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Requiring Immunizations for Health
Care Workers: Fair and Just?
Lisa M Lee, PhD, MS
2014 HEAL Conference
April 11, 2014
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Edmund D. Pellegrino
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Approaching the Question
What we
are able to
do
What we
should do
Action
What we
are
permitted
to do
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Working Thesis
• We should protect the vulnerable
• We should implement a comprehensive approach to
ensure vulnerable populations (e.g., ill persons) are
protected from seasonal influenza
– Hand hygiene
– Respiratory hygiene and cough etiquette
– Isolation of infected patients and sick days for ill
workers
– Full vaccination of staff and patients
• Unless medically contraindicated
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Which Lens of “Should”?
Clinical ethics lens
HCW
Immunization
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Which Lens of “Should”?
Public health ethics lens
HCW
Immunization
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Which Lens of “Should”?
Justice lens
HCW
Immunization
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Clinical Ethics
• Focus
– Provider & patient interaction
– Fiduciary duty to patient
• Principles
– Respect for autonomy
• Respect choices based on personal values and beliefs
– Nonmaleficence
• Obligation not to inflict harm
– Beneficence
• Provide benefits to others
– Justice (distributive)
• Fair access to or allocation of resources
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Unresolved Tensions: Clinical Ethics Framework
• Fiduciary duty versus HCW autonomy
– Stems from Mill’s harm principle
– Takes on special significance when one individual is
healthy HCW & other is medically fragile patient
• Attempts to resolve: Professional obligation, special
social status
• Reciprocal benefits assumption not met with influenza
immunization
– Population intervention, not individual intervention
– Benefits accrue to individuals only when population is
protected (herd immunity)
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Herd Immunity
Ill
Susceptible
Immune
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Public Health Ethics
• Focus: Community or population as ‘patient’
• Duty to community’s health
• Principles
– Least restrictive intervention to meet goal
– Evidence-based action, precautionary principle
– Health equity (reducing disparities)
– Community engagement
– Reciprocity
• When asked to act in the interest of the greater good, this
act is facilitated
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Additional Work and Unresolved Tensions of
PH Ethics Frameworks
• Takes us further than clinical ethics framework
– Helps us with herd immunity
– Addresses reciprocity resistance
– Addresses health equity concerns
– Allowable under precautionary principle
• Fails to fully address our obligations to contribute to
the greater whole
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Justice
Justice is the first virtue of social institutions, as
truth is of systems of thought.
Rawls J. A Theory of Justice, p 3.
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Justice
• Focus
– Plurality, solidarity
– Doing together what we cannot do alone
• Principles
– Equity (different than health equity)
• How I would like to be treated if I were you
– Obligation to follow the law
• Discretion to do only what one prefers nullifies the state’s
ability to protect citizens
– Fairness essential for cooperative schemes
• Role for every party, all responsible for their part
• Whole is greater than sum of its parts
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The 4-Way Stop
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The 4-Way Stop
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The 4-Way Stop
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Implications of Applying Justice
• Protection for self depends on full participation of all
– Benefits of cooperation far exceed individual action
• Exemptions
– Challenging to acquire
• Promotes solidarity, fair distribution of burden
• Equitable in the just sense
– Medical only
• Declared or reassigned to protect vulnerable
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Working Thesis
• We should implement a comprehensive approach to
ensure vulnerable populations (e.g., ill persons) are
protected from seasonal influenza
– Hand hygiene
– Respiratory hygiene and cough etiquette
– Isolation of infected patients and sick days for ill
workers
– Full vaccination of staff and patients
• Unless medically contraindicated
• Requiring all components is ethically justified to reach the
goal of protecting vulnerable patient populations
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Ethics and “Should”
Ethics is a social technology, one for which there are no
experts. There is only the possibility of conversation,
ideally free of factual mistakes and imbued with mutual
sympathy.
-- Philip Kitcher, Science in a Democratic Society (2011) p 12.
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Questions & discussion