Role of Bioethics in HCW Flu Vaccination

Pennsylvania Health Care Worker Flu Immunization

CampaignA Patient Safety & Employee Health Initiative

Training Resources:Ethics Module

Version 1.4June 2011

Role of Bioethics in HCW Flu Vaccination

Bioethics as strategy to apply clear thinking to decision-making and implications of decisions:

- Testing against ethical principles can provide guidance – not the same as “legal finding

Center for Vaccine Ethics and Policy/Penn following this issue for several years

- Not entirely neutral given the evidence

This exercise to orient meeting participants at very high level to ethical frameworks and how they link

Your programs WILL encounter ethical issues…even dilemmas!!

Vaccination Requirements and Mandates:

Ethical Frameworks and Principles

EffectivenessProportionality

NecessityInfringement

Public JustificationProfessional

Codesof Ethics

Adapted from: Jason L. Schwartz, MBE, AM, Center for Bioethics; Department of History & Sociology of Science University of PennsylvaniaNVAC Health Care Personnel Influenza Vaccination Subgroup31 May 2011

AutonomyBeneficence

NonmaleficenceJustice

Harm Principle

Bioethical ‘Principles’ Applied

Autonomy – Respect individual choice and freedom to decline any health intervention

Beneficence – Do good that benefits others, including prevention or removal of harms (safety) (also “rescue imperative” - no cost is too great to save a human life)

Nonmaleficence – “Do no harm” and, by implication, assure patient safety

Justice – Fair allocation of health care resources to assure that good is done fairly across populations and other contexts

See Beauchamp, TL, Childress, JF Principles of Biomedical Ethics

Adapted from: Jason L. Schwartz, MBE, AM, Center for Bioethics; Department of History & Sociology of Science University of Pennsylvania

NVAC Health Care Personnel Influenza Vaccination Subgroup31 May 2011


Harm Principle

John Stuart Mill, On Liberty:“The only purpose for which power can be rightly exercised over any member of a civilized community against his will is to prevent harm to others.”




Harm Principle

Tipping points: - A known threat or harm to others can be

avoided by exercise of such power (e.g. mandated vaccination)

- Form of exercise does not imperil or risks are known and accepted

- Professional duty/accepted code of ethics or conduct already address issue at some fundamental level




Professional Codes of Ethics

Unique status of professional codes of ethics– Developed and agreed to by members of a

profession– Reflect standards and norms that members

of a profession accept as central to their professional duties

– Supplement/complement general ethical norms

Hippocratic Oath (5th c. BC); AMA Code of Ethics (1847); ANA Code of Ethics (1995)

Jason L. Schwartz, MBE, AM, Center for Bioethics; Department of History & Sociology of ScienceUniversity of PennsylvaniaNVAC Health Care Personnel Influenza Vaccination Subgroup31 May 2011


AMA Code of Medical Ethics

American Medical Association:– “A physician must recognize responsibility to

patients first and foremost.”– “A physician shall recognize a responsibility to

participate in activities contributing to the improvement of the community and the betterment of public health.”

– “To preserve the quality of their performance, physicians have a responsibility to maintain their health and wellness… When health or wellness is compromised, so may the safety and effectiveness of the medical care provided.”

From AMA Code of Medical Ethics

Adapted from: Jason L. Schwartz, MBE, AM, Center for Bioethics; Department of History & Sociology of Science University of PennsylvaniaNVAC Health Care Personnel Influenza Vaccination Subgroup31 May 2011From AMA Code of Medical Ethics

Code of Ethics for Nurses (ANA)

American Nurses Association:-- “The nurse’s primary commitment is to the patient, whether an individual, family, group or community.”

-- “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”

From ANA Code of Ethics for Nurses


Ethicists on Health Care Worker Influenza Vaccination Mandates

“Health care workers' own code of ethics dictates that they put the interests of others — their patients — first.

“Getting a flu shot is the least those who claim to be bound by professional ethics ought to do.”

- Art Caplan, Penn Center for Bioethics MSNBC.com, 8 October 2009


Professional Codes of Ethics

Challenges:– Translating general statements about

obligations of health care personnel to patients and selves to specific applications (e.g., influenza vaccination); who decides?

– Extending obligation to receive vaccine based on duty to patients to other personnel working in health care facilities (including those not part of a health profession, per se)


General Principles: “Tests”

Childress, et al. “Public Health Ethics: Mapping the Terrain,” Journal of Law, Medicine, and Ethics, 2002

Effectiveness – Infringement will probably protect public health

Proportionality – Probable public health benefits outweigh infringed moral consideration

Necessity – Absence of other effective, proportionate strategies to attain desired public health goal

Least Infringement – Designed to minimize degree of infringement

Public Justification – Transparency and explanation of infringement—essential to trust and accountability


Observations I

Vaccination requirements for HCWs well-established

New requirements/mandates for any vaccination should meet critical tests against bioethics and other societal principles

Responsibility for patient safety empowers health care providers to take prudent action: work rules, mandates, etc.

Assuring HCW flu vaccination levels appropriate to patient safety falls within this empowerment

Observations II

Patient safety imperative implies that work rules, immunization requirements, etc. could and should apply to all who can compromise safety

Irresponsible to allow conditions which compromise patient safety to continue where corrective action is available, safe, affordable, effective

Observations III No compelling argument encountered to date

that mandated programs are “unethical” per se Does not mean that any given program

(voluntary OR mandated) is free from questionable/unethical policies, practices…

Each program and new element must face the same tests…patient safety imperative does not mean “no challenges allowed”

Case studies in this training offer a range of options…no cookie cutter solutions but templates for effective action!

Group Exercise

Share an example of an “ethical” issue or challenge you and your institution faced in your current HCW flu vaccination program… How was it addressed and who addressed it?

Share an example of an ethical challenge ahead, perhaps a new program element for the 2011/12 season, or one you think might emerge if you move towards a mandated program…

We will use these examples to build a collection of “ethical issues and (potential) answers” for the website

Documents

Role of Bioethics in HCW Flu Vaccination