Vaccination, ethics and health care workers.

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Vaccination, ethics and health care workers.

Flu season will soon be upon us and once again the issue of “encouraging” or perhaps “coercing” health care workers to get vaccinated will be upon us. The accepted evidence is that flu vaccination is the best available method for reducing both the spread and the influence of influenza. Therefore, because health care workers care about the safety of their patients there are good ethical reasons for getting vaccinated. Health care organizations should encourage vaccination as a legitimate patient safety initiative and I would argue health care professional associations should do the same. Health care organizations also have an obligation to ensure that vaccination is as easy as possible. However, what happens when vaccination rates in a particular organization remain low? One approach, increasingly adopted by hospitals in Ontario was to adopt a “vaccination or mask” (VOM) policy. A VOM policy requires hospital staff to be vaccinated – or, if they cannot or choose not to be, they must wear a mask. The nuances of the policies vary, sometimes a mask is required for the entire flu season sometimes it is only required when there is an outbreak – either in the community or within the hospital. Hospitals argue that the legitimate goal of protecting patients permits them to introduce such polices and that employee rights are respected in that the employee can choose his or her method of patient protection. These policies resulted in a number of grievances being filed across the province and the first of those regarding the Sault Area Hospital was adjudicated this month. Arbitrator’s decision in the Sault Hospital’s Vaccinate or Mask policy. The arbitrator was asked to – and did, evaluate all the scientific evidence presented. He took the view that it was his job to decide on the weight of the evidence, not to declare a “draw” in the face of competing evidence. An alternative approach would be to accept that an employer has the right to act on the basis of “good” though not unchallenged evidence. The arbitrator found that the vaccination or mask policy was introduced to drive up vaccination rates and that the requirement to wear a mask for the entire flu season (up to six months) was not warranted on the grounds of patient safety. The policy was therefore found to be coercive. The arbitrator took the way in which the vaccination or mask policy had been adopted and implemented to be significant. The, “or mask” part of the policy was adopted quite clearly as a means of driving up vaccination rates and the mask requirement was introduced despite the lack of evidence that surgical masks would make an appreciable difference to patient safety. A sledgehammer and a nut. The benefits to patients of a vaccination or mask policy accrue if transmission from health care workers to patients is diminished. But the benefits of the policy only come from diminished transmission by those HCWs that only got vaccinated or wore a mask because of the policy. Many HCW would get vaccinated or wear a mask regardless of the existence of a VOM policy. The evidence that reduced transmission from this group is significant is lacking. The policy that requires wearing a mask for the whole flu season is therefore disproportionately onerous and unjustified. Further, if wearing a mask was warranted on the grounds of patient safety, then, in a year where there is a significant mis-match between the vaccine and the prevalent flu strain, rendering vaccination substantially ineffective, all staff, vaccinated or not, should be required to wear a mask. This, of course, does not happen. Ethics and policy. An ethicist should probably not be seen arguing for the limits of ethics and policy setting but it is worth pointing out one other significant and salutary part of the arbitrator’s discussion. The Toronto Academic Health Science Network’s Healthcare Worker Influenza Immunization Working Group published a report in February 2014. In that report the ethical considerations relevant to influenza vaccination policies were reviewed. They included the duty not to harm others, proportionality, individual liberty, and privacy. They concluded that VOM policies were less intrusive than simple vaccination-required policies, and that VOM policies would be ethically defensible if voluntary vaccination rates remained low. The report also identifies that the key factual pieces – that mask use reduces transmission or that VOM policies have resulted in reduced outbreaks of influenza in hospitals would have to be established. However, the report contains no evidence that supported either of those two key factual components. In ethics there is a long-standing division between “facts” and “values,” or between “is” and “ought.” Roughly, the facts alone cannot tell you what you “should” ethically do. However, ethical reasoning often relies heavily on facts. Often in our ethical decision-making we argue, we should do this because – it fits with our values or principles, and these are the relevant facts. But the facts have to be there and they have to be right. Do you get vaccinated? (I do.)

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