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Youth and children: Vaccines update Commentary| Volume 35, ISSUE 2, P106-108, February 2013

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Morality of influenza Vaccine Mandates

  • Arthur L. Caplan
    Correspondence
    Address correspondence to: Arthur L. Caplan, PhD, Division of Medical Ethics, NYU Langone Medical Center, 227 East 30th Street #753C, New York, NY 10016
    Affiliations
    Center for Vaccine Ethics and Policy, and the Division of Medical Ethics, New York University–Langone Medical Center, New York, New York
    Search for articles by this author
      The policy of requiring health care personnel to be vaccinated against influenza as a condition of employment has been rapidly gaining adherents in the United States and Canada. In 2004, Virginia Mason Hospital in Seattle, Washington, became the first hospital in the United States to attempt to make vaccination a condition of employment.
      • Swendiman K.S.
      Mandatory Vaccinations: Precedent and Current Laws.
      In 2008, the Department of Defense (DoD) issued a policy directive requiring “all civilian health care personnel who provide direct patient care in DoD military treatment facilities to be immunized against seasonal influenza infection each year as a condition of employment, unless there is a documented medical or religious reason not to be immunized.”
      Department of Defense/Joint Forces
      HA Policy: 08-005, Policy for Mandatory Seasonal Influenza Immunization for Civilian Health Care Personnel Who Provide Direct Patient Care in Department of Defense Military Treatment Facilities, April 4, 2008.
      There are now >200 hospitals, long-term care facilities, and health systems that have instituted influenza vaccination mandates.
      Immunization Action Coalition
      Honor Roll for Patient Safety: Mandatory Influenza Vaccination for Healthcare Workers.
      On October 23, 2012, Rhode Island became the first state to mandate vaccination for all health care workers.
      • Moyer C.S.
      American Medical Association
      State's Flu-Shot Mandate for Health Workers 1st of Its Kind in Nation.
      British Columbia, Canada, set out a mandate as of December 1, 2012.
      Decades of relying on voluntary efforts to secure adherence to influenza vaccination have not succeeded. Influenza immunization rates among health care workers have averaged ∼50% over the past decade in the United States.
      • Caban-Martinez A.J.
      • Lee D.J.
      • Davila E.P.
      • et al.
      Sustained low influenza vaccination rates in US healthcare workers.
      • Harris K.M.
      • Maurer J.
      • Kellermann A.L.
      Influenza vaccine: safe, effective, and mistrusted.
      Given the failure of voluntary vaccination strategies and the concomitant dangers of low vaccination rates present to vulnerable patients, should all health care workers not be required to be vaccinated against influenza as a condition of employment? The ethical case for employment mandates for those who care for patients is persuasive.
      First, every code of ethics adopted by physicians, nurses, nurses' aides, social workers, pharmacists, and other health care professionals states clearly that patients' interests must come before providers' interests. Because newborns, the elderly, the immunocompromised, and others vulnerable to influenza have a powerful interest both in avoiding morbidity and mortality caused by the transmission of influenza from those caring for them and in having a healthy workforce available to treat them, patients' best interests require the vaccination of health care workers.
      Second, all health care workers are obligated to honor the core medical ethics requirement of “do no harm.”
      • Jonsen A.R.
      • Siegler M.
      • Winslade W.J.
      Clinical Ethics.
      Given the evidence that vaccination can help to prevent disease transmission to patients,
      • Carman W.F.
      • Elder A.G.
      • Wallace L.A.
      • et al.
      Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial.
      the most fundamental moral requirement in all of health care demands that those in caregiving roles treat vaccination as obligatory. Furthermore, those who run health care institutions and programs ought to act on and be guided by that principle and insist on influenza vaccination as a condition of employment.
      Third, health care workers have a duty to vulnerable patients who cannot protect themselves. Newborns, infants, the cognitively impaired elderly, and the seriously immunocompromised can do little to protect themselves against acquiring diseases in hospitals, long-term care facilities, and home care settings. Influenza vaccines are not always protective in the elderly and immunocompromised. Few people living in health care institutions choose their health care providers or even know to ask whether they have been vaccinated. Health care providers have an absolute duty to do what can be done to ensure that they do not transmit disease to those at grave risk who cannot protect themselves.
      • Talbot T.R.
      • Babcock H.
      • Caplan A.L.
      • et al.
      Influenza vaccination of healthcare personnel.
      Vaccination against influenza and other communicable diseases is an important step in fulfilling this duty and should take priority over personal choice.
      There is still another powerful moral reason to ensure 100% vaccination rates among those working in health care. By not being vaccinated, health care workers feed fears about vaccination, reinforce antivaccination sentiments, and set a dismal example for the public. Because health care workers a play key role in seeing to it that the general public gets influenza and other important vaccines, it is ethically important that they set a virtuous example by supporting vaccination mandates for themselves.
      The moral case for limiting health care workers' choice concerning influenza vaccination rests on 4 principles: the professional duty to put patients' interests first, the obligation to do no harm, the requirement to protect those who cannot protect themselves, and the obligation to set a good example for the public. It is hard to see how the invocation of personal liberty claimed by some health care workers who oppose mandates could overcome this powerful “four-legged” moral case in support of an influenza vaccination mandate.
      Mandates work in terms of increasing vaccination rates. Rates are now well over 98% at many institutions that have adopted mandates.
      Immunization Action Coalition
      Honor Roll for Patient Safety: Mandatory Influenza Vaccination for Healthcare Workers.
      • Poland G.A.
      Mandating influenza vaccination for health care workers.
      Nonprofessional workers—food handlers, volunteers, and contract employees–have been motivated by the high vaccination rate to accept mandatory influenza vaccination.
      It is vital to the success of mandates that health care workers fully understand the empirical and moral rationale for such a requirement. Every mandate should be preceded by a thoughtful and comprehensive educational program for current workers, including counseling for those with doubts or concerns.
      • Feemster K.A.
      • Prasad P.
      • Smith M.J.
      • et al.
      Health care worker support of an influenza vaccine mandate at a large pediatric tertiary care hospital.
      • De Sante J.
      • Behrman A.
      • Shofer F.
      • Caplan A.L.
      Physician attitudes toward influenza immunization and vaccine mandates.
      New employees should understand that vaccination is simply a condition of employment.
      Mandating vaccination is consistent with professional ethics; benefits many, some of whom must rely on health care workers to protect them; and sets an example that permits honest engagement with the public in educating them to do the right thing about all recommended vaccines.

      Conflicts of Interest

      The author acknowledges the support of the Center for Vaccine Ethics & Policy, a program of the Division of Medical Ethics, NYU Langone Medical Center; the Wistar Institute Vaccine Center; and the Vaccine Education Center at the Children's Hospital of Philadelphia. The author has indicated that he has no other conflicts of interest with regard to the content of this article.

      Acknowledgments

      Dr. Caplan is the sole author of the paper and was responsible for the literature search, data interpretation, and writing of the manuscript.

      References

        • Swendiman K.S.
        Mandatory Vaccinations: Precedent and Current Laws.
        Congressional Research Service, Washington, DCFebruary 24 2011
        • Department of Defense/Joint Forces
        HA Policy: 08-005, Policy for Mandatory Seasonal Influenza Immunization for Civilian Health Care Personnel Who Provide Direct Patient Care in Department of Defense Military Treatment Facilities, April 4, 2008.
        (Accessed December 2, 2012)
        • Immunization Action Coalition
        Honor Roll for Patient Safety: Mandatory Influenza Vaccination for Healthcare Workers.
        (Accessed December 2, 2012)
        • Moyer C.S.
        • American Medical Association
        State's Flu-Shot Mandate for Health Workers 1st of Its Kind in Nation.
        (Accessed December 2, 2012)
        • Mickleburgh R.
        Flu Shot Policy for Health-Care Workers Sparks Backlash.
        (Accessed December 2, 2012)
        • Caban-Martinez A.J.
        • Lee D.J.
        • Davila E.P.
        • et al.
        Sustained low influenza vaccination rates in US healthcare workers.
        Prev Med. 2010; 50: 210-212
        • Harris K.M.
        • Maurer J.
        • Kellermann A.L.
        Influenza vaccine: safe, effective, and mistrusted.
        N Engl J Med. 2010; 363: 2183-2185
        • American Medical Association
        AMA's Code of Medical Ethics.
        (Accessed December 2, 2012)
        • Jonsen A.R.
        • Siegler M.
        • Winslade W.J.
        Clinical Ethics.
        6th ed. McGraw-Hill, New York, NY2006
        • Carman W.F.
        • Elder A.G.
        • Wallace L.A.
        • et al.
        Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial.
        Lancet. 2000; 355: 93-97
        • Talbot T.R.
        • Babcock H.
        • Caplan A.L.
        • et al.
        Influenza vaccination of healthcare personnel.
        Infect Control Hosp Epidemiol. 2010; 31: 987-995
      1. Nurses Can Help Improve Vaccination Rates, Study Suggests.
        (Accessed December 2, 2012)
        • Poland G.A.
        Mandating influenza vaccination for health care workers.
        Vaccine. 2010; 28: 5757-5759
        • Feemster K.A.
        • Prasad P.
        • Smith M.J.
        • et al.
        Health care worker support of an influenza vaccine mandate at a large pediatric tertiary care hospital.
        Vaccine. 2011; 29: 1762-1769
        • De Sante J.
        • Behrman A.
        • Shofer F.
        • Caplan A.L.
        Physician attitudes toward influenza immunization and vaccine mandates.
        Vaccine. 2010; 28: 2517-2525