Ethical arguments strong for mandatory vaccination
Patients’ welfare is key
Public health interventions that are mandatory and infringe on personal liberty and autonomy can be ethically justified — but only if the interventions are reasonably safe and effective, voluntary participation has failed, and many people will be harmed if the intervention does not occur, according to Alan R. Fleischman, MD, clinical professor of epidemiology and population health at Albert Einstein College of Medicine. "I believe mandatory flu vaccination programs for health care professionals meets these criteria, and should be widely implemented," he concludes.
The Centers for Disease Control and Prevention surveyed 2,348 health care providers in April 2012 and found that 66.9% reported having had an influenza vaccination for the 20112012 season.1
The main ethical concern in the debate regarding mandatory influenza vaccination of health care workers is the potential tension between protecting patients’ welfare and restricting workers’ liberty, says Armand H. Antommaria, MD, PhD, FAAP, director of the Ethics Center at Cincinnati (OH) Children’s Hospital Medical Center.
"Given their role, health care workers have an ethical obligation to be vaccinated," says Antommaria. "Unfortunately, voluntary vaccination programs have not been sufficiently effective."
Flu epidemics continue to kill largenumbersof people each year, and while immunization is not fully protective against the flu, it greatlydiminishesthe likelihood of infection and attenuates the severity of the illness, says Alan R. Fleischman, MD, clinical professor of epidemiology and population health at Albert Einstein College of Medicine in Bronx, NY.
"Overriding the strongly held principle of autonomy should only be considered when an individual’s decision directly injures others," he says. Studies show that infected health care professionals frequently transmit flu to vulnerable patients, which can result in very serious illness and death.2
"In addition, the vaccine appears to be safe, with very few serious acute reactions or long-term complications," says Fleischman. "These are the facts that must be taken into account as one discusses the question of mandatory immunization in health care workers."
Putting patients first
Another ethical consideration is the obligation of health care professionals to behave in a manner consistent with ethical codes of practice, which clearly prioritize patient interests over personal concerns and well-being. "The ethical principle of beneficence asks each health care professional to maximize benefits to patients and minimize harms," says Fleischman. "This principle even requires professionals to place themselves at some level of risk to protect the interests of their patients."
Serious efforts to educate and incentivize health care workers to obtain immunizations have not resulted in a substantial majority of workers being immunized. "Whether this is misunderstanding the risks of immunization, fear of shots in general, or a fatalistic belief that whatever will be will be’ when it comes to illness, health care workers, particularly nurses and aides, have not voluntarily agreed to annual immunizations in sufficient numbers to counter the argument for requiring vaccination as a prerequisite to employment or work," says Fleischman.
Mandatory immunization programs have been successful in various hospitals, nursing homes, and health care systems, resulting in close to 100% rates of vaccination.3,4
"To be fair, such programs should allow individual workers to opt out for personal medical reasons," says Fleischman. "Workers should be compensated for any lost wages or costs that might result from an acute or long-term complication of the mandatory immunization program."
As for what types of exemptions should be granted, Antommaria says policies might legitimately exclude workers without direct patient contact, but should treat all workers with direct patient contact equally.
"For example, penalties for noncompliant physicians should be as stringent as penalties for noncompliant janitorial staff," says Antommaria.
If conscientious objections are prohibited, medical exemptions must be justified because they also place patients at risk, he adds. "Granting nonmedical, conscientious objections does not fundamentally undermine the goals of mandatory immunization programs," says Antommaria. "If you prohibit such exemptions to protect patients, you have to explain why you are willing to grant medical exemptions which also place patients at risk."
2. Wendelboe AM, Avery C, Andrade B, et al. Importance of employee vaccination against influenza in preventing cases in long-term care facilities. Infection Control and Hospital Epidemiology 2011;32:990-997.
3. 2007 National Influenza Vaccine Summit Immunization Excellence Awards: Virginia Mason Medical Center’s Mandatory Vaccination Campaign. 2007. Presentation at Flu Summit; April 20, 2007; Atlanta, GA. Available at:http://www.preventinfluenza.org/summits/2007/Session_Four/Hagar_2007.pdf.
4. Mandatory flu vaccination program achieved almost total compliance. March 23, 2009. Available at:http://www.pediatricsupersite.com/view.aspx?rid=38084.
- Armand H. Antommaria, MD, PhD, FAAP, Director, Ethics Center, Cincinnati (OH) Children’s Hospital Medical Center. Phone: (513) 636-3656. E-mail: firstname.lastname@example.org.
- Alan R. Fleischman, MD, Clinical Professor of Pediatrics/Clinical Professor of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY. Phone: (917) 439-6364. E-mail: email@example.com.