary

This spring’s debate over whether companies should compel protection against the coronavirus, which has infected at least 30.6 million people in the United States and killed nearly 556,000, is heir to a controversy that has lingered for more than a century, pitting public health against individual liberty.

The winter of 1905, the Supreme Court ruled that the Cambridge, Mass., board of health had the authority to require that city’s population to be vaccinated against smallpox, as the infectious disease sparked outbreaks.

“Vaccination mandates are ethical,” said Lawrence O. Gostin, a professor at Georgetown University Law Center with expertise in health law. “Everyone has a right to make decisions about their own health and welfare, but they don’t have a right to expose other people to potentially dangerous or even lethal diseases.”

State and local governments have a long history of requiring certain vaccinations for schoolchildren. Compelling adults to be vaccinated is rare.

The coronavirus vaccines in use so far in the United States — manufactured by Pfizer-BioNTech, Moderna and Johnson & Johnson — have an extra wrinkle. They are being allowed by the Food and Drug Administration for use on an emergency basis. They have yet to be granted full FDA approval, though Pfizer has said it plans to apply for the more thorough evaluation and stamp of approval this month.

Gostin noted that the FDA’s emergency use authorizations specify that each person being vaccinated must give consent. As a result, he said, the government “mandating a vaccine that’s only authorized for emergency use is a gray area of legality and may be unlawful.”

The Centers for Disease Control and Prevention has been silent on the question of the government or anyone else compelling vaccination. So has the Occupational Safety and Health Administration.

However, in December, the Equal Employment Opportunity Commission said as part of lengthy guidance about the pandemic that employers deciding to mandate coronavirus vaccines would not run afoul of federal disability law or civil rights statutes on discrimination.

The EEOC said an employer could exclude an employee from a workplace if refusing to be vaccinated posed too great a threat. But, the agency said, the worker must be offered accommodations such as telework or a leave, and employers must allow exemptions when a shot would conflict with religious beliefs.

For many health-care companies, this guidance has not clarified what they should do.

Providence is a health system with 51 hospitals, more than 1,000 clinics and 120,000 employees in seven Western states. It was on the pandemic’s ground floor. The first known U.S. patient with covid-19, the disease caused by the coronavirus, walked into a Providence clinic near Everett, Wash., to be tested in January a year ago and, when he tested positive, was treated for five weeks at Providence’s hospital in Everett.

“If I could wave a magic wand, I’d love to mandate” a coronavirus shot, said Amy Compton-Phillips, Providence’s chief of clinical care. But, she said, “without full-on FDA saying absolutely, this is permanently approved ever more, we just don’t feel we can do that. We’d have to look our unions in the eye. . . . It’s not quite the same firm ground to stand on.”

With 70 percent of the Providence workforce vaccinated so far — higher percentages among doctors and other professional staff — the health system is treating the coronavirus vaccine the same way it does flu shots. It holds a campaign each year to encourage workers to get a flu shot and gives them a choice: get vaccinated or, in the time when masking was uncommon, wear a mask.

It is unclear whether that will remain Providence’s stance on the coronavirus vaccine. “We’ll think about it down the road,” Compton-Phillips said. “As we get more and more data on how safe it is, how well it works, how long lasting the protection is, it will be much easier to mandate the vaccine.”

Across the country, “hospitals are beginning to ask the question, ‘Should we?’ ” said Nancy Foster, the American Hospital Association’s vice president for quality and patient safety. For now, she said, even ones that require flu vaccine are not going that far for coronavirus immunization. They are encouraging vaccination and, increasingly, offering time off to get vaccinated or even cash bonuses.

‘It saves lives’

A phlebotomist named Taheera at Morristown Medical Center in New Jersey has not gotten a flu vaccine, even after Gov. Phil Murphy (D) last year signed into law a requirement that employees of hospitals, long-term care facilities and other health-care settings receive a flu shot by each December, unless they have a medical reason not to.

She does not intend to get a coronavirus shot, either, she said. “There is too much unknown” about the vaccine, said Taheera, 39, who is divorced with four children and spoke on the condition that her last name not be identified, to avoid criticism from co-workers. “I’m cautious, of course,” she said. “Keep your immune system boosted. Wash your hands.”

About three months ago, when the hospital began offering coronavirus shots to employees, she began getting texts on her phone every day urging her to sign up.

“I just ignore ’em, but it is a little annoying, because I don’t want to hear about it,” Taheera said. Her hospital imposing a mandate would be “violating your rights,” she said. “I don’t like people to force me to do something I don’t want to do, especially when it involves my body.”

In contrast, Tammy Day, who cleans operating rooms after surgeries at Beaumont Hospital, Dearborn, near Detroit, would be delighted if her health system required the vaccine. The number of covid-19 patients in Beaumont’s eight-hospital system soared from 135 on March 1 to 593 the last day of the month, as Michigan endures a fourth pandemic surge.

Day, 47, keeps hand sanitizer in her car, her coat pockets, the coat pockets of her husband and their three college-age children, and in everyone’s backpacks. Since the pandemic began, she said, “I haven’t gone anywhere, I don’t do anything” except go to the hospital where she has worked for 28 years and make quick trips to the grocery store.

When Beaumont began offering its workers coronavirus shots, she drove the half-hour to the company’s corporate offices two days before Christmas. Her second shot was Jan. 14.

The other day, when the head nurse for the operating rooms convened a department huddle, Day said, the nurse mentioned vaccination would be required for visitors to patients who do not have covid-19. Day said there was talk, too, of a possible mandate for workers, if the union went along, even though a Beaumont spokesman said that is not the plan.

Some of her co-workers told her they would refuse to get it, Day said. “I had one guy tell me it has a microchip in it so they can track us,” she recalled, incredulous.

But she said, “I think it’s great, I think everyone should get it. It’s like polio [vaccine] or anything else. It saves lives.”

The Post-KFF poll found that 1 in 6 health-care workers overall said they would leave their jobs rather than get vaccinated.

When Silverado’s March 1 mandate began, company officials weren’t sure how many employees might object. Its requirement applies to all employees at the memory-care facilities but not to 700 or so workers at hospices the company runs.

So far, 137 employees — about 10 percent of the memory-care workforce — have asked for an exemption. The company granted three dozen of the requests on religious or medical grounds. Ten people resigned, and slightly more than two dozen are on leaves of absence while they think through what to do. The rest got their shots.

Scott Clement and Emily Guskin contributed to this report.