Autonomy The apparent violation of the health care worker's autonomy is a major ethical argument against mandatory vaccination. Autonomy essentially means that a person has the right to make his or her own decisions and choices in regard to his or her own body once fully informed of the situation.8 If a patient has the right to refuse vaccination, doesn't this same privilege apply to the health care worker?
Nonmaleficence As with all ethical issues, a balance must be found between the competing interests. McLennan and colleagues argue that the possibility of doing harm to others by spreading an infection is a compelling interest that would override the principle of autonomy.4 van Delden and colleagues state that "the prevention of harm to others is considered a legitimate cause for constraints on autonomy."19
Reasons for not being vaccinated include concerns about possible adverse reactions, a perception of not being vulnerable to infection, and a belief that the vaccine is not effective.4 The influenza vaccine is not 100% effective; however, vaccination does dramatically decrease the incidence of disease. Fear of possible adverse effects is held by some based on an incidence of Guillain-Barré syndrome (GBS) that occurred with the 1967 swine flu vaccine. However, no other incidences of GBS have been associated with influenza immunization.2
The most commonly reported adverse effects associated with influenza vaccination is soreness at the inoculation site, which is mild, resolves within 2 days, and does not interfere with the person's daily activities. Other side effects include generalized myalgia and swelling at the inoculation site. These reactions are considered minor and not statistically significant when compared with placebo. When the facts of influenza immunization are presented, arguments against vaccination do not appear convincing.
Justice The ethical principle of justice relates to the distribution of resources. Nichol and colleagues report a cost savings of more than $115 per person vaccinated against influenza from reduced hospitalizations, fewer respiratory conditions, and lower overall mortality.20 Increased incidence of illness among health care workers because of a lack of immunization may lead to staff shortages, increased workload, and excess costs. Poland and colleagues describe data presented to the Advisory Committee on Immunization Practices that showed staff shortages in 35% of 221 surveyed organizations; 43% reported ICU bed shortages and 9% needed to divert patients to other facilities during the height of the influenza season.3
The role of trust in the context of influenza immunization has also been discussed.4 As professionals who provide health care, trust from our patients is a necessity: trust in our abilities, trust in our decisions concerning their well-being, and trust that our actions or inactions will not harm or endanger them. Health care workers who do not take reasonable and prudent steps to avoid being vectors of nosocomial infection are acting in bad faith to the ethos of health care and disrupt the milieu of trust that should prevail.4 Trust involves the power, knowledge, and susceptibility included in the health care of a person and embodies the tenants of ethics.4
Some exemptions to vaccination should be granted. Persons whose religious beliefs oppose all vaccinations should be exempt. People with allergies to the vaccine or any part of the vaccine or with other medical contraindications should also be excused from mandatory vaccination. In these cases, the health care worker should be assigned to areas where he or she would not come into contact with vulnerable patients.
The arguments that favor immunization of health care workers are persuasive. Mandatory immunization against influenza and other diseases, unless legitimate exemptions apply, is ethically responsible. JAAPA
Ralph Rice is Associate Professor and Associate Program Director, Department of Physician Assistant Studies, Wake Forest University School of Medicine, Winston-Salem, North Carolina. The author has indicated no relationships to disclose relating to the content of this article.
F.J. Gianola, PA, DFAAPA; Jim Anderson, PA-C, ATC, department editors
REFERENCES
1. World Health Organization (WHO). Influenza (seasonal). WHO Web site. http://www.who.int/mediacentre/factsheets/fs211/en/index.html. Accessed May 12, 2010.
2. Fiore AE, Shay DK, Haber P, et al; Advisory Committee on
Immunization Practices (ACIP), Centers for Disease Control
and Prevention (CDC). Prevention and control of influenza.
Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. MMWR Recomm Rep. 2007;
56(RR-6):1-54.
3. Poland GA, Tosh P, Jacobson RM. Requiring influenza vaccination for health care workers: seven truths we must accept. Vaccine. 2005;23(17-18):2251-2255.
4. McLennan S, Gillett G, Celi LA. Healer, heal thyself: health care workers and the influenza vaccination. Am J InfectControl. 2008;36(1):1-4.
5. Hofmann F, Ferracin C, Marsh G, Dumas R. Influenza vaccination of healthcare workers: a literature review of attitudes and beliefs. Infection. 2006;34(3):142-147.
6. Young A. Flu shots for workers hit sticking point. USA Today. November 6, 2009:3A.
7. Park A. It's a jab or your job. Time. 2009;174(15):55.
8. Stewart AM. Mandatory vaccination of health care workers.
N Engl J Med. 2009;361(21):2015-2017.
9. American Academy of Physician Assistants. Guidelines for Ethical Conduct for the Physician Assistant Profession. http://www.aapa.org/images/stories/documents/about_aapa/policymanual/19-EthicalConduct.pdf. Accessed May 11, 2010.
10. Cunney RJ, Bialachowski A, Thornley D, et al. An outbreak of influenza A in a neonatal intensive care unit. Infect Control Hosp Epidemiol. 2000;21(7):449-454.
11. Weinstock DM, Eagan J, Malak SA, et al. Control of influenza A on a bone marrow transplant unit. Infect Control Hosp Epidemiol. 2000;21(11):730-732.
12. Carman WF, Elder AG, Wallace LA, et al. Effects of influenza A vaccination of health-care workers on mortality of elderly people in long term care: a randomized controlled trial. Lancet. 2000;355(9198):93-97.
13. Potter J, Stott DJ, Roberts MA, et al. Influenza vaccination of health care workers in long-term-care hospitals reduces mortality of elderly patients. J Infect Dis. 1997;175(1):1-6.
14. Thomas RE, Jefferson T, Lasserson TJ. Influenza vaccination for healthcare workers who work with the elderly. Cochrane Database Syst Rev. 2010;2:CD005187. doi:10.1002/14651858.CD005187.pub2.
15. Wilde JA, McMillan JA, Serwint J, et al. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA. 1999;281(10):908-913.
16. Lester RT, McGeer A, Tomlinson G, Detsky AS. Use of, effectiveness of, and attitudes regarding influenza vaccine among house staff. Infect Control Hosp Epidemiol. 2003;24(11):839-844.
17. Harris J, Holm S. Is there a moral obligation not to infect others? BMJ. 1995;311(7014):1215-1217.
18. Verweij M. Individual and collective considerations in public health: influenza vaccination in nursing homes. Bioethics. 2001;15(5-6):536-546.
19. van Delden JJ, Ashcroft R, Dawson A, et al. The ethics of mandatory vaccination against influenza for health care workers. Vaccine. 2008;26(44):5562-5566.
20. Nichol KL, Lind A, Margolis KL, et al. The effectiveness of
vaccination against influenza in healthy, working adults.
N Engl J Med. 1995;333(14):889-893.