Flu, Pandemics and the Duty to Provide CareSeptember 8, 2009
When push comes to shove, ethical decision-making and the last ventilator…September 22, 2009
Flu season is imminent and fears of a possible H1N1 flu pandemic are rife. Recent reports from Vancouver Island suggest that there may be the beginnings of an outbreak there; and across Canada and around the world health authorities are gearing up. Those preparations of course include vaccination campaigns and various strategies are being entertained to encourage people, especially health care providers to get vaccinated. But what happens when encouragement is unsuccessful, what happens if too few health care workers agree to get vaccinated? It is unknown what percentage of healthcare workers will choose to get vaccinated this year, but in previous years, despite extensive campaigns, many healthcare organizations report vaccination rates that hover around 50%. New York State has decided to take more drastic action. It will require health care workers to get a vaccination by November 30th a move that has met with concerted opposition – particularly from the unions that represent health-care workers.
So, just what the issues at stake in mandatory vaccinations?
Community Benefit, Personal Risk
The whole point of vaccination is to eliminate, or minimize a particular disease or disorder from a community. The idea, of course, is that if sufficient numbers in a population are immune to a disease then even if that disease enters the community its spread will be limited. So, it is good for a community if its members are vaccinated. However, typically, vaccination is not completely without risk. Some very small proportion of the population may suffer an adverse reaction to the vaccine. In extreme cases the result could be permanent injury, or death. However, from a population perspective, immunity for the group is worth the risk that a very small number of members of the group suffer adverse consequences. It is in the interest of the community that we have vaccination programmes. But, of course, it does not look that way from the perspective of the person who ends up suffering as a result of the vaccine. Paradoxically, from a completely self-interested perspective each individual should wish that everyone else in the community be vaccinated in order to achieve so-called “herd immunity” while he or she does not – thus “free-loading” on the risks taken by others.
Personal risk-benefit analysis
For each individual there is also a personal risk-benefit analysis. On the one hand there is the risk of contracting the disease, on the other hand there is the risk associated with the vaccine. In some cases the risk-benefit analysis is simple. If the disease is catastrophic, and the chances of catching it are high while the known risks of the vaccine are very small, then it may well be prudent for me to have the vaccine. However, at the other end of the spectrum, if the effects of the disease are quite mild, then any risk associated with the vaccine may not be worth taking.
The risk benefit analysis is further complicated for the flu. Otherwise healthy health care workers may have little to fear from contracting the H1N1 virus; the effects on them may be relatively mild. But that is not the case for the vulnerable populations with whom the health care workers work. The more prevalent the H1N1 virus is in the population, and the more prevalent it is especially amongst health care workers, the more likely it is that significant numbers of vulnerable populations will catch the flu: with potentially catastrophic consequences.
The other set of arguments that gets offered on this topic tends to be grounded in personal freedom. What gives the state the right to tell me that I have to have a substance injected into my body? What happens to notions of bodily integrity and personal control if it is possible for the state to require an injection? How could the state justify that sort of intrusion into a person’s bodily integrity? (In passing I would suggest that the arguments grounded in religious belief are a sub set of the arguments grounded in personal freedom. It may be a person’s religious beliefs that cause him or her to wish to exercise control over his or her body in this way.)
An employer’s perspective
Let us complicate thing slightly. If an employee is sick, for instance with the flu, then he or she is unable to work. Most health care organizations provide some form of sickness benefits for their employees. If an employee is sick then not only is his or her valuable contribution lost to the community, the employer also has to continue to pay that employee. It is therefore in the interest of the employer to reduce days lost to sickness to a minimum. So, it is in the interest of an employer to encourage vaccination to prevent sickness.
Doing good for others
So far we have looked at this issue solely from a self-interested view, but there is a further, significant perspective. Vaccination for health care workers imposes a small – perhaps negligible personal risk, but the potential benefit for the vulnerable populations served by health care workers is huge. Should we, as health care workers do something with which we may not agree, for the sake of the good it will bring to others? (Pretty clearly I think the answer to that question ought to be a yes…)
So, we come back to compulsory vaccination. Much is lost if a community, or an organization uses force or power to achieve even a worthwhile or beneficial goal. Individuals are immediately pushed onto the defensive, with a reflexive retreat to “rights” and entitlement (itself a form of power.) We very rapidly get locked into an “us” versus “them” struggle where the real benefits of the programme at hand may be lost in a struggle over power and authority. So, how do we avoid that outcome? I’m sorry to sound a little clichéd here, but the way forward is through good-will and good reasoning. The good-will comes in through a reluctance to use power and a willingness to communicate openly and honestly in a reasoned and evidence-based fashion. The good reasoning will be seen in a thorough-going commitment to the use of the best available evidence. We have lost trust in our civic discourse. We are fearful that we are being deceived, or that the facts are being “spun” to achieve a predetermined outcome. In the health care community we need to rebuild that trust – not blind faith, but a trust grounded in openness and good reasons. The issue of compulsory vaccination for H1N1 for health care workers is one of the issues where we can begin to rebuild the trust in health care. If compulsory vaccination is viewed by some as necessary – just what are the evidential grounds? If some people are going to be required to give up some of their personal freedoms how do we reward them for doing that and how do we compensate them (or their families) in the tragic event that there are adverse consequences for an individual as a result of the pursuit of a community good?
Let us watch, and participate in that discussion, and let each of us be quick to reason and slow to retreat to the exercise of power.