1

Requiring Immunizations for Health Care Workers: Fair and Just?

Lisa M Lee, PhD, MS

2014 HEAL ConferenceApril 11, 2014

2

Edmund D. Pellegrino

3

Action

What we should do

What we are able to

do What we are

permitted to do

Approaching the Question

4

• 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

Working Thesis

5

Which Lens of “Should”?

HCW Immunization

Clinical ethics lens

6

Which Lens of “Should”?

Public health ethics lens HCW

Immunization

7

Which Lens of “Should”?

Justice lens

HCW Immunization

8

• 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

Clinical Ethics

9

• 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)

Unresolved Tensions: Clinical Ethics Framework

10

Herd ImmunityIll Susceptible Immune

11

• 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

Public Health Ethics

12

• 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

Additional Work and Unresolved Tensions of PH Ethics Frameworks

13

Justice is the first virtue of social institutions, as truth is of systems of thought.

Rawls J. A Theory of Justice, p 3.

Justice

14

• 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

Justice

15

The 4-Way Stop

16

The 4-Way Stop

17

The 4-Way Stop

18

• 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

Implications of Applying Justice

19

• 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

Working Thesis

20

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.

Ethics and “Should”

21

Questions & discussion